Engaging with the NHS in 2009
pharmafile | January 22, 2009 | Feature | Sales and Marketing |Â Â NHS, event, healthcare, prioritiesÂ
Delegates arriving at the conference to the strains of Jeff Wayne's War of the Worlds must have wondered whether they were attending a meeting or a set-piece battle with entrenched enemies.
But while the music may have reflected attitudes beyond the walls of the Royal College of Physicians conference hall, there was no war inside the Wellards-TNS conference 'Looking ahead to 2009/10: engaging with a changing NHS.'
On the contrary, far from being combative, pharma's executives exuded an air of cooperation, and seemed determined to gain an understanding of the changes occurring within their customer organisations.
An industry view
Dr Richard Barker, director general of the ABPI, summed up the mood by saying that although pharma is adapting to its changing environment, it has deep-rooted challenges to address.
"The changes we're seeing in marketing are even more profound than those in R&D," he said.
Decision-making has changed for good, the old approach of focusing almost solely on the prescriber has been past its sell-by date for some time, and the emphasis on value for money is an international phenomenon.
The industry has itself made significant changes, including the drive towards joint working. It has accepted value-based pricing in the Pharmaceutical Price Regulation Scheme, and there is a growing understanding that NICE should be treated as a customer rather than as an adversary."
But despite the progress that has been made, serious problems remain, including the post-credit crunch economy and the need for pharma to find ways to engage with NICE in order to reach an understanding that, while cost per quality-adjusted life year (QALY) is a good measure, other factors should also be taken into account.
The issue that worries Barker most is a continuing distrust of the industry among NHS staff. Research shows that PCT staff feel they cannot trust pharma, and industry representatives report that PCT staff are generally very suspicious of the industry.
Pharma's access to decision-makers is also limited by the attitudes of GPs: "Some 87% of medical representative appointments with GPs are cancelled," said Barker, "and many doctors won't see reps at all."
Pharma needs to establish new relations with the NHS, and a key to this will be joint working on issues ranging from health promotion to problem-solving. Now that service quality is firmly on the NHS agenda, finding ways of helping NHS organisations in this area would allow the industry to rebuild trust.
It was announced that an ABPI working group has revised the Code of Practice guidance after members reported that it placed unnecessary restrictions on joint working, and this would be published shortly.
After the credit crunch
Professor Chris Ham, professor of health policy and management at the University of Birmingham, offered his analysis from a political and economic perspective, while Nigel Edwards, director of policy for the NHS Confederation, explored the significance of the Darzi report.
Ham had a stern warning: after the credit crunch, things are going to get tough. "In fact, the problems in banking and the economic difficulties that follow will be much more important than any change of government," he said.
In any case, there is little chance of a radical alteration in direction even if the government does change. "If you have a Labour government providing choice and rewarding hospitals according to their performance," he asked, "what scope is there for a Conservative government to do anything very different?"
The opposition has laid out points of difference in its policy, including a stronger focus on public health and on outcomes instead of targets, and the idea of an NHS board that will place the health service at arms-length from politics, but these are really nuances.
NICE is supported by both Labour and the Conservatives, and in any case, Ham believes there is another, more cynical, reason that NICE will stay: "Politicians will always want to have a body like NICE that they are not directly in control of to take some of the flak around some of the unpopular decisions. I don't think the industry should expect NICE to go away," he concluded.
Edwards argued that the Darzi report is consistent with existing policies, and has actually brought little that is surprising or very new. The big question is whether it includes enough to bring about real change.
Earlier proposals have lacked levers to ensure they came into effect, but this is different. "Darzi brings together all the mechanisms for change that you could possibly try, other than coercion by force," he said.
"Every single policy lever is in this report: markets, regulation, managerial methods, developmental methods, network type methods." Will it be enough? If not, the reason is likely to lie with leadership.
The big opportunities are in contributing to prevention strategies, working with the NHS to develop policy, information systems, care pathways and commissioning, and helping practices to implement quality accounting and achieve targets.
The NHS view was powerfully expressed by Sophia Christie, chief executive of Birmingham East and North PCT, and Dr Peter Brambleby, director of public health for North Yorkshire and York PCT and North Yorkshire County Council.
World class commissioning
World class commissioning, Christie said, is a paradigm shift that places emphasis on return on investment, and NHS managers are thinking much more about health gain based on information about disease, investment in services and outcomes.
It will lead to huge changes in the NHS, she argued, and revolutionise expectations of what the health service should deliver.
Health inequalities are an issue that is particularly close to the heart of health secretary Alan Johnson, and also to inner-city PCT chief executives like Christie. In her area there are wards where infant mortality is the same as in Pakistan. There is an area where men's life expectancy increases by six years in a distance of just six miles.
