Delivering mutual benefit from NHS and Pharma partnerships - grasping the opportunities

What are the benefits, drawbacks and practical problems in forming and implementing joint working partnerships for the NHS and the pharmaceutical industry? Does the industry believe partnership with the NHS is a nicety or an essential part of its business? With the help of a panel of eminent speakers with a wide range of experience and expertise this half-day PM Society conference, held at the King's Fund in London, set out to discuss the best way for the industry to engage with the NHS going forward, particularly in the light of the changing commissioning arrangements in the NHS.

Ivor Eisenstadt (PM Society) opened the meeting by outlining that partnership working is central to the ABPI agenda. A growing number of joint initiatives are now under way. A recent survey of pharmaceutical advisors and medicines management advisors working within PCTs show that these joint working arrangements cover a whole range of areas, such as developing care pathways, implementing clinical guidelines, patient education programmes and educational support. They are also taking place across a wide range of PCTs and in numerous different disease areas. The most popular programmes are in smoking cessation, diabetes, COPD, asthma, mental health and CHD. Conversely however, the survey reveals that many PCTs have no experience of joint working or partnering with the industry at all and many believe that in the current climate it is more important to address basic medicines management in the new NHS.

Meeting chair Roy Lilley went on to stress that history is currently being made in the health service. Many people will find the changes uncomfortable and at such a difficult time it is important to concentrate on initiatives that are known to work well, in Roy's view. Partnerships between the NHS and the pharmaceutical industry have been shown to work. Sometimes they are tentative and can be difficult, there are sometimes suspicions and they are sometimes awkward, but there have been some spectacular successes.

At this turbulent time it is important for the industry to cherish its address book and keep in touch with the customer. GP consortia are the future, though how many consortia there will be is unclear at the moment. Whatever happens the people on the ground are the industry's greatest asset, and retaining existing relationships is vital to be able to take partnerships forward.
 

The changing dynamic in the NHS

First speaker Sarah Phillips (Head of Health, Ipsos MORI) examined the changing dynamic in the NHS from three points of view: the relationship between patients and GPs, the relationship between GPs and the NHS and the relationship between the NHS and the pharmaceutical industry.

Regarding the relationship between patients and physicians, a new type of patient is now sitting in the doctor's waiting room. These patients are knowledgeable. With high expectations and with access to far more information than ever before, they have a much greater awareness of the treatments available. The physician must deal quite differently with this type of patient, who can be quite intimidating. This new dynamic means that the paternalistic relationship that used to exist between physicians and patients is completely changed. While it is good that these 'new' patients are potentially more compliant and better controlled because they are interested in their disease and its treatment, it is not so good when they have the information wrong.

Driving this change in patient attitudes is the Internet. Patients have always discussed their health and wanted to share information but what is different in the landscape now is access to web 2.0 platforms that allow patients to share their experiences on a much larger scale. It is no longer a case of people reading the Daily Mail. Patients are out there in the ethernet, and not just younger people with access to iPhones, but also retired people who have time to search for information. And the passion to be in control of your own health increases the more you know.

Sarah went on to emphasise just how passionate the public in the UK is about the NHS. In August 2008, 63% of the general public agreed that Britain's National Health Service is not just good but the best in the world. The public also want to maintain the NHS in the form that they currently see it. However, when asked their views on the new NHS agenda, very few people really understand what the recent White Paper is about. In general terms they strongly support the idea that more control needs to be given to doctors and nurses than to managers and politicians. So while the public are unclear how the changes to the NHS will affect them, overall they believe that a policy change will give more power to clinicians at the local level rather than the bureaucrats.

However, Sarah cautioned that the NHS changes will mean that primary care will be in the firing line. The debate about how healthcare budgets can be most fairly shared out is now one for the GP rather than the PCT. GPs need to understand that, up to now, the PCTs have been the lightning rod bearing the brunt of any criticism. Taking the PCT away means that the GP will now face that criticism. Everything will become very personal and will change how the public perceive the primary care physician.

The responsibility for maintaining public satisfaction and feeling of positivity towards the NHS will therefore rest with GPs. If the public fail to understand these challenges and their expectations are not managed, there could be a backlash. Sarah believes that public engagement and understanding of the patient, as the ultimate customer, will be crucial.

