Giving patients more choice

pharmafile | April 15, 2004 | Feature | |   

You might be forgiven for having missed the launch of Labour's new policy statement on patient choice, Building on the Best: Choice, Responsiveness and Equity in the NHS, launched by Health Secretary John Reid in mid-December.

Not because it wasn't launched without the usual hype we have become accustomed to, but probably because, like most of the pharma industry, you were up to your eyes trying to deliver on your targets before Christmas.

Why have Labour chosen to drive the 'choice' agenda beyond their bland 2001 manifesto statement "We will give patients more choice"? There are a few schools of thought: Mr Reid says the driver is providing greater equity, which will resonate well with Old Labour.

He said: "At the moment the choice that exists in the NHS serves only relatively few people who can find their way through a difficult system. If we make these choices available to everyone, the ability to find their way through the system will not belong to just a few, but to the many.

Patient choice can help maximise NHS capacity

If patients have more choice, then the NHS will be able to maximise the increased capacity being created. Others see the political importance being put behind this policy as a real push to break up the monolithic nature of the NHS, where vested interest and behind-the-scenes manipulation keep the service rooted in a paternalistic past.

Ray Rowden, a commission for health improvement (CHI) reviewer said: "Failure to get effective public involvement and deliver on choice will undoubtedly compromise the Blair reforms."

Perhaps the answer to the question of why Labour is opening what seems like a Pandora's box to many, can be summed up in an equation: choice  equity modernisation = re-election?

Pandora's box for Labour?

That the choice agenda is a Pandora's box, is undeniable. I cannot remember the number of focus groups that HealthGain has run, involving patient organisations and doctors, where we don't get an impasse on the issue of patient choice.

Doctors who are advocates of best practice and evidence-based medicine (EBM), fall back on their inherent belief that "my patients don't want choice, they want me to decide what's best".

So where is the evidence to suggest that this might be something that will be a vote-winner? Labour presumably did their homework before asking Harry Cayton, the patient tsar, to lead the consultation exercise in June 2003 which looked at answering the following questions:

• What choices do patients/carers want?
• What information do they need to exercise these choices?
• What changes in the system, or how people work, or communicate would be needed?
• How could these choices be made fair for all?

Eight themes – maternity care, children's health, primary care, emergency care, planned care, mental health, people with long term medical conditions and older people were chosen for the task forces to focus on.

Apparently 110,000 people contributed to the consultation exercise, all of whom wanted the opportunity to share in health and social care decisions and make a choice where appropriate – 90% wanted more information to be able to make better choice decisions.

To prove those consulted were 'real people' the document makes much of their desire to "shape the health system around the people, not the people around the system".

What will Labour do next?

Now the listening exercise is over, what do Labour actually intend to do? The first 23 pages of their Building on the best… document are actually best avoided in the interests of your own mental health, unless you are a PR executive seeking a new approach to 'spinning waffle into wool'.

Not until page 24 do you get to any actual clarity on the public consultation exercise that informed the policy development and there are six priorities for NHS organisations on delivering choice, including giving people a bigger say in how they are treated and increasing choice of access to a wider range of services in primary care.

For a document that is determined to make the NHS less patronising, some of its language is surprising. An example: 'Patients are not a cluster of symptoms, but individuals with needs and wishes'.

Interactive choice via the Internet

To make our wishes come true we will have an electronic health aspirations tool, HealthSpace, described in the document as a 'secure personal organiser on the Internet'. This will enable us to record our wishes from 'do not resuscitate' to 'organ donation' to 'no drugs of animal origin'.Healthcare professionals will be expected to be aware and act on those wishes.

During 2004 HealthSpace will start with simple entries and e-mail reminders about appointments and be fully implemented by 2008. Commercial implications mean that people may be more likely to attend chronic disease management appointments, that patient recall facilities are improved and that messages that are communicated through PR campaigns may well be recorded as a desire by patients and therefore filter back to prescribers via the system.

That the optimistic view. In reality there will be big challenges to overcome: secure sites and the NHS's IT development track record are just two.

New customers and new ways of working

New customers working in new ways is a message we have expounded since the NHS Plan launched three years ago. Marketing strategies are now being developed by leading edge companies to expand on their traditional target audience. To create the necessary capacity to deliver the choice agenda, Building on the Best…demands access improvement by encouraging more healthcare professionals to diagnose and prescribe. This direction will accelerate over the next two years.

