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June 2008

Industry intelligence in association with STAR

This month, Customer Insights profiles Omar Ali, a Formulary Development Pharmacist. Successful interaction, it seems, depends on representatives learning a new language.

What is your title?

I am the Formulary Development Pharmacist for Surrey & Sussex NHS Trust. Other titles such as Prescribing Advisers, Pharmaceutical Advisers, Medicines Management and Heads of Commissioning with Pharmacy Services perform similar roles. We have seen an emergence of an evolved and new role, with a variance of titles, all working in a very similar mindset.

What does the role entail?

I have four main objectives. Firstly, the managed entry of New Clinical Entities onto the formulary. Every time a new product comes to market, my role is to evaluate it and provide this as a summary for the Area Prescribing Committee. Our approach is one of ‘Shared Care’, which means the system spans both primary and secondary care. We have moved away from separate hospital and PCT formularies, and now have just one formulary across this Health Economy. Either a new drug is approved across the health economy, or it is not. Current guidance from both the National Prescribing Centre and the DoH are recommending this model. Secondly, I create and write the shared care guidance for new drugs once they are approved onto the formulary. This directs which physicians are responsible for pre-agreed elements of prescribing and monitoring and referral criteria. They will also detail the restrictions that inevitably apply to most new drugs which are successfully added to the formulary. Thirdly, I look at budgetary impact and horizon scanning. This incorporates new commissioning decisions, horizon scanning for new molecules yet to come to market and how best to plan for such eventualities and requirements for new business cases.

Finally I also have to ensure implementation of NICE guidelines within three months of publication (laid down in statute). I collate NICE guidance and evaluate/summarise and present at the next area Prescribing Committee, with a view to how our Health Economy will need to implement. Often, mini-projects will be set up if significant implementation is required.

Describe a typical week?

The main element of my work is issuing prescribing guidance to doctors and other healthcare professionals. These usually detail new Formulary decisions, aspects of recent clinical trials, safety information from the MHRA and any ‘blacklisted’ drugs which are not recommended for use within the Health Economy. I also prepare all new drug applications for the Drug & Therapeutics Committee (D&TC), write a review of each one, and send them out to every member of the D&TC. There is one meeting every two to three months. Membership of these prescribing committees typically comprise of Pharmaceutical Advisers, Hospital Chief Pharmacists, Formulary Advisers, GPs, Consultants, Finance Managers, Commissioners, Director(s) of Public Health and the Medical Director of an Acute Trust. You often get one or two nurses.I am currently working on a prescribing website (www.surreyandussex.nhs.uk/TF) – one of the few websites in the UK where GPs and hospital doctors can view the same prescribing formulary. Apart from the Formulary Drugs, this website also contains prescribing guidance, PDFs on new drugs, downloadable finance forms (PBR excluded drugs) and links to NICE/SMC/MHRA etc.

Who are your main influences?

Through the D&TC I have access to most of the key decision-makers across the health economy. Key influences at a local level are the PCT Pharmacists and the Consultants. In certain disease areas, nurses are very important (ie respiratory nurses, diabetes nurses). Urology is also becoming more nurse-led.

What interaction do you have with pharma?

The majority of interactions I have with the industry aren’t particularly useful. Some companies are beginning to formulate an approach based on my needs, but the majority seem confused as to how I work, what I do and importantly, what information I really require. I see on average around three representatives a week. I probably have around seven or eight who are trying to see me daily. Hence, the first time I see a representative is usually ‘make or break’. I usually make a decision on that first meeting as to whether or not I will see that person again.

What are your needs?

My needs are fluency in prescribing language. For example, I talk in terms of ‘evidence’, ‘cost-effectiveness’, ‘numbers needed to treat’ and ‘hazard ratios’ – representatives need to understand what those phrases mean. The majority will not be able to correctly explain the difference between’ cost effectiveness’ & ‘cost-benefit’ (despite claiming their product exhibits both!) The NHS doesn’t really care about ‘bricks’, sales v market share, call rates, and regions. Pharma needs to get geared up to speak the language that Pharmaceutical Advisers speak. We can’t even agree what ‘evidence’ means! For example, I will say there is no ‘evidence’ for a product, but the rep will say ‘there’s evidence our product is great’ – the reason we disagree is because we don’t have a similar viewpoint on what we mean by the term ‘evidence’.

What could improve access for the industry?

Access is always going to be difficult and some of it will be down to luck. But a lot of it is about working hard, working smart and thinking laterally. For example, there are a lot of public (admittedly boring) meetings that anyone can go which cover NHS Trust/PCT priorities. Often the same key individuals will reappear on other committees that you don’t have access to.

With respect to Pharmaceutical Advisers/Formulary Pharmacists, sadly, some representatives still don’t know their drugs well enough and that, coupled with poor understanding of NHS priorities and local implementation, will lead to a poor quality sales call. In addition to this, many ‘Account Managers’/‘NHS Liaisons/Business Managers’ roles are simply measured on sales! So why isn’t the industry trying to find a better way of measuring these new roles? Challenging I think…

Finally Pharma territory alignment often bears little or no relevance to NHS health economies/SHAs, which in turn correspond to D&TC decisions and budgets. These prescribing decisions often cut across different regions and bricks for a given drug company. When I have tried to be helpful to reps in the past, explaining who/targets to see, they will often reply with a whole host of excuses why they can’t see DrX or NurseY mainly due problems of overlapping bricks/regions/territories. I have seen molecules fail the D&T purely due to geography. In today’s NHS, geography (postcode) is everything. Pharma somehow needs flexibility to allow crossover with effective and timely communication without any interference. I’m afraid your ‘brick system’ is artificial (from our perspective) as it is based on sales and not the NHS.

On a positive note, some companies have set up their systems so that reps can see ANY customers seemingly across ANY territory. True Account Management is not bound by bricks or regions but by decision-makers.

What is your best advice for a sales professional?

Believe in your product.
My brother is a lawyer – he states that a good lawyer doesn’t ask or question his defendant’s guilt. For that indeed is the task of the jury. His role is purely to state the defendant’s case. I used to think that it was similar with reps; purely to ‘defend your product’. Maybe, like my brother, it was irrelevant whether or not you believed in it - you just defended it.

It later occurred to me that when I decide to put a drug onto formulary for the first time, or a GP first comes to prescribe a drug it is a giant but important leap of faith. Evidence, NICE, the cost of 28 days prescribing – that doesn’t give you ‘faith’... Something else comes into play…

I am now firmly of the opinion that “belief in your product” is required anytime an NHS healthcare professional decides to use/prescribe that first script of a new unfamiliar drug. And that ‘belief’ is translated ‘belief’ from the representative. If the rep does not believe in their product it becomes all too apparent, all too quickly, with dire consequences for you and your product and possibly your company. A lack of faith in one’s own convictions is possibly the worst sin you can commit.

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