From consultation to discussion: Time to talk about the NHS Pharmaceutical Sales Management December 2006
In some quarters of the NHS, ‘reform fatigue’ might become a new work-related stress diagnosis, as the effort expended in reconfiguration increasingly appears unmatched by outcomes (overspends and redundancies in a number of trusts were not envisioned).
The gap between the perception of reform at the ministerial and higher departmental level and that of the professions, public and media is widening. An outsider might presume that NHS changes are formulated in a vacuum and then implemented directly. Such a perception would be inaccurate, however, as changes to the structure of the NHS are always preceded by a consultation that allows interested parties time to submit their views and aspirations to the Department of Health.
The process is not risk-free: any consultation is a potential hostage to fortune. If you ask another’s opinion, there is a risk that they will give it to you and expect you to do something with it. The potential for this to ‘confuse’ a carefully-orchestrated policy is clear. The knack is to solicit opinion that can be incorporated into the general direction of intent.
The usual channels
The recent consultation exercise conducted as part of Commissioning a Patient-led NHS – determining the number and structure of PCTs and SHAs – is a good example of the type. The intention was to ‘consult widely and formally with the public and their representatives on these proposals’, while making it clear that this was a consultation about administrative changes, not services, and that if proposed changes might lead to altered patterns of service provision there would be subsequent and separate consultations. Clear enough, then. Structural changes have been ‘achieved’, and it is now left to the NHS and suppliers to recalibrate themselves in order to accommodate the new-look service.
Views on the efficiency of the consultation system range from the optimistic (an opportunity for the public to have their views on NHS policy considered and acted upon) to the cynical (a politically-motivated smokescreen to give patients and organisations the false impression that their opinions count).
Less severely, it could at least be acknowledged that the consultation system is by nature something of a one-way street, falling short of being a real opportunity for dialogue. Submissions made within the deadline fall into a ‘black box’ , with no further interaction occurring until the intended course of action is announced.
Behind closed doors
Could the process operate more effectively? The NHS does not operate in a closed system, but depends upon its many suppliers – for example, the private sector pharmaceutical industry for the provision of drugs. This relationship is symbiotic, yet is often conducted with a degree of caution that may puzzle the observer.
The popular dichotomy is that the inner workings of the NHS are utterly esoteric to private-sector suppliers, while to mention the involvement of these suppliers within the confines of an NHS hospital is to solicit the sudden appearance of a crucifix and garlic. This dichotomy is false, but it underlines a prevalent suspicion: that reform of service configuration occurs within the NHS, with limited input from outsiders; and that the imperatives that determine reform are best understood as belonging to the political and departmental stratosphere.
From the outside, the perception is that the NHS reform agenda is a closed shop. Ministers and senior civil servants sit in darkened rooms with damp towels wrapped around their heads, deciding the configuration of services before announcing them, alongside a public consultation exercise, to industry and the public alike. Those on the outside are left to tail-chase and predict what will be announced.
What is perhaps not adequately considered is the effect that restructuring has on the businesses that support the NHS. While change in the NHS is expensive, controversial and often painful, the same may also be true for the companies that supply the NHS with essential products and services. Any change in service structure, with its attendant reshuffling of personnel, is disruptive to the workflow of service providers. New systems need to be understood and evaluated, new contacts must be established. Often, as in the case of recent changes to commissioning, whole new buying chains need to be incorporated into existing structures.
We might suspect the existence of an Illuminato of ministers and departmental officials, meeting at the Athenaeum Club to chart the course of NHS reform. But this is unlikely to be the case. The real question is whether a more transparent dialogue with suppliers could improve services and efficiencies.
The current timing might be propitious, with the NHS increasingly looking outward in its desire to provide better-contested services. Whereas in the past, Government departments could be accused of operating within self-created and well-defended silos, the eclectic nature of the NHS reform agenda makes such parochialism increasingly difficult to justify.
