14-15 - The new NHS landscape – is pharma ready for a revolution?

In the words of the Health Secretary Sajid Javid, 2022 will be a “year of reform” for the health and care system. The same can be said for its commercial suppliers. They will have to meet the need for:

New rules of engagement, as time-scarce health professionals demand more precision and focus in the communications they receive
New value propositions, as the NHS pivots away from disease management towards a greater focus on population outcomes
New account management structures, as the traditional dividing lines between primary and secondary care dissolve and more networked decision-making takes over
New methods of securing market access, as NHS reforms rewrite the way localities select and pay for the medicines they use
New skills and competencies to make sense of changes to the commercial landscape and stay effective in a period with almost no face-to-face access to healthcare professionals.
How, then, do organisations navigate through this period of accelerated change and reform? There are five dimensions that will affect the way that the industry relates to the NHS.

First is the political environment. The NHS has always been buffeted by political forces and 2022 will be no exception. The government’s flagship Health and Care Bill will probably become statute from April 2022: a big moment for the health and care system as it codifies a lot of the organisational and funding changes of the last 18 months.

Yet, even with a healthy parliamentary majority, negotiating contentious health reforms through both chambers of parliament can be perilous. Added to this are the acute operational challenges facing the NHS, the effects of an ongoing pandemic and a new Health Secretary keen to make an impression. All of this means that politics may intrude further, and significantly, on NHS business.

There are several areas where political opposition may yet affect the legislation before it obtains Royal Assent in the Spring. These include:

Workforce planning – an amendment by Jeremy Hunt to force publication of workforce projections was narrowly defeated in the Commons, but may be resurrected
Ministerial powers – there has been opposition to the enhanced powers the Bill would give the Health Secretary to intervene on reconfigurations of services
Composition of Integrated Care Boards – there have been concerns raised about the potential presence of private sector providers on new Integrated Care Boards
Changes to procurement rules – the relaxation of competition rules for tendering services has also been criticised as a way of facilitating increased private sector involvement

Intriguingly, at the same time, the Health Secretary is reportedly interested in pursuing measures, via an Integration White Paper, that would force integrated care systems (ICSs) and local authorities to pool budgets.
The speculation underlines the point that, even after April, there could be significant new national policy initiatives. There may be further layering of reform on reform if these integration proposals take shape in the year: watch this space.

There is a sense that the Health and Care Bill merely reflects ‘the legalities catching up with the realities’ of what’s been building within the NHS for several years.

At system level, most ICSs have appointed their first chief executives to work alongside the designated chairs. Underneath them, many teams nominally still part of clinical commissioning groups are already working for ICSs, while other prominent system level roles have also been filled.

ICSs are, therefore, no longer abstract, shadow entities. They will be producing a raft of strategic plans over the coming months that pharma will need to scrutinise. These will set the agenda and core priorities for their entire system footprint.

Yet, while there is a tendency to see ICSs as the pre-eminent force in the new NHS landscape, place and neighbourhood are the focal points for practical discussions about pathway design and redevelopment – and pharma needs to be involved. Place and neighbourhood are the engine rooms of innovative practice and service delivery in 2022.

The reforms will fundamentally change the way the NHS operates, including the workforce mix, the way pathways are designed and the focus of activity in different healthcare settings.

Pharma will need to understand how clinical decision-making works in different areas, including the central role that clinical reference groups and clinical networks will play in shaping which brands are used across a given pathway. In each locality, for each disease or patient pathway, pharma must understand the dominant players and the dynamics within these networks.

Further, the NHS is shifting out of hospitals and into the community with preventative healthcare. This introduces a new list of influencers, including a wide range of allied and community health professionals.

Many companies are going back to basics and undertaking a thorough audit of who is a priority for a particular pathway or disease area. This requires a deep understanding of how the patient journey is changing, and what this means, in terms of the different touchpoints they access during their care. A customer in 2022 looks very different from one a few years ago.

The reforms dissolve many of the institutional boundaries that have shaped the way industry relates to the NHS for generations. This means pharmaceutical companies will need to organise their teams to engage most effectively in a more fluid and networked stakeholder landscape.

Traditional models have tended to focus on giving field forces defined territories and a set of KPIs built around an agreed number of customer contacts and frequency. This worked in a context where decision-making was linear and built around institutions (in many cases acute hospitals) and specialisms. In an environment where decisions are made by clinical networks working across a pathway, this approach is too blunt.

The emphasis must shift from engaging with decision-making units (DMUs) and key opinion leaders (KOLs) in individual Trusts to influencing whole networks – potentially involving many different types of healthcare professional working across a system or multiple systems.

Similarly, it will no longer be enough to focus energies on a select group of favourable KOLs. Engagement with a broader range of clinical decision-makers within a network may be necessary to ensure a product or offer wins approval. Deep knowledge and understanding of priorities and decision-making within localities will have to be found through sourcing and reading plans and board minutes.

Finally, the way pharma transacts with the NHS is also evolving, in terms of brand planning, securing market access and negotiating funding and governance obstacles.
A particular issue involves the new structure and composition of formularies. Pharma will have to negotiate a more layered and complex environment for market access, with different formularies and formulary committees potentially operating at system- and place-based levels.

All brand planning and go-to-market strategies will need to be aligned to these local realities, recasting value propositions to meet the changing context. As stated in the last article, positioning a product as the most effective way of securing improved outcomes at a population health level will be increasingly important.

At a functional level, commercial optimisation support can help organisations deal with the effects of these changes on issues like CRM, how customers are grouped or segmented, what kind of targets should be expected at each level and how different elements of the salesforce should be configured.

Industry will need strong strategic account management to activate broader and more multidimensional engagement, plus a new way of measuring its effectiveness, built around the quality of interactions with priority stakeholders, and not just volume.

Over 500 pharma executives at a recent webinar were asked what level of change was needed within industry to meet these future challenges. More than half (59%) said “a great deal”, while more than a quarter (27%) said nothing short of “a revolution” would do.

The changes underway across these five dimensions will require greater organisational agility, extensive local knowledge and intelligence, plus a deep understanding of how the new NHS works at system, place and neighbourhood levels.

For pharma, 2022 is the year the revolution must begin.