How might this dynamic become one of the solutions in joint working? The ABPI/Department of Health Best Practice Guidelines for Joint Working note that the benefits that joint working with Pharma could bring to patient care and the difference it could make to their health and wellbeing are clearly advantageous. Joint working puts the patient and patient outcomes at the centre but the relationship between the joint working partners has to be transparent for it to work.

Sarah explained how St Helen's PCT, alongside the QIPP agenda and in partnership with GSK, wanted to build patient pathways and treatment protocols to support their management of COPD patients. This included a bespoke training programme to upskill nurses, prioritisation of patients for review, monitors in clinical consulting rooms and a survey to measure the patient experience and the quality of the process.

The total number of patients reporting an improvement in their understanding of how to manage their symptoms was 50%, so patients felt more confident in their ability to deal with their condition. The vast majority of patients (88%) were fairly or very satisfied with the quality of service they received at their lung check-up (the PCT had identified specifically that there were issues with this check-up prior to the joint working intervention). This St Helen's example shows that improvements can happen and that these can be measured. However there is not one simple solution that can be implemented tomorrow.

In summary, Sarah stressed that the challenges in joint working are the massive changes currently ongoing in the NHS, the change in the patient's expectation of the physician, and the fact that GPs will move to the front line in answering those patient expectations. The question is whether bringing in a different dimension via a commercial partner can help with training and facilitation. And ultimately it remains to be seen how joint working will interact with the new GP consortia.
 

Discussion
Roy Lilley asked about the scalability of joint working, and how we are to get traction to make this kind of initiative work. Sarah's view is that with up to 500 GP consortia there will be less traction because it will be harder to interact. Setting up a joint working partnership requires a lot of negotiation and transparency and this will be hard to achieve 500 times over. The challenge for Pharma is how to scale these programmes up without having such an administrative burden that any initiative is killed before it starts.

Public health in the new world – What relationship could a 'Medical Officer of Health' possibly have with pharmaceutical marketing?

Public health is the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society. Chris Packham (Director of Public Health in Nottingham City PCT) added that the wider determinants of health are gender, geography, sexuality, socioeconomic group, disability, age and ethnicity.

In the future, GP consortia will commission healthcare, cover clinical audit and effectiveness, manage area-prescribing committees and implement NICE technology appraisals and guidelines. However GP consortia will not undertake a wide range of functions that currently come under the remit of the Public Health Service/Local Authority (such as health protection) or Regional NHS Commissioning (such as specialised services, cancer networks, and clinical governance).

Chris stressed that local authorities and public health services are likely to be responsible for pharmaceutical needs assessments (which remains statutory and will require public health and community input) and in supporting and encouraging further development and involvement of community pharmacies in local health improvement programmes. Not just patients will scrutinise GP consortia - elected members of the local authorities are increasingly anxious about being handed performance management of life expectancy with limited influence over the commissioning of NHS services required to achieve those health gains.

Nottingham is the fourth richest English city, but also amongst the most deprived:  health inequalities are common in all large inner cities. Many problems dominate and as in many large city areas, alcohol-related disease is becoming increasingly important.

Work with Pharma is extensive locally. The INFORCE initiative (breathing new life into COPD in Nottingham) was a project similar to that in St Helen's and has worked well. In coronary heart disease the 'Happy Hearts' health improvement programme begun five years ago in partnership with seven pharmaceutical companies – as a consequence CVD health checks are far advanced locally.  In diabetes there is an ongoing project where the predominant pharmaceutical involvement has been in educational activity for practices and patients.

Based on these three partnership projects in Nottingham, the NHS has learned that for joint working to add value, it is vital to have good buy-in from the top down in all organisations concerned, to ensure the right people are around the table who can see the strategic advantages even if short term individual product sales are less affected, and to face up to the elephants in the room such as how to handle PCT prescribing guidelines. Our experience was also that the NHS significantly underestimated the project management involved and the effort required to win over GPs, poor quality data recording issues, and that we nee dto pay meticulous attention to staff training. Conversly, industry was less good at working with deprived non-standard communities, and some partners missed the opportunity to engage senior enough personnel to spot and develop longer term benefits.

