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NHS Trust - can pharma win it?

Published on 01/02/05 at 11:02am

Sometimes pharma companies could be forgiven for thinking they are in a catch-22 situation. On the one hand local NHS trusts, which are already overstretched, are crying out for assistance in delivering healthcare.

Companies should be only too willing to accept calls for help - after all, it is their products that are being used and it is often in their best interests to know that their medicines are being utilised to their utmost potential, not to mention correctly prescribed.

On the other side of the equation is the fact that the closer companies get to the NHS, the more negative publicity they seem to attract. The majority of the public still see the doctor as the prescribing king, and invariably view any partnership between industry and health service with suspicion.

Transparent and ethical  alliances

Take medicines review nurses, for example. The concept of a company employing nurses to perform audits and assist GPs in doing treatment reviews is nothing new but that hasn't stopped national newspapers breaking the news this year, implying that the nurses are being paid to encourage patients via the schemes to use their employer medication.

The industry of course refutes this suggestion but isolated cases, such as the GSK incident last year, do not help the cause of pharma companies.

The British number one had its knuckles rapped after one of the asthma-audit nurses it sponsored made unauthorised changes to a GP repeat prescription database, adding respiratory drug Seretide to all but two patients' treatment regimens. The ABPI Prescription Medicines Code of Practice Authority (PMCPA) noted that GSK's instructions for carrying out the audit had not been followed.

Health policy analyst Ray Rowden has no problem with the concept of medicines review nurses, saying: "It's evident that the UK has a hard-pressed general practice service, and often a practice nurse is a great resource. The problem is that the practice nurse has to be a 'generalist' by definition and is therefore going to be covering many different disease areas."

He does, however, accept that in the case of the GSK asthma-audit nurse, what occurred was "unacceptable and probably a breach of the Nursing and Midwifery Code of Professional Conduct".

Dynamic win-win partnerships

Rowden goes on to explain that the advantages of having the support of a designated resource for a period to help improve clinical practice are obvious: "If you've got an expert nurse in there who is focused on one disease area that can help a practice review its patient population and get a better outcome, it shouldn't matter that they're employed by a pharma company. Lots of very busy GPs are appreciative of this kind of support. As long as it open, ethical and transparent then it's going to be viable but if any of those three things are compromised then it's ineffective."

Now the industry's dealings with the NHS are progressing beyond the simple sponsoring of medicines review nurses and moving into the formation of dynamic 'win-win' partnerships to improve the provision of healthcare.

Aventis' Insulin for Life programme, created at the University of Warwick, currently provides training to local experts to go back to their patches and in turn 'up-skill' their peers, such as GPs and practice nurses, in the intensive management of type II diabetes.

Pfizer showing the way

Last February, Pfizer announced what many herald as the most advanced NHS partnership scheme so far.

Linking up with Haringey Teaching Primary Care Trust (TPCT) in North London, the global number one has set up a chronic disease management programme based around 600 patients.

The project also aims to investigate the benefits to patients of a US-style telephone-based and technology-supported disease management solution and whether it can reduce the demands on local health services.

There are currently an estimated 17.5 million people in the UK suffering from long-term chronic diseases such as heart disease, diabetes and depression. It would be fair to say that Haringey has its own specific problems: when the scheme was announced, the area had a mortality rate from heart disease 33% higher than the London average.

The 12-month pilot project, Team Health, is intended to help patients with coronary heart disease, congestive heart failure and diabetes to better manage their conditions.

Medical community sceptical

But the medical community is sceptical about such schemes. The British Medical Association has actually called for new ethics standards to be agreed immediately "to protect the independence of doctors and patients".

Speaking to the Daily Telegraph in September last year, Dr Charles Simenoff, a member of the BMA's prescribing committee, and a general practitioner in Manchester described the Haringey project as bordering on the unethical.

"If these care managers see that patients aren't being treated with Pfizer drugs then they might put the suggestion in patients' minds that maybe they should," he said.

Speaking to the Daily Telegraph, Dr Richard Nicholson, editor of the Bulletin of Medical Ethics called for an "immediate public debate" on the Haringey project and accused the DH of being a"happy to work with drugs companies regardless of whether this is in the long-term interest of patients". 

But do companies really deserve such close scrutiny? Despite occasional transgressions which rightly invoke the wrath of the PMCPA (like the GSK case mentioned above), the industry on the whole prides itself on its ethical conduct.

Eric Hansen, head of PR consultancy ECCO Healthcare says: "The key to success is a strong definition of the goals of the programme, agreed by the parties involved. There can be no room for opportunities for abuse of the arrangement and most problems can be avoided if there is clear communication of the project and its objectives to the PCTs involved and the local salesforce for the pharma company."

Hansen suggests that this should include a list of dos and don'ts to ensure that the company is not perceived to be 'meddling' or influencing sales through the programme.

Over the years, as the NHS has evolved, the industry has realised that it needs to remain at close quarters with health professionals and is becoming increasingly innovative at doing so.

How will pharma companies benefit?

