The plan to introduce value-based pricing (VBP) for NHS drugs was “flawed from the start” and should be scrapped, according to a healthcare think tank.

A report from 2020health argues that VBP could reduce patient access to expensive drugs by replacing the existing patient access schemes.

It also argues that VBP will “politicise” drug pricing by exposing it to lobbyists and media campaigns.

Under the current Pharmaceutical Price Regulation Scheme (PPRS), companies’ total income from the NHS is restricted but individual drug prices are not.

VBP, currently being negotiated between the Government and the ABPI and due to be introduced in 2014, aims to relate drug pricing to value in a broad sense – i.e. to apply NICE’s current decision-making process to drug prices.

The report states: “Value-based pricing sounds like an excellent idea with a well-researched methodology. On further examination the cracks begin to appear... The real concerns of patients, doctors, and carers are only hidden from view.”

One problem, it says, is that the drug access schemes negotiated by the industry and the Department of Health will disappear, potentially reducing patient access to much-needed drugs at a time of NHS austerity.

Another is that “patients could become political pawns” if the availability of a particular drug is focused on by “the press, a political party or an MP”.

Julia Manning, Chief Executive of 2020health, said: “The Government’s new plans for pricing will politicise a formerly non-contentious issue. Despite the intensive negotiations and new promises to include patients further in deliberations, this is an idea it seems was flawed from the start.”

The report urges the Government to improve the existing drug pricing system by further encouragement of patient access schemes, and by tightening controls on any one company’s revenue from the NHS.

New vaccines schedules from the DH and Public Health England include offering a nasal flu vaccine for all children aged two years in England from September.

The NHS will also vaccinate primary school and pre-school aged children from 2014, and secondary school aged children from 2015.

New vaccination programmes for rotavirus, shingles and meningitis C are also planned in the strongest demonstration to date of the priority of disease prevention in the new public health system.

Providing the nasal flu vaccine to all children aged two years, in time for the late autumn seasonal outbreaks, will protect some 650,000 infants.

In addition, babies aged less than four months will be vaccinated against rotavirus – a common cause of diarrhoea and vomiting in infants – from July.

It is estimated that the vaccine will halve the number of cases of rotavirus infection in infants (currently 140,000 per year).

According to Mary Ramsay, Head of Immunisation at Public Health England, the introduction of oral rotavirus vaccine “has had a major impact” on protecting young children from the disease”, resulting in “rapid and sustained reductions in childhood rotavirus hospitalisations”.

At the opposite end of the age scale, an NHS shingles vaccination programme for people aged 70 is planned from September, as well as a catch-up programme for those aged up to 79.

The two programmes will protect some 800,000 elderly people this year from a disease that can cause prolonged neuralgia and disability.

A US study found that vaccinating adults aged 70 or older halved the incidence of shingles and reduced post-herpetic neuralgia by 40%.

Vaccination against meningitis C is also changing from September: a new booster jab at age 12–13 will replace the current booster at four months.

The chair of the Royal College of General Practitioners (RCGP) has hit back at claims by Health Secretary Jeremy Hunt that doctors are to blame for the increased pressure put on A&E services.

Dr Clare Gerada (pictured) issued a statement claiming Mr Hunt was wrong to blame GPs for a lack of out-of-hours provision and said doctors were being used as a “scapegoat” by the Health Secretary.

She said it is “not acceptable” to point the finger of blame at GPs for rising levels of A&E use and there is “no evidence” to prove this increase is down to the 2004 GP contract – as some ministers have claimed.

Hunt first made the accusation in the House of Commons when he was discussing the 2004 GP contract introduced under the former Labour government. A DH spokesperson subsequently insisted the Health Secretary was “clearly not blaming GPs.”

However, Hunt reiterated that doctors were to blame during a speech at Age UK where he outlined plans to “rethink the role of primary care” and said that “inaccessible primary care” had resulted in increased pressure on A&E services.

Dr Gerard insists “it is not true that the rise in demand on A&E services is due to a reduction in out-of-hours provision by GPs” and that there are “numerous reasons why our colleagues working in A&E departments are under pressure.”

She highlighted a shortage of consultants and a lack of integration between community and social care which has caused a “myriad of problems, including unnecessary admissions.”