Going forwards, the essence of successful commissioning dictates that good public health skills will be needed in the future. NHS rationing (in the shape of prioritisation) and the balancing of cost-effective interventions will be a challenge for GPs without such skills. As consortia will be expected to deliver much of this capacity from private sector input, Pharma may want to think about future public health skill capacity itself.
 

Discussion
Roy Lilley noted that it is legislation that makes the difference in public health, e.g. seat belts in cars, crash helmets, health and safety at work and more recently smoking in the workplace. Asked if the future of public health is in persuasion or in legislation, Chris believed it to be both, though probably mostly in persuasion. In the short term, the role of public health is to help other professionals. Chris conceded many aspects of health promotion are poor, noting that traditionally only one in twenty people respond to health promotion initiatives. If health promotion is better targeted, with better messages and using social marketing, it can be one in three. Pharma could utilise its existing skills in this area much more widely with emerging public health and consortia systems.

QIPP in a cold climate

Neal Maskrey (Director of Evidence Based Therapeutics, National Prescribing Centre) qualified as a doctor in 1975 when the NHS felt like it was held together with Elastoplast and string. It still feels that way today, in Neal's view. The NHS is a complex organisation and necessarily somewhat ad hoc. Nevertheless, it is beloved by almost the entire population, and widely held to be one of the great creations of civilisation.

In terms of partnership working, Neal agrees that the projects already discussed have worked well on a local basis, but questioned whether they will scale up to a national level, citing as an example UK PharmaScan. Neal was on the Board for this project, signed up to by the Department of Health and the ABPI, whereby Pharma companies committed to putting information on drugs in development onto the confidential UK PharmaScan database (run by NICE). The aim is to allow the NHS to plan ahead for new medicines in the pipeline. UK PharmaScan went live in June, but very few medicines in development have been added to database so far.

Health spending rates grew steadily at about 7% over the term of the last government but since the 1970s percentage real-term increases in NHS expenditure have fluctuated considerably, making it difficult to plan a service. Neal stressed that the current situation will get tighter, despite protection for the NHS, with growth limited to inflation at best. With demographics changing and technologies continuing to improve, a standstill or a 1% or 2% growth will feel like a 5% cut year on year.
 
One of the other drivers is patient choice and voice - an international social trend not limited to the UK. 'No decision about me without me' is currently the key phrase. But data show that about one-third of patients want the healthcare professional to make the decision for them, one-third want discussion and a joint decision, while one-third make the choice for themselves. Low concordance rates with some long-term preventive treatments could reflect the difficulties in the consultation – doctors are used to making decisions for the patient and do not feel particularly skilled in joint decision making.

With regard to staff morale in the NHS, Neal emphasised that the situation has changed. It used to be that pay was not good in the NHS (for some ancillary staff it was frankly appalling) but jobs were for life, with a good pension and excellent esprit de corps. All these aspects have changed, to a greater or lesser degree, and working in the NHS feels very different now. There is a great deal of uncertainty.

A key element going forward is to reduce the unjustifiable regional variations in clinical practice. Neal cited the example of treatment of women with uncomplicated urinary tract infections. According to the Health Protection Agency treatment should be three days' trimethoprim or nitrofurantoin as there is evidence from a Cochrane review that longer courses do not give any better cure rates. The same review says the adverse drug reactions are 17% lower with a shorter course (less nausea, less vomiting and diarrhoea, fewer skin rashes and fewer cases of vaginal thrush). The cost savings of shorter courses are minimal so this is entirely a quality agenda. The variation between PCTs is considerable, with some achieving 66% short-course prescriptions and some achieving only 14%.

There are at least 30 or 40 such disease areas where prescribing costs could be decreased without affecting the quality of care. We need to work at achieving these quality and productivity savings, so that these savings can be invested in areas like oncology drugs. It is about improving management of chronic conditions at lower cost while making capacity for new technologies which are currently underused. In Neal's view the way forward is collaboration. He quoted Atul Gawande, who states that: 'Better is possible. It does not take genius, it takes diligence, it takes clarity of purpose, it takes ingenuity, it takes a willingness to try.'
 