The Haringey scheme has drawn praise from other quarters of the health industry which see it as much needed pioneering non-product related assistance in public health management. Pfizer has emphasised that the project in no way demands the prescription of its own heart drugs and the final say on which drugs patients receive remains with the NHS doctor. But if this is true, then the question needs to be asked: What is Pfizer getting out of this?

"In terms of financial benefits, not a great deal in the short-term," said Rowden.

"I would think Pfizer is a big enough outfit not to have to worry about a patient population of 600."

But he adds that in the long run, if Pfizer's project can prove it gets better focused prescribing, more patient information, better patient self-management and more effective use of pharma products then that will stand not just the company, but the industry as a whole, in good stead for future NHS partnerships.

"If the add-on that the pharma company brings to the table proves to be a resource that takes the pressure off the GP and transfers it somewhere else then that will be very welcome," he explained.

"You can see why Pfizer is doing this - if you can demonstrate a true partnership between the PCT and the pharma company in improved chronic disease management, you're playing to the government's agenda of greater patient choice, and you're probably getting better value for money out of your prescribing budget," he says.

"What is more, if you can get more effective practice going in a patch and can prove the model can be done in a way that doesn't compromise the ABPI Code of Conduct or the ethics of the NHS then surely people are going to be impressed."

Proactive patient-centred care the target

Pfizer insists that a move towards patient-centred care is at the heart of the Haringey scheme.

The recently announced Public Service Accountability Agreement (published by the DH) has made it clear that over the next three years the NHS is determined to become more proactive in the provision of services and interventions that help to reduce the incidence and complications of long-term conditions. Therefore, a different service model is required from the traditional reactive service that has been the trademark of the NHS.

Pfizer spokeswoman Sally Goodenough says that over the last two years the NHS has come to recognise the importance and benefits of being more proactive in the management of the risk factors that contribute to the morbidity and mortality associated with conditions such as diabetes, heart failure and heart disease.

"Pfizer is investing in new ways to achieve better outcomes for patients," she said. "The purpose of this programme is for a PCT to explore how it can better implement changes that deliver a more effective and efficient healthcare service for its local community. The partnership enables the NHS to make the most of good practices from the private sector and gain access to a wealth of worldwide healthcare knowledge and expertise."

Care managers

The scheme also employs care managers ('health coaches') to reinforce the care provided by GPs; they are similar to medicines review nurses but are actually registered employees of Haringey TPCT.

Pfizer is keen to stress that they work to national and local guidelines and that all recommendations in the programme have been formally approved by the independent medical advisory panel.

"The care manager's role is to motivate, support and encourage patients to better understand and manage their health," explains Goodenough.

"Through this approach it is more likely that the patient will take the treatment chosen and prescribed by their doctor - it is well known that many patients expose themselves to unnecessary and avoidable risk by not using medicines as directed by their physician."

Of course, new partnerships take time to gel and the different mindsets of PCTs and pharma companies means that procedures need to be thought out rigorously in advance.

"There are of course obstacles to overcome in order to achieve an effective working partnership but Pfizer has followed a few basic rules," says Goodenough. "It's important to first establish a proper and transparent governance structure and in this particular case also have the full approval of the local ethics committee."

She adds that the company set out clearly its aims and objectives, outcomes and deliverables, as well as funding and resources.

"As well as being clear about what the partnership is about, we have also been explicit about what it is not about," says Goodenough. "The primary focus of working in partnership is to improve patient outcomes."

Co-ordinated PR campaign important

An added complication is the need for a co-ordinated PR campaign which provides timely information about the project, a joint response to queries as appropriate and, where possible, meet requests to make presentations at healthcare conferences.

"The activity is conducted very much as a partnership and the communications team at Pfizer and Haringey TPCT work together," says Goodenough.

"Much of the focus to date [of the PR work] has been explaining what the project involves and how all the relevant stakeholders are working together. The project is now up and running so the next stage will be to talk about the results and outcomes for patients and Haringey TPCT - an evidence based approach is essential for communications around this type of programme."

For his part, Rowden sees no major potential problems or pitfalls in a pharma company working effectively with the NHS.

"One partner is selling products to people that need to take them, and the other is trying to provide that in the context of wider health provision. After all, we know that chronic disease management has been badly done in many cases in the past and that there is room for improvement," he says.

Audit provision needed

However, he adds that one thing he would like to see in the Haringey partnership is provision for some solid, independent audit valuation.

"In any project where both parties have interests which might be vested, the sensible protection would be to instigate some form of external scrutiny," he says.

It remains to be seen to what extent other companies will follow Pfizer's lead, but as long as the Haringey pilot comes up with some positive results later this year, then more discussions will most likely take place between big pharma and health authorities or hospital trusts across the country.

Rowden believes that while companies have made significant progress in listening to the voice of the patient, there is still some way to go before they can boast an effective partnership with the NHS in general.

"I suspect that too much of the industry is still very traditional in its approach," he says.

"Companies are still whacking out teams of reps to get through the doors of GPs and key opinion leaders in the hospital sector and it's not realising that it has now got to talk to much broader audiences in today's world, such as nurses, therapists and pharmacists. I get the impression that in terms of NHS partnerships, the industry as a whole is still in pretty much the same position and it has to realise that the world is moving on and moving on quickly."

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