The chair added that assumptions that the NHS “starts and ends with hospitals” should be ended and called upon the Health Secretary to consider the wider picture before pointing the finger of blame. “We are one NHS with patients accessing different services at different times,” she said.

“These are tough times for us all and one of the issues Mr Hunt should be addressing is the shortage of 10,000+ GPs across all services, not just out-of-hours. As a national health service we should all be working together with Government to improve patient care, not blaming GPs for perceived ‘inadequacies’ in patient care.”

This month Brigadier Pinching shares a surprisingly palatable civil service coffee with the Department of Health’s NHS/big pharma relationship expert, Naima Khondkar.

I love Elephant and Castle. If you are in any doubt about where you are, just outside the station, there is large sculpture of... an elephant and a castle. Oxford Circus, King’s Cross and Cockfosters have clearly missed out on a neat trick. Anyway, I digress, for I was in central London on important business – to chat with Naima about how the private and public sector could make their marriage work. Having spent six years in curious governmental buildings, this was my territory. Bring on the future!

Hi Naima, what’s your story?

At the Department of Health I work in the Medicines, Pharmacy and Industry Group. The head is Giles Denham and he has a number of teams which sit under him. One looks after the pricing environment – which is very topical right now because of the negotiations – while the pharmacy team takes care of community and pharmacy issues. Another concentrates on prescription policy, and I’m in the industry sponsorship team.

How do you guys roll?

We’re almost account managers for the pharmaceutical industry, within government, and also the first port of call on health policy issues concerning research-based pharma companies, including global outfits that have locations in the UK. There’s a very high-level of strategic engagement, driven by the Ministerial Industry Strategy Group, which combines global heads of pharma, from as far afield as Japan and America, and ministers from health, business, the treasury and UKTI (UK Trade and Investment). The discussions are a great way to highlight how government policy can help partnerships. Our minister, Earl Howe, is a particularly engaging contributor, while ‘No 10’ frequently sends along a representative, indicating how serious the Government is about forming cohesive inter-sector partnerships.

How has the concept of joint working progressed?

Over the last few years we have carefully considered how to fundamentally improve the relationship between industry and the NHS, and a lot of this consideration has been carried out in conjunction with colleagues at the ABPI. There is still a lot of mistrust on both sides, however, and that is one of the greatest challenges reform needs to overcome. The NHS has the perception of pharma as being a big bad wolf, just above the arms and tobacco industries in terms of popularity! For some reason people have a big problem with the pharmaceutical industry making any kind of money. Sometimes I think the level of suspicion is unjustified, but then again, I don’t think pharma do themselves many favours sometimes. It’s important to be open and honest about these things! Equally, the NHS can sometimes be over-sensitive – they don’t like to be told by other people how to do their job.

What needs to change?

There needs to be a shift in how people on both sides view one another and they must learn to wipe the slate clean. Bad relationships can date back to minor incidents that happened 25 years ago, when a young, naive rep went into a meeting with a box of doughnuts to help flog a new product. Something as trivial as this may have resulted in a door being shut. Whereas now NHS representatives need to re-engage, open doors and think about the broader benefits of working together with the pharmaceutical industry towards joint goals. It’s really important that both sides build allegiances and forget past animosities. Ultimately this will benefit everyone.

Do the ‘different’ motivations of the public and private sector make gelling difficult?

There is an incorrect perception that, because pharma makes money, someone else has lost. We must remember that if people have their lives extended due to better treatment then NHS, industry and wider society has won. Recently Helen Bevan, NHS Director for Transformation, said both industries have been very target driven in the last 15 years and, consequently, the humanity factor has eroded. Healthcare professionals on the frontline have been too busy with waiting lists and reductions, while sales reps have been under enormous pressure to shift products and been too focussed on sales. Patient cases have become about performance measurement rather than health outcome, or quality of experience. Clearly there needs to be a radical change in priorities.

What can big pharma do to engender trust?

Their approach can be ill-informed sometimes. Often they think they know the NHS, but actually they need to fully appreciate the complexities of what is an ever-evolving beast. Companies need to consider who they make responsible to forge vital connections and forming sustainable relationships. They regularly send an under-qualified person, who might have the enthusiasm, but not the authority. With joint working one of the big issues has been compliance and, often, the pharma representative at the table can’t actually make a decision about whether a company can work in a certain way. This is one of the areas we are really trying to help with.

How should they alter their approach?