Panel discussion
Roy Lilley noted that there are only 150 PCTs and yet there are huge variations in prescribing. So what chance is there for Pharma when there are 500 GP consortia? Neal Maskrey believes that Pharma will need to interact with the same skilled and motivated people as before but they will be working in different organisations.

Phil Krzyzek (Quintiles) asked about the uptake of joint working across PCTs and the differences in thinking between Pharma and the NHS. Roy Lilley agreed that the NHS want everything for nothing and Pharma want to make a profit. Sarah Philips has no data to prove that view but clearly there is a collision of cultures between private and public sectors - their interests are different but complementary. Sarah believes the answer is transparency with regard to what each party wants to achieve with joint working. It will only work if everybody has the same level of confidence. From the Pharma perspective, this means a lot of work to actually win the NHS over. And if there are to be 500 GP consortia this is potentially a barrier.

Neil Copping (Inform Pharma) questioned whether partnership with the NHS is just a way of Pharma securing long-term income at lower cost without any incremental gain in public health. Chris Packham felt that it is not difficult in the world of evidence-based medicine to make partnership a win-win situation, especially if it is done one a large enough scale. Once the model is in place it can be rolled out using toolkits, etc. The difficult part is developing the model.

Gavin Egan (BMJ Publishing Group) mentioned a conference recently run by the BMJ in response to the White Paper, predominantly on GP commissioning (with a mixed audience of GPs and practice managers). The mood there was that much of the decision making on procurement and commissioning will be taken on by practice managers. It is therefore wrong to assume that the GP will necessarily make the decisions. They will actually be reluctant to do so. Neal Maskrey agreed, noting that GPs clearly feel they need help as these tasks are more complex than they first appear. Chris Packham believes it is right to involve GPs. However the management support required is not at the practice manager level. Negotiation with large teaching foundation trusts will require serious skills and experience, covering legal issues and ethics, etc.

Neal Maskrey felt that much of this is confounded by the headlines. It is actually about managing growth and capacity for an increasingly elderly population. Demand management is important. Because 70% of NHS spending goes on staff costs, saving money involves serious reductions not just in back office staff but also some frontline staff. Roy Lilley pointed out that the NHS supply chain will be privatised - 45% of its management structure will go and with it the organisational memory. Managers are condemned as being the cause of all the problems and yet management costs represent only 3% of the total NHS total budget.

Chris Packham felt that about half of the £20 billion savings will come from better housekeeping and better back-office efficiency. At some point however, we will have to be honest about rationing and prioritisation, e.g. how much to spend on cancer, and whether this should be spent on primary prevention or tertiary care. Chris believes the industry should not be afraid of helping to bring that debate out into the open.

With regard to the use of generics rather than branded products, Neal Maskrey stressed that the new paradigm is that the NHS will need to reduce variation in management to attain the best available quality care for chronic diseases, thereby saving money within the drugs bill to create headroom for new technologies.

As to whether joint working will hasten the decline of the medical representative and whether GP commissioning will be the change that allows account management in Pharma to become a reality, Chris Packham stressed that GPs are still independent contractors and it cannot be assumed that they will all fall into line. They may well want to prescribe outside formularies.

Louise Brant (Sanofi Aventis) noted that when Pharma tries to suggest collaboration the doors are often closed. Chris Packham stressed that Nottingham had the advantage of having on board one of the three ABPI national personnel set up to do this kind of work. Once the umbrella organisation was in place and pharmaceutical advisers and NHS people were happy to under this, the ABPI person managed the relationship with individual companies, making working together much easier.

Sarah Philips reiterated that the changes will have a major impact on the patient's relationship with the GP. One of the major issues is building trust between the industry and the NHS and the GP. A GP needs to develop particular skills in order to manage the situation when he or she has to refuse a patient a particular treatment. It is a different skill set requiring training, a facilitation that the commercial sector can provide.

Paul Midgley (NHIS Newark Beacon) wondered if rather than being medicines police, medicine management could be advocates for the right medicine in the right place at the right time to prevent inappropriate hospital admissions. Neal Maskrey agreed, but noted that preventing someone going into hospital does not necessarily saving any money, because the nurses and doctors are still being paid and the building is still being heated, etc. Preventing admissions helps with capacity, but unless the staff and the number of hospitals are reduced, no real cash is saved.
 

