Out with the old, in with the new
Out with the old, in with the new
As 2008 draws to a close, the UK pharma industry is facing a number of challenges – some new and some deep-rooted. Pf reviews the Wellards/TNS Conference and looks at how NHS change is driving new strategies for pharma.
The pharmaceutical industry still has deep-rooted challenges to address but is adapting to its changing environment, Association of the British Pharmaceutical Industry leader Dr Richard Barker said at the Wellards- TNS conference in London this October. The ABPI Director General told senior pharma industry staff that finding ways of helping NHS organisations to improve the quality of care would allow the industry to make progress and to rebuild trust. They should establish new relationships with the NHS on issues ranging from health promotion to problem-solving through greater joint working, he added. “The changes we’re seeing in marketing are even more profound than those in R&D.”
According to Dr Barker, the industry had already made significant changes, including its realisation that the National Institute for health and Clinical Excellence should be treated as an influential customer, and its acceptance of value-based pricing in Pharmaceutical Price Regulation Scheme negotiations. However, the issue that worried him most was the deep-seated distrust of the industry among NHS staff. ABPI research showed that many primary care trust staff felt that they could not trust pharma, while industry representatives also reported that they found NHS staff suspicious.
Although there were still industry people who had not understood the point, he believed the old approach of focusing almost solely on the prescriber had been past its sell-by date for some time. “Some 87 per cent of medical representative appointments with GPs are cancelled,” he told the conference, “and many doctors won’t see reps at all.” The pattern of decision-making had changed for good. Pharma had to learn to regard the influential organisations as new customers, with NICE the most influential customer of all. It also had to find ways of engaging and making its case, including the key industry argument that cost per quality of life year (QUALY) is a good measure but other factors should also be taken into account in measuring the cost-effectiveness of therapies.
View of NICE shifts
The pharmaceutical industry’s view of the National Institute for health and Clinical Excellence has changed, Dr Carole Longson told the conference. Dr Longson, who is Director of NICE’s centre of health technology evaluation, said her organisation’s research had revealed that a large fraction of the industry now welcomed its health technology appraisal role. NICE had only failed to recommend five per cent of the drugs that it had appraised, she added.
NICE regards its relationship with the industry as key to its effectiveness, she said. “Engagement with industry is very important for us. 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’re now implementing that programme.”
Will Darzi review lead to real change?
Nigel Edwards, policy director, NHS Confederation, said that the big question about the Darzi review was whether it included enough to bring about real change. It was consistent with existing policy and brought little that was very new.
Many of its proposals had been seen in earlier reviews and policy documents, added Mr Edwards, but they had lacked levers to ensure they were brought into effect.
“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. Is it going to be enough?” If it wasn’t enough, he said, the gap was likely to be in the leadership.
The big opportunities for pharma were in contributing to prevention strategies, working with NHS organisations to develop policy, information systems, care pathways and commissioning, and working with practices to achieve quality targets and implement quality accounting. Also, the emphasis on giving more managerial responsibility to health professionals would give pharma some important new people to talk to.
Shift in NHS expectations
There will be huge NHS changes and a large shift in people’s expectations of what the health service should deliver, said Birmingham East and North PCT Chief Executive Sophia Christie. Under world class commissioning NHS managers would have to think much more about investment for health gain using data about patterns of disease, investment in services and outcomes, she said. These included health inequalities, spending on inappropriate treatments for patients near death, and potentially wasted appointments with hospital specialists.
“We have to do something serious about health inequalities,” she said. In her area there were wards where infant mortality was the same as in some developing countries, and areas where the average life expectancy of men changed by six years in a distance of just six miles; and while 50 per cent of children in her area were overweight or obese, 20 per cent were malnourished. And across all specialties, 70 per cent of first outpatient appointments ended in no further action.
According to Sophia Christie, most attention had 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.”
PCTs had to be clear about what the issues were locally based on intelligence, and that these were the areas where the money had to go. It would no longer be possible to simply act across the whole PCT but instead on particular areas of need, she said, adding that the procurement and intelligence skills involved in world class commissioning were new for many people in the NHS, which had in the past largely been ‘an intelligence-free zone’.
GPs challenged
North Yorkshire and York PCT and York County Council Director of Public Health Dr Peter Brambleby presented aspects of his work using the techniques of social marketing, programme budgeting and marginal analysis.
Dr Brambleby defined the three techniques. Social marketing was, he said, another word for needs analysis, while programme budgeting used financial data to set objectives and inform future spending. Marginal analysis, on the other hand, assessed changes in costs and benefits when individual resources were increased, reduced or redeployed, and was used in assessing resources, identifying possible areas of disinvestment and new investment, and deciding on priorities.
“PCTs need information about inputs and outputs, and also a lot more information about outcomes, because we have to make an informed case for change and improvement, and we have to carry our clinical colleagues with us,” said Dr Brambleby. “We also need to understand the ‘narrative’ – just walking the patch opens up new questions and information that can take you to a new and better place that makes more sense to patients and to staff.”
As an example of this approach, Dr Brambleby said that he and his colleagues were changing the way information was fed back to GPs in his area. “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 on the local medical committee, the practice-based commissioning group and PCTs had agreed that GPs should be given much more coherent feedback on how they were doing in relation to other GPs in their area. The GPs would then be challenged to explain the variations that emerged, which might 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.”
For further information on the Wellards-TNS conference visit www.wellards.co.uk.