Pharmaceutical companies in the UK need to be equipped for practice-based commissioning (PBC) in the National Health Service (NHS), even if it is not really happening yet.

That was the general take-out from a meeting on ‘The Changing NHS: Practice-based Commissioning for Pharmaceutical Marketeers’, held this week by the PM Society at Altana Pharma’s UK base in Marlow. It was an opportunity to hear two sides of the PBC story, from a pharmaceutical company representative and an Oxfordshire general practitioner – both more or less engaged in the process but with markedly varying degrees of scepticism.

Conceived in 2004, PBC is a flagship policy amidst the Labour government’s sweeping and much-criticised programme of healthcare reforms. The idea is that giving general practices a budget to commission their own services will translate into higher-quality care for local communities.

A recent survey by the King’s Fund and the NHS Alliance found that 73% of the 250 GPs and general practice managers polled were “firmly committed” to the policy, although 53% of respondents felt PBC had failed to improve the quality of patient care. Obstacles cited included lack of support from primary care trusts (PCT), financial constraints, short-termism and excessive bureaucracy.

A 'gloomier' view

The PM Society meeting gave a far gloomier picture. According to Dr Lisa Silver, a GP from Nettlebed, Henley-on-Thames, fewer than 5% of GPs are actively engaged in PBC, despite claims from the Department of Health that the vast bulk of general practitioners have taken the policy on board. Silver put this disparity down to GPs having pocketed the ‘aspiration payment’ for PBC in 2006/07, while in reality “we aren’t doing it.”

Among the components of the strategy are assessing local healthcare needs; planning and designing healthcare services to meet those needs; placing contracts for the provision of healthcare; carrying out audit, review and evaluation of the contracted services to ensure they are delivering health gains effectively; ‘payment by results’; healthcare resource groups; and indicative budgets for GPs.

Despite all these possibilities, and three sets of guidance from the government, PBC remained a “rather elusive” concept, Silver commented. Moreover, GPs did not have time to pursue it and there were “practically no” real incentives for them to do so. She also blamed the “dead hand in PCT land,” which made it difficult to embrace PBC in a collaborative spirit. One of the reasons the policy had failed to take off, Silver suggested, was that PCTs resented the “inquisitorial” scrutiny of GPs over how and where healthcare budgets were being spent.

While Silver found it difficult to envisage where pharmaceutical companies could fit into this process, she did agree with David Southern, healthcare strategy manager, UK for Napp Pharmaceuticals, that there was inexorable pressure to manage demand and contain escalating costs in the NHS.

Commissioning 'here to stay'?

This was why pharmaceutical companies needed to “be there waiting” when PBC really did start to take a grip, Southern insisted. The fundamentals of healthcare funding in the UK – an ageing population, longer life expectancy, exponential increases in the cost of care for the over-65s, expenditure that was inching up towards the Organisation for Economic Co-operation and Development (OECD) average as a percentage of gross domestic product (GDP) – indicated that resources were at full stretch and rationing and commissioning were here to stay.

In other words, he told the meeting, if PBC did not work, then something else would take its place. While demand-side health reforms like practice-based commissioning might have been compromised by their introduction some two years behind supply-side reforms such as foundation trusts, they were the most important element of change and were “absolutely vital” to the future of the NHS.

In this light, pharmaceutical companies should be keeping pace with their customers, which meant understanding the commissioning process, building tools to enable PBC and being more prepared to enter into partnerships.

Creating an environment in which your own products could thrive was about engaging both with PBC at primary care level, to show how particular services could generate properly managed demand, and with secondary care to generate the supply of those services, Southern pointed out. It came down to making sure the appropriate patients presented at the appropriate time to use your drugs in the most effective way possible.

This involved all kinds of partnerships, with foundation trusts and their executive teams, consultants and their teams, PCTs and commissioning GPs – and it was hard enough sometimes just getting these constituencies to talk to each other, Southern observed. On top of that came partnerships with other suppliers, such as diagnostic and equipment suppliers, with the aim of presenting a more desirable “portfolio” of skills.

This might lead to a reduction in the field force, with more emphasis on fewer experts, Southern warned. But it was worth paying that price, as partnering split risk and cut the resources needed to make an impact. The bottom line, he said, was that “we need to think differently” and “really be in bed with what the NHS wants to do” – which, essentially, was to rein in costs.