Q. When is a physician not a physician? A. When s/he is a payer...
| Jun 21, 2012
A radical restructuring of the UK health service has been underway since the Health and Social Care Act was introduced in the UK a few years ago in an effort to deal with the ever-rising cost of caring for an aging population and the growing administration costs of running Primary and Secondary Care Trusts. Its early stages of introduction involved the setting up of commissioning groups that operate with much less red tape than the trusts and therefore, on the face of it, have much more freedom to spend their budget in a businesslike manner.
The idea is that General Practitioners (GPs) are set to take more and more control of the region’s National Health Service’s annual budget by sitting on these commissioning bodies. They still have to do their day jobs – seeing patients, diagnosing illnesses (in the UK they have a mere seven minutes consultation time) and prescribing medication or referring that patient onto someone with more specialist skills – so effectively they are covering the roles of both physician and payer.
Although the Act achieved Royal Assent in March, the far-reaching nature of the changes means that they will take some time to implement. Already busy GPs are struggling to squeeze in time to go through budgeting processes. They are also struggling with the constant dilemma of getting the best value for money while also doing what they were really trained to do – that is, provide the best patient care.
The new situation really highlights the fact that the UK market access model - based on getting a drug onto the market with a reimbursed price, having submitted dossiers and health economic models, gone through lobbying, phase IV trials and set up patient group partnerships according to centralized guidance from NICE – is really about highlighting stakeholders’ interests and it’s the proliferation of stakeholders and their decentralization that has turned the situation on its head. Pharmaceutical companies are struggling to get to grips with many, many more decision-makers at a very local level, trying to understand what these new stakeholder ecosystems look like, where the influence really lies and how best to identify and engage with the true influencers.
NHS Confederation chief executive, Mike Farrar, highlighted the issues when he commented, "Let there be no doubt that this will be among the toughest projects the NHS has ever taken on. We have to find our way through the considerable confusion and complexity that has been handed to us as we build and stress-test the new NHS system. We need to heal the rifts that have opened as many of our clinical staff have debated the merits of the bill. We need to completely redesign NHS services against a backdrop of unprecedented financial pressure, bringing the public and staff with us. We have to do all this with significantly reduced management capacity."
In a recent survey, we asked traditional payers where they thought the influence was in the NHS and where it should sit in an ideal world. This infographic, which was put together following qualitative interviews with key UK payers during which they were asked to evaluate the influence of various stakeholders from a pricing, market access and reimbursement standpoint. They were also asked to put themselves in the shoes of GPs and specialists and rate the influence of stakeholders from a commissioning perspective. Finally, they were asked to compare what they saw as the current spheres of influence with their view of the ideal influencer landscape. NICE in these payers’ eyes should have much more of an influence on the market access process. However, it’s not clear if they are saying this because, in a world of unknowns, they may have felt the old way of doing things was at least familiar or whether they really feel there is real value in the involvement. What is clear is that they are not ready or willing to let go of control but they have little choice.
The UK is not the only European country going through these changes. After years of mismanagement and general inefficiency, the Spanish Health System is going through similar radical reform. Maybe both the UK and Spain need to seek even more radical change? They could look to the US for an understanding of how to engage a diffuse set of decision-makers and negotiators (e.g. managed care) or to Germany where, in contrast to the majority of other health care systems, market access is mainly achieved through coverage by statutory sickness funds. Whatever they do, the situation just goes to prove the Darwinian theory of evolution – that it will be most adaptable and most agile players in the pharmaceutical marketplace who will survive in the face of this market access revolution.