Value-based pricing and formularies in the new era

Every specialty wants to use the newest and best drugs rather than generics. As has been said, cutting staff will only save a small proportion of the £20 billion savings required of the NHS. The rest has to be found via prescribing or redesigning services. Omar Ali (Formulary Development Pharmacist with Surrey & Sussex NHS Trust) outlined how, in this climate, value-based pricing means that NICE will set the price of a medicine so that everyone can use it.

A few years ago the Office of Fair Trading noted that the cost of certain drugs appeared out be of step with patient benefit. The idea behind QIPP (Quality, Innovation, Productivity, Prevention) was to look at why drugs are used and what benefit they are to the patient. Over time drug companies redesigned their trials to reflect the QIPP agenda and the theory was that ultimately pricing would be related to patient- and payer-related outcomes. Also out of NICE has come the Care Standards Commission, with quality indicators all based around outcomes. Three Standards have so far been published - on DVT, stroke and dementia - and more are in progress.

The overarching mantras are to prevent people dying prematurely, enhance quality of life, and help people recover from illness. Even if people are unwell the aim should be to speed up their recovery and move them out of hospital. Omar agrees with Neal Maskrey that preventing someone being admitted does not necessarily save money to the Trust provider but it does reduce unscheduled care bills to the commissioning group.

With regard to the patient experience, patient reported outcomes are becoming more and more important, as is safety (of the environment and of medicines). Omar believes we will not move away from indicators, but they will be based around improving outcomes rather than meeting targets. This is where the pharmaceutical industry can be involved.

Bringing a drug to market costs the pharmaceutical company money - to undertake research, conduct the increasing number of trials required by the regulatory authorities, demonstrate cardiovascular safety, and undertake post-marketing surveillance. The argument is that once a drug is licensed the company has very little time to recoup these costs. But all this has nothing to do with the outcome achieved for the patient. The government are therefore suggesting a new roadmap based on outcomes rather than what it costs the company to develop the drug. But what constitutes value? What constitutes an outcome? If you prevent a stroke, what about the carer and the cost of the carer, and how is that built in to the cost of a drug?

The other argument from some companies is that they will no longer invest in this country (some US companies do not want to come to the UK because they do not understand NICE, SMC, HTA). So the UK government (as part of trade and commerce) are working to ensure the UK economy does not lose out.

Omar would argue we have always had value-based pricing via NICE, but the new element is that the costs will change. The tariff price for COPD admission is over £3500 so an inhaler that prevents admission would be good value. But studies show that after four years in 6000 patients an inhaler versus placebo showed no difference in FEV1 or hospitalisations. The inhaler also made very little difference to the patient. NICE does in fact endorse the drug concerned, but in the new world of value-based pricing the cost of this drug will not be ten times the cost of the generic.

At the other extreme, Eaton-Lambert syndrome (rather like myasthenia gravis) has only about 200 patients in the UK. Patients take an unlicensed medication four times a day which helps them considerably. This costs under £1000 per year. So these 200 patients are treated because that is all there is. Then a pharmaceutical company introduces a new product to meet these patients' unmet need at a cost £60,000 a year but which is in fact the same molecule. This is why we need value-based pricing.

With regard to best-practice tariff, CABG is currently an 'activity tariff' and the GP still has to pay the cost of the procedure even if the patient subsequently has a stroke, gets MRSA, or ends up on dialysis. Best-practice tariff means that that the money is paid by the GP only if the patient does not have a stroke or DVT, for example, within two months of discharge. The provider will therefore look at what therapeutic interventions will achieve this outcome so that they get their money. So if they use the cheapest drugs or poorer quality equipment the hospital will lose money.

In respiratory illness such as asthma or COPD outcomes, such as hospitalisations, admissions and morbidity allow us to see how prescribing relates to outcomes. If it does not we have to look at what else is involved - very often it is the wraparound care package rather than the drug that delivers the outcome.

