10-12 - 2024: Epic trail!

We’re going to hear a lot about the NHS this year (especially on the campaign trail). In my last article for PharmaTimes – ‘Victorian Era’ – we looked at the arrival of new Health and Care Secretary Victoria Atkins and her various challenges. Waiting times! Strikes! Trusts in the red! And overwhelming demand!

But reading the NHS’s press releases at the beginning of the year, you’ll actually be struck by the number of good news stories.

The English referral-to-treatment (RTT) waiting list shrank by 96,000 patient pathways in November 2023, and average waiting times also fell by 1.6 weeks to 44.3 weeks RTT. No mean achievement when you consider the context.

Outpatient numbers have also gone down significantly owing to more systems using PIFU (patient-initiated follow up – a way of reducing unnecessary appointments).
And the number of incomplete pathways has also gone down – although to nowhere near pre-pandemic levels yet.

This year’s election (and we now know it is going to be in the autumn) could at least in part focus on how ‘well’ the Tories have done on Rishi Sunak’s ubiquitous ‘five pledges’.

He’s been lucky in that inflation has fallen – but now that there may be another slide into recession, there’s little movement on national debt and zero chance of ‘stopping the small boats’ by then – the government may well decide that the pledge to cut NHS waiting lists is the only one that looks anything like an achievement.

Meanwhile, Labour is going to have to tread carefully; in saying how much extra funding it would give the NHS, in how it would respond to pay demands and curtail industrial action and in what its overall programme of ‘reform’ – which will almost certainly involve more private sector use – will look like.

With the Tories seizing on any uncosted spending and hyping up whatever progress the NHS does make this year, Labour could have a task on its hands “stopping the small gloats”.

There’s no denying that it’s still a challenge accessing NHS decision-makers because of all this.

An atmosphere of financial and operational uncertainty still dominates and time is at an absolute premium. If you can secure meetings and engagement from your principal KOLs and wider DMU – well done.

The other facet of time is that staff time is now being spoken of as a more important currency than acquisition cost, in terms of impact on systems. Products that shorten pathways and free up staff time, for example by allowing out of hospital care, are doing well.

One of the principal challenges to companies launching in the calendar year will be shifting structures of this time-poor customer base.

The 2023 Major conditions strategy underlines this – and one of the big reveals of the forthcoming NHS planning guidance is likely to be new structures for specialised service delivery, along the lines of hub and spoke models piloted in oncology.

We’re also getting intel from our colleagues at Health Service Journal that a series of mergers could be on the cards, in part driven by a need to stay afloat and rationalise staff and services.

For example, of the 211 Trusts, 71 – a third – already have a joint CEO or chair, which could pave the way for more formal unions later in the year.

There are permanent ‘group’ structures, neighbours simply sharing chairs and CEOs, chairs with several unrelated roles and short-term joint governance arrangements. And they’re all very much doing their own thing – both because they must, to cope with demand and squeezed resources, but also through policy, which of late has been about empowering local decision-making.

So, with all these shifts on the cards, I spoke to Stuart Shotton, former commercial director at both AbbVie and Danone, and now an expert advisor to industry on market access, to get his insights on how he thinks companies should prepare for launch in 2024.

Q: As a commercial director, what would be your thoughts about the current NHS before launching a product?
A: Quality insights lead to optimal business decisions – particularly with all these structural changes in the NHS.

It’s not only about what those changes look like, but asking what they really mean in practice and how far is each territory ahead with the execution of their business plans and development of those structures. How would that impact you in terms of product launch?

There’s never been a better time to test historical insights and assumptions. What you might have known before may not hold true now.

The pattern of prescribers, treaters, networks and the behaviour of competitors – you’re really going to have to think carefully about whether what you knew before was relevant.

Q: Why aren’t customers engaging as they used to? And how do you turn this around?
A: What I’m hearing is the most common reason not to engage at the moment is time.
There’s always been an access issue for the 20 years I’ve been in industry trying to see physicians, but now it’s become very acute indeed. It’s the facts of the current NHS workload.

Product safety, efficacy and acquisition costs are now not guaranteed to gain payer’s interest. They’re just not looking for that – or not only that – anymore.

Workforce, and how you can reduce workload, is the new currency – that’s what you hear increasingly – and consistent value across whole systems is the language companies need to be talking in now, and acting on.

There’s a lot of companies out there that are still doing the traditional clinical sell and not getting this. Increasingly companies are reaching out for external support from agencies.

Personally, I’ve had to take advice on contracts and rebates, and how that works in the new set-ups.

But if you want to get your product on formulary, and preferential guidelines, and to have prescribing advisors promoting it, quality, efficacy and cost is not going to be enough. You’ve got to show the value across the system.

Q: So, are companies that are confidently working ‘above brand’ experiencing better sales?
A: Increasingly this will be the case, and you’re seeing it already.
As the NHS’ priorities and budgets shift away from a primary focus on acquisition cost, to integrated system value, addressing health inequalities, reducing waiting lists and patient access to services, you’re seeing companies focus more on this and getting results.

Basically companies that are going above brand on things like this will have the winning formula going forward. Even more localisation is required too – but in a smart way. With 42 ICSs you have to cluster them up in terms of similarities.

You’re never going to come up with 42 uniquely bespoked value propositions, but you do have to differentiate between them.

Q: What are the pitfalls of not having the right fieldforce?
A: For most companies the fieldforce is still the lynchpin of any go-to market strategy. Even when you consider what they’re doing digitally, it’s still pretty much the salesforce that is their focus – even more in pharma than other industries.

It’s also typically the biggest cost in the P&L. They’re still valued! The death of the salesforce is a totally premature concept.

But, the movement away from simple share of voice and numbers of boots on the ground, that’s definitely happening, and a move towards more specialised, concentrated teams.

You’re also getting primary and secondary teams working together more, merchandising guidelines together and working in a more integrated way – just as the NHS is supposed to be doing.

With a typical rep salary on £150k and a cost of about £500 per call, you’re seeing companies looking more carefully at return on investment, particularly in primary care teams and with wage inflationary pressures.

Pharma’s margins have always been so good they haven’t had to worry about this, but now, it is hitting margins.

To address this you need a more clearly optimised fieldforce, calling on the right customers with the right messages at the right frequency. But in-house capabilities to do this kind of smart commercial optimisation – even in some big organisations – are not always there, and things like proper market segmentation, effective KPIs and monitoring, are not generally as well thought out as they could be.

Q: How do you prepare your reps to target their individual patch?
A: My reps have had different key tasks sitting before them and have generally been good at getting things onto formulary where needed, merchandising guidelines, getting things onto primary care because that’s where the volume sits, having value propositions for payers – and knowing which customers they have to access to achieve these things.

It comes down to having the right roles in the right blocks. In the community, where you need to merchandise those guidelines, you might need one set of skills and experience, then another for secondary care.

We think about the right team and numbers for every layer of the health economy as a baseline. We as managers, and they as salespeople, don’t always get it exactly right, but it comes back to having the right people in the right numbers in the right places, and the rest follows.

Q: Are companies putting the correct amount of resource into the areas where there is the most potential for sales?
A: The most successful ones I’m working with are.

I’m seeing ability to fully map brand influencers at the local level and deploy a channel strategy that prioritises access to those customers with the most influence or value, particularly in relation to prescribers where value is often a component of potential (size of opportunity) and propensity (ability to achieve the potential).

You need to have access to sophisticated account management tools though. But in my experience, this can make all the difference.

Epic trail!

Time is of the essence

In the know

The future and beyond