To date, the facts behind these new customers include: treatment centres carrying out 250,000 operations per year in 80 centres by 2005. There are 23 open to-date, two of which are independent, proving the commitment to plurality of provision. Questions to be asked include how are potentially  interested companies developing  communication strategies for these centres?

Walk-in centres have cared for 1.3 million people since they first started but how many reps selling medicines for acute conditions are calling on the doctors and prescribing nurses practicing in these centres? NHS Direct has taken 4.7 million calls since it began but what does the service need to know about our medicines?

And there are now 1,345 GPs with special interests delivering complete treatment pathways for a range of conditions from Ear, Nose and Throat (ENT) through to epilepsy.

Pharmacists are running minor ailment clinics and will be encouraged to expand their diagnostic and prescribing skills with the new contract in 2004.

PCTs will be asked to encourage new entrants to offer the full range of GP services and specialist services (such as polyclinics) and selected aspects of GP services such as chronic disease monitoring. We can expect these services to be provided in nurse-led clinics, by PCTs or by private providers.

From 2004 we will have NHS Direct Digital providing 24/7 advice and information and this could be worth exploring from a commercial angle. Chronic disease management of asthma and blood pressure in the pharmacy rather than the GP practice is also a common theme in the policy document and one which the visionary pharmacy chains are preparing for.

Opening up commercial opportunities

Probably the most obvious commercial outcome for the industry in the choice document is to be found in the section on improving access to medicines. The headlines include expanding the existing 28 pharmacist-led minor ailment schemes and 75% of PCTs want to develop such schemes.

The minor ailment areas likely to be developed include hay fever, asthma, pain management and migraine.

Expansion of OTC medicines

There will be an expansion of the range of medicines available OTC: the recent proposal to allow simvastatin to be available is an indicator of just how radical the government are willing to go on this.

Of course this proposal is subject to a consultation exercise, but this is not a tide that is likely to be stemmed with a target of doubling the number of changes to legal status to an average of ten per year. What do people in the NHS think about the rhetoric or reality of the choice agenda?

Michael Sobanja, chief executive NHS alliance and director of HealthGain said: "From an NHS perspective, this agenda has enormous potential, but can it be handled by a publicly funded service and PCTs working for populations? They need to consider who has responsibility for implementing it, what it means in practice and how it will change the shape of the NHS.

Asked what it might mean for the industry, Mr Sobanja noted: "The choice agenda may negate the need for formularies – you cannot promote the concept of choice and then have the medicines that are available locally restricted by formularies.

Accelerating improvements in services

Commissioning director for three southern PCTs, Richard Ellis, feels the choice agenda could help accelerate service improvement through the development of care pathways. "We need new partnerships now to work with patients on pathways of care. For long term conditions – diabetes, chronic pain, respiratory problems, kidney disease as well as cancer or CHD – patients will expect to be offered opportunities for choices that are also clinically sound. Commissioners can help turn this into service agreements for patient cohorts," he said.

Mr Rowden said: "CHI primary care reviews in 2003 demonstrated that PCOs and professionals are struggling with this agenda. This topic will be central to the new inspection process from CHAI in 2004."

CHI will be replaced with the Commission for Healthcare Audit and Inspection (CHAI) in April 2004. "All PCOs should consider rigorous staff training to remove fear about choice and equip them to be more proactive," Mr Rowden continued.

Some companies have already seen this customer need. In 2003 Wyeth, in collaboration with the engaging services users network and HealthGain, launched a PCO resource pack to enable PCOs to develop new skills and tools to ensure a more systematic approach to working with mental health services users, which benefited both parties.

Revisiting the earlier 'reality or rhetoric?' question, I think Labour is sincere in its commitment to drive this agenda through as it is key to delivering on capacity, which is the main NHS election issue. That translates into downward pressure on our customer base as seen to be driving it too.

Focus on the big issues

Commercially, there will be market changes, opportunities and threats as a result of this policy direction. Our counsel would be to focus on the big issues in the choice document; the pharmacy agenda will matter in 2004, as will patient involvement in care pathway development, POM to P status and new practitioners specialising in key disease areas with enhanced prescribing ability. Consider whether you want to be a leader or follower in developing programmes that encourage patient engagement and choice.

This year will certainly be he Year of the Patient and those that pay lip-service to it will feel the chill wind of Whitehall  breathing down their necks.

The size of the challenge is emphasised in a cautionary note from Mr Ellis: "We have to be realistic about where we are starting from on choice – some NHS organisations still don't have decent maps!"