And while 50% of children in her area are overweight or obese and just 20% are a healthy weight, the rest are malnourished. When world class commissioning talks about adding years to life, what it often means is adding years to the lives of those in the most disadvantaged communities, she said.
"We can't any longer just look at the big issues across the PCT," she said. PCTs have to look at the detail of the problems of different communities within their areas and decide what will be the best interventions to deal with them.
This brings big challenges in information management and in prioritising investment, she said, and will mean that money will not always be spent in ways that hospitals or pharma want.
World class commissioning is also about adding life to years, including the kind of life people should have in their last years:
"At the moment, about 90% of what we spend on an individual is spent in the last six months of life, and we spend it for them to have an awful time, with unplanned admissions, for them not to know what's going on, for them to be away from home and for their carers to be feeling guilty."
It would be much better to invest some of that money in providing support at home, to allow people to have a safe, pain-free, dignified experience in their own bed with their loved ones around them.
But that is only one anomaly among many. Another is that, across all specialties, 70% of first outpatient appointments end in no further action. Yet another is the decision to give Herceptin to patients with breast cancer. This is the wrong priority, said Christie, visibly angry that the money was not spent on a much bigger problem in her area the huge number of deaths due to cardiovascular disease in men aged 5570 years.
Most attention has to be paid to primary care. "If we really want to make a difference, we have to focus on how we're commissioning primary care.
"If people aren't getting the basic support from their GP, accurate recognition of when they've got something wrong with them and rapid access into secondary or tertiary care, then we haven't got a hope in hell of making a difference in health outcomes, or of giving them a decent healthcare experience."
If the NHS is going to be doing things differently, it will need different people. Christie described her PCT's joint working project with Pfizer Health Solutions as fantastic: the assertive care project over the telephone has reduced health service utilisation by 50%, demonstrated overwhelming patient satisfaction and shown significant improvements in clinical indicators.
The pilot included 2000 members over two years, and the scheme is being extended to include 27,000 members over the next four years.
New techniques to understand local needs
Dr Peter Brambleby, of North Yorkshire and York PCT and North Yorkshire County Council presented aspects of his work as director of public health for the region. He has used the techniques of social marketing, programme budgeting and marginal analysis to understand the fine detail of the health needs in his area.
He began by explaining that social marketing simply means needs analysis, programme budgeting uses data to set objectives and inform future spending, and marginal analysis assesses changes in costs and benefits when individual resources are increased, reduced or redeployed.
"We have to make an informed case for change and improvement, and we have to carry our clinical colleagues with us," he said. As an example of this approach, Brambleby said he and his colleagues are changing the way they feed information back to GPs.
"We give various pieces of feedback to GPs – the finance director talks to them about their budgets, medicines managers talk to them about their prescribing habits, and the performance director talks to them about their outpatient referrals."
But he and colleagues have agreed that GPs should be given much more coherent feedback on how they are doing in relation to other GPs in their area. The GPs will then be challenged to explain the variations that emerge, which may be due to deprivation or an older population, or to aspects of practice.
"Asking questions we've found is effective – simply going to the GPs with the right answers doesn't work, but if we go to them with a question, we're much more likely to get a useful answer. Until we ask new questions, we will keep getting old answers."
THE VIEW FROM NICE
NICE's Dr Carole Longson told the conference that there is evidence the industry's view of the institute has improved.
Dr Longson, director of the NICE Centre for Health Technology Evaluation said research suggests that a fraction of the industry now welcomes NICEs health technology appraisal role.
She reminded the audience that NICE has only failed to recommend 5% of the drugs that it has appraised.
NICE regards its relationship with the industry as key to its effectiveness, and is working on issues it has identified, including the question of the evidence it requires for its appraisals.
"We came to realise quite early that many clinical development programmes do not capture the evidence necessary for health technology appraisal – and that's a problem for everybody, not just industry.
"So we decided to close the evidence gap by bringing in earlier engagement with the pharma industry.
"We've done a pilot study that worked extremely well, and we are now implementing that programme."
NHS evidence
Longson also talked about her organisation's evolving plans for the new clinical evidence web portal, NHS Evidence.
NHS Evidence will be a kind of Google for medicine, and will kitemark high-quality sources of information through an independent accreditation process, she reported. It will be principally designed for NHS staff and developed in conjunction with clinicians and commissioners, but will also be available to patients and the public. It will also highlight ongoing clinical trials and make primary research evidence available for specialist searching.
Gavin Atkin is a freelance medical and marketing writer and editor. He can be contacted at gmatkin@gmail.com.
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