Dialogue at higher levels
There is a growing perception in the pharma industry that the blitzkrieg approach to selling – employing an increasing number of representatives and winning the sales war by weight of numbers – is not sustainable. Many pharma companies across Europe are looking to more sophisticated approaches to drug selling than the traditional ‘rep meets doctor’ pattern. More complex relationships with purchasers (especially new commissioners) and service planners are being formed, in line with an understanding of the reform agenda.
The Department of Health might represent the high point of contact for this kind of interchange. It is not too difficult to envisage a situation where the DH opens its doors to suppliers at its own planning stage, thus gaining full awareness of the many factors in the private sector that affect the delivery of healthcare in the NHS.
This would raise consultation to a more businesslike level. Presently, it is directed more to service recipients (patients) and organisations that support or represent them. An active and open engagement with suppliers would be geared more to a consideration of business efficiencies, with a view to streamlining existing structures, opening the healthcare environment to competition, and ensuring transparency of information so that suppliers are not surprised by reforms.
The dangers of simplicity
What might the objections be to a more wide-ranging discussion before major reforms? Most probably the logistical problems it would entail. The NHS relies on an army of private sector suppliers, all having an opinion on proposed reforms – and some having aspirations that conflict with others. Then, of course, there is the fathomless general public. An administrative structure to accommodate such a discussion would require some engineering.
The current consultation system is manageable precisely because its boundaries are well-defined: a one-way line of communication to a prescribed deadline. It is, as a source in the DH said, “an efficient, self-contained process”. We might question, though, how its effectiveness can be evaluated. It is customary for the findings of a consultation to be made public (at least in outline), so that interested parties can gauge the responses. But whether this provides an indication of the success of the process itself is debatable.
Should an estimate of success be based on the number of people (or organisations) who responded, or whether they thought their contribution was influential, or whether the reforms that followed the consultation matched their intentions? There are many yardsticks that could be applied, though perhaps the only meaningful one would be an assessment of the outcome: whether the reform under consultation delivered on its promise. In other words, whether the DH got it right.
This, of course, can only be assessed much later, and leads to an analysis of consequences: if the reform is unsuccessful, who is to blame? If the DH acted upon consultation submissions, can a disaster be blamed on those who contributed? That seems unlikely, as the DH alone is responsible for its decisions.
If the current consultation process does not go far enough and a more involved discussion would be impractical, should there be a consultation at all? After all, the DH ministers in the DH – and the key professionals who run the department – are employed to apply their expertise to problems that are beyond the public ken.
There is a legitimate expectation on the part of the public and service providers that those elected or appointed to administer the system should be able to do so. A consultation to take account of wider opinion may be of interest, but should it be axiomatic? If not, it is difficult to resist the suspicion that consultation is a political tool rather than one designed to improve services.
Now’s the time
One thing is certain: those working within the NHS, as well as its external suppliers, are suffering visible battle fatigue from the seemingly endless reforms that began in the late 1990s. Whether or not these reforms have proven to be beneficial to patients seems almost to be lost in the general static of adverse publicity and expressed uncertainty. Also, the possibility of a change of government in the near future must shorten the odds of further reforms.
If unprecedented cash investment will not convert easily into the 21st-century NHS that the Government has promised, other methods of achieving beneficial change must be considered. A more open and transparent process of NHS reform might lead to a ‘hedge-fund’ mentality, ensuring that policy direction takes account of the many disparate factors that, balanced with each other, may serve to mitigate risk.
Just as the increasing involvement of a self-funded private sector is now an accepted part of the delivery of services, perhaps a more inclusive and stable mechanism of NHS reform that turns consultation into discussion, and involves all suppliers, is the only expedient answer.
• The process of public consultation in the development of NHS reforms lacks genuine interaction, and can appear to be a limited exercise.
• The importance of pharma companies as stakeholders in the NHS merits their inclusion in a more serious dialogue.
• The pharma industry is working towards higher-level dialogue with the NHS to build stronger commercial relationships.
• Despite the administrative barriers, more open discussion with suppliers is essential to the success of NHS reforms.
John Chater is Binley’s Editorial and Development Manager. For more information, please e-mail email@example.com or telephone 01268 495600.