With regard to financial penalties, Omar outlined that if a patient with COPD is admitted three times in a month the hospital will in future only receive one payment of £3500 rather than three payments. However the PCT and GP commissioners will still have to pay three £3500 payments, with the other £7000 going to the government. This penalises both sides and is the government's way of saying that both sides need to sit down at the table and prevent this happening because it is not helping either the commissioners or the providers.

With regard to formularies, if your company has a drug on formulary that is good news. Looking at tafluprost eye drops, the only preservative free prostaglandin analogue, Omar's PCT spends £1.5 million on 36 different glaucoma eye drops. Of this, £1 million is spent on just four of these and the other £0.5 million is spent on the other 31. Managed exit set out that ophthalmologists can use tafluprost but should also switch to generic when the first generic latanoprost comes to the market next year. Doing this now represents and invest-to-save policy. Quality, innovation and prevention cost money but there is no money. So to achieve the QIPP agenda, the productivity element has to pay for the other three letters of QIPP.

Omar closed with the thought that decisions are about one patient, as well as about one million patients, and it is important not to give up on any individual patient. But as a budget holder assessing a drug with a chance of success of one in a million, how can it be funded? Realistically, it can't.
 

Discussion
Asked by Roy Lilley if the industry has really grasped this concept, Omar Ali felt that some companies do understand that what the payer wants is different from the regulatory authorities. These companies are looking at what kind of studies could be bolted on to the regulatory trials to provide some outcomes of interest to the payer. However it is often the case that the UK company understands but the global and US arms of the company do not. Given the globalised nature of decision making in the industry, will there be that subtlety? A lot more is needed than simply stating that a drug did not kill dogs and it works better than nothing, in Omar's view.

Andrew Roberts (Head of NHS Partnerships at AstraZeneca) noted that some companies have been looking at value-based pricing since long before the White Paper. Also, other countries are already doing it so there are models within the pharmaceutical industry globally.

With new products that do not have the history of use, Omar Ali noted that a number of companies, while they have some evidence, have also set up national registries. Those using a particular drug based on limited evidence do so on a restricted positioning on the proviso that data must be collected on a registry. The restrictions may open up as more data is collected but may close if experience shows the drug not to be as good as promised. Roy Lilley felt this would be difficult enough with 150 PCTs, but with the prospect of 600 consortia it becomes almost unimaginably difficult.

Partnership – business jargon or reality

Andrew Roberts (Head of NHS Partnerships at AstraZeneca) came back to what partnership means. There are subtle differences between joint working and simple collaboration. Funding is an example of collaboration but it is not joint working. True joint working is a form of collaborative working and a form of partnership with the NHS.

From a Pharma viewpoint, joint working could be really important to engage better with the new NHS. Andrew signposted the DoH/ABPI joint working toolkit (which can be obtained from the DoH or ABPI websites). This defines joint working as patient focused, so the rationale for engaging in joint working is all about the patient. If projects are to work there must be significant joint investment from both the NHS and the industry. In many cases this represents a big shift for the NHS organisation to commit that resource, and linked to this there must be a carefully put together project plan that will deliver those outcomes for the patient. This robust project plan is vital to guarantee some sort of return on any investment, both for the NHS and for the industry. Also, everything must be done in an open and transparent manner. Nothing can be withheld.

All three joint working programmes with which Andrew is involved at AZ (currently around 15) are patient focused and aimed at improving outcomes for patients. Resource investment from both sides is significant and there has been a big cultural shift in the NHS at these 15 sites. Andrew admits that at all of these sites the NHS culture was already fairly open so the company was pushing on an already half open door. This makes things far easier than when you meet negativity, prejudice and a negative mindset about the benefits of joint working.

Where the pharmaceutical companies are working in COPD programmes, Andrew noted there has been a significant reduction in unplanned care. When costed out, in terms of tariff pricing this it represents a significant reduction. This is one of the biggest drivers behind many of the joint working programmes in COPD, and with the 30-day readmission target they are becoming even more important.

With regard to scaling these projects up Andrew stressed that AZ would be unable to resource 150 COPD joint working projects. However there is plenty of opportunity for every company to engage in similar projects that would provide this benefit to the NHS, particularly to deliver some of the objectives within QIPP.
 
As the NHS goes through a difficult period, trying to engage with key stakeholders around joint working is becoming increasingly difficult. However Andrew believes there is a benefit in that industry can shape things so use of resources is more structured and planned, with better and more efficiently managed care pathways. These efficiencies will fund more of the QIPP agenda. Most joint working agreements only got off the ground last year but where outcomes exist they are showing that a more structured approach to care delivery in the locality does indeed release those efficiencies.

Finally, joint working is a reality. Since the APBI/DoH joint working toolkit was launched there has been a huge increase in the number of joint working projects. There has also been an escalation in wider collaborative working, i.e. projects that are not truly joint working but that are very much benefiting patients and the NHS.

Regarding cultural shift, the industry must play a part, in Andrew's view. Really good data is required to persuade the NHS that the industry understands patients' needs. It is therefore vital to show outcomes from existing pilots. When the NHS can see outcomes, and can be encouraged to talk to colleagues with experience where joint working has worked well, then there will be a change in mindset.
 

Discussion
Roy Lilley noted that the concept of industry consortia is interesting – getting the big Pharma juggernauts to hitch their wagons together has historically been difficult. Andrew Roberts believes we have started to move in that direction - the Nottingham project was with a consortium of pharmaceutical companies. Much of the drive for this has come from the ABPI. The industry did not actively seek to get together but companies recognised that in future they have to work collaboration with other companies, particularly on the big long-term conditions like diabetes and COPD. Asked by Roy Lilley where the where the shareholder value is, Andrew stressed that there is none. No company goes into joint working programmes to directly sell more brand. Joint working is about participating in reshaping the way local pathways are managed and delivered. There is a genuine desire to be involved at a local level and the industry recognises this as an opportunity at a time when it is becoming increasingly difficult engage with the customer in the way it has done traditionally.

As a prescribing adviser, Omar Ali wants drugs that work at the right price, but believes that Pharma bringing other NHS parties they have worked with successfully to the table can work well. For example, he might not know what has happened in Nottingham. Andrew Roberts added that a whole raft of activities is being driven by the industry which is taking partnership, networking and collaboration forward. The rationale for Pharma to be part of this is access to our customers. However it may turn out in the long run that it is not a sustainable activity.
 

Nagging suitor, reluctant bride

Partnership is defined as a relationship between individuals or groups that is characterised by mutual cooperation and responsibility for the achievement of a specified goal. Andy Davis (Sales Director, Lundbeck) made the comparison between business relationships and personal relationships, suggesting that the reasons for working relationships not getting off the ground are in fact the same as in personal relationships. Why do some last while others are unsuccessful?

Relationships can fail from the outset because of a failure to engage. If the suitor does not appear to be immediately attractive, the reluctant bride will not be persuaded by letter after letter from the suitor saying they find the situation unacceptable. You will never engage a prospective partner by getting aggressive. Remember too that the NHS does have some 'antibodies' to the Pharma industry, which is sometimes regarded as oppressing the masses and making too much money. However Andy believes that the industry can no longer use that as an excuse, if it ever was. Unfortunately, while one particular company might be regarded favourably by the NHS, the NHS tends to group industry together and a bad experience with one company colours their judgement of all the rest. It is therefore incumbent on the industry as a whole to get its act together for the benefit of everybody.

Why do relationships fail? In personal relationships one reason is infidelity. In working relationships this equates to a question of trust. The customer may suspect that the industry is only 'pretending' that they want to engage. Communication breakdown is another reason for failed relationships. Industry and the NHS talk different languages, use different terminology and words have different meanings for different people. Physical or emotional abuse is also a reason for failure of personal relationships. In the context of working relationships this means threatening behaviour between the two parties, for example the Pharma company threatening to pull out if there is no ROI, or the NHS threatening not to engage.

Taking the analogy further, financial issues affect both personal and working relationships. Conversations about financial resources and rewards are difficult to have if you do not have a reasonable relationship. Another issue is boredom. At the beginning of a relationship the industry will be energetic and committed, but these are long-term relationships that you cannot just take up when you want. Working relationships fail when companies move on to the next big thing, or the company is taken over.

Why do relationships succeed? Again, many of the same things apply to both personal and working relationships. It is important to be positive. Far too often in the NHS there is only reluctant engagement in partnership. Being unselfish is also important. Even if there are joint objectives, sometimes one partner has to subjugate to what the other partner wants. Partners should also be willing to use their skills and abilities. The industry has skill sets that the NHS could benefit from. A £40,000 a year NHS executive does not have the skills which the NHS needs to modify its delivery of healthcare, in Andy's view.

It is also important to be a team. One of the most successful aspects of the Nottingham experience was the hard work put in get to everybody together, to have a joint steering committee comprising public health, health promotion, medicines management and with commissioning, all of whom worked as a team with shared goals and objectives. Success was measured by the success of these shared goals rather than by ROI or prescriptions. Above all, it is important to be content. You will not get everything you want. You will not satisfy all your criteria. But be happy that you are engaged and at the party, because many companies are not.

Another problem with many relationships is the extended family. In joint working this means the environment we work in. The ABPI supports joint working but the Bribery Act in April 2011 will change the game. CEOs will be worried about this as there is a realistic chance that somebody might go to prison. It will no longer be about nuances around the code of practice, but nuances regarding the law, which is very complicated. If five companies are working together, each with its own legal and medical departments, all with different views, a joint working agreement can be extremely difficult. This is the biggest challenge for joint working in the future, in Andy's view.

What does the customer want at the payer level on a day to day basis? First, they want a peer to peer discussion with a budget holder and decision maker. They want discussion about achievement of the NHS goals, local healthcare priorities and the wider NHS agenda. It is vital for the industry to understand what the customer is trying to achieve and the environment they are working in. They want discussion about the service and the patient and not about medication. The days of presenting the NHS with a clinical paper stating drug X is better than drug Y are long gone. Yet Andy reminded us that every company still does it.
 

Panel discussion
Roy Lilley felt that ultimately there has to be some calculation of ROI from joint working programmes. Andy Davis stressed that discussing ROI 'on the first date' will not get anywhere. He applauds GSK and AZ who are getting involved in joint working agreements, but pointed out that AZ turn over £500 million a year and are involved in 13 joint working projects, GSK turn over £1 billion and they are involved in 35.

Omar Ali felt that while some companies are trying to up the game with key account managers, the majority of what most companies do is disappointing, still measuring success in terms of sales rather than relationships. Also, in most cases, the person coming to see Omar is inappropriate for his needs. As to whether the account manager of the future will be a regional account director paid £80,000 plus with profit and loss responsibility rather than the hospital rep, Omar stressed that what he wants is someone who can talk about the product, the evidence, the cost budget impact model and also about key aspects of prevalence, incidence and sectioning of the disease area.

Andrew Roberts agreed that there is a misalignment between what is happening and what the customer actually expects. However the industry is working hard at this, taking time in their learning development departments to realign those capabilities.
Roy Lilley added that the days of the post-it pad, the pen, and the mug are gone. Now industry is looking at an expensive investment in field staff.

Peter Carr (Courtney Alexander Consulting), who has been running similar projects over the last three years with 17 different PCTs, asked how these joint working programmes will stand when the NHS changes. Roy Lilley stressed that in future joint working will have to be consortia driven because there will not be anybody else.

Andrew Roberts felt that it is hard to predict what will happen under consortia. The really good examples of joint working thus far are aligned to a high degree of consensus between all those involved (from practice nurse, GP, commissioner, and Pharmaceutical advisor, to the chief executive and the finance director). Usually it is around an unmet need in a particular disease, such as COPD, and a need to do things differently. Do not forget that the patients will not change under the White Paper reforms.

Andy Davis stressed that Pharma has traditionally been able to do well where the NHS has not been well organised. During the next few months there will be chaos, and this will create opportunities, but it will also create paralysis. Everything will change and the industry must get people on the ground to engage at the right level with the right people, and play it area by area. Omar Ali agreed that the NHS situation could be good for the industry and stressed that same medicines management personnel will still be there, but working in different organisations. Andrew Roberts felt that while there are enormous opportunities the real question is whether or not the industry can flex, and adapt to the needs of the NHS in the future.
 

Held on: 14/10/2010