If pharma goes in simply looking for a market share increase, they’ll get figured out straight away. Representatives of the big companies need to prove that they genuinely want to improve a health economy or health outcome, before profits. These are the aspects that make the whole system better, and ultimately everyone wins. The CCGs want more people appropriately treated and that means less hospital admissions and, in turn, more financial resources will be available for commissioning. In this respect pharma needs to look at the bigger picture. Remember, every service that the NHS uses is a business – from nurses to bed sheets – but because of the fractious history, the NHS is suspicious about pharma making money. When they do engage the NHS needs to feel like pharma is an integrated and credible part of the solution, as opposed to a procured service. It’s a fine balancing act.

What are the priorities when it comes to galvanising joint working?

Since joint working was outlined as part of NHS reform we have been keen to establish how it can be improved. A policy working group in 2007 carried out some market research and they came up with some recommendations. The two major areas of focus, on our side, were the issuing of guidance – clear definitions of how the NHS works - and the language that should be used. This is a refreshingly concise 11 page document. We also addressed the practical side by combining with the ABPI to launch the, ‘Joint Working tool kit’. It’s an interactive quick-start guide, which includes exactly what the NHS’s definition of joint working is, essential templates and a versatile project management tool. Above all, it avoids jargon and allows people to understand what is required straight away. This has been endorsed by NICE, the NHS Alliance and Confederation among others. We will be looking again at how we can update these documents and make them more practical in the ‘new world’ and also partnering with industry [through the ABPI] and the NHS to review and revitalise both these tools.

Are you optimistic about fruitful partnerships?

Joint working will continue to be an important focus and a part of my day job. QiPP came and went, so we had to hold fire for a while, but now Innovation Health and Wealth (IHW) has provided a restructure, we are pretty sure of what is happening; six months ago we sat down and established that the shift of power is moving to CCGs. Now individual CCGs. Director of Partnerships, Ivan Ellul is particularly keen on localised, dynamic relationships and Mike Farrar is also a champion. Ian Carruthers is the NHS England lead for IHW and is also keen to encourage this type of engagement.

Do you feel that the tide is turning already?

I’m resolutely positive about changes within the NHS. I’ve had heated discussions with clinicians and pharma about joint working, because a lot of them see it as more rhetoric. Some companies, however, are hugely proactive and want to be pioneers of change. GSK are a good example. They’ve shifted their entire salesforce to encourage new ways of working with NHS counterparts. Their leader, Andrew Witty, is passionate about successfully transforming approaches and he’s someone you can believe in, because GSK have freed up patents, conformed to the ‘alltrials’ ideology and shared data. This has filtered down to the way they engage with the NHS and the company have been very smart, as they realise it’s about increasing the whole market. If a healthcare pathway improves it will produce better diagnosis, and better diagnosis means more appropriate and timely use of medicines.

Well said, thanks Naima!

Health Secretary Jeremy Hunt has pointed the finger of blame at GPs for rising A&E admissions and the added pressure placed on emergency services.

Speaking to MPs, Hunt said that “poor primary care provision” was behind some four million additional people unnecessarily visiting accident and emergency services.

But the General Practitioners Committee called Hunt’s claims “nonsense”.

A Department of Health spokesperson played down Hunt’s accusations insisting the Health Secretary was “clearly not blaming GPs” and that he was referring to procedures set by the former Labour government.

Hunt was responding to figures published by Labour that showed the NHS had missed its national A&E waiting times each week for the past six months.

He claimed this was down to poor alternatives to primary care which was the result of changes introduced by Labour to the GP contract.

“The reason that there is so much pressure on A&E is because of the disastrous GP contract that was negotiated,” he told the House of Commons. “That is what is causing the huge pressure. That is what we are determined to put right.”

The Health Secretary said the solution to the rising number of A&E admissions was to analyse the GP contract, introduce alternatives to secondary care and integrate health and social care services.

The new statutory regulations for CCG commissioning will mean that lawyers can overrule clinicians, doctors and legal experts have warned.

While a debate and vote on the new regulations in the House of Lords are scheduled for 24 April, campaigners have warned that they will lead inevitably to a full privatisation of the NHS.

Explicitly intended to ensure that CCGs obey the principles of the Health and Social Care Act, the new regulations make it possible for private providers to challenge commissioning decisions on the basis of business law.

The Department of Health, which revised the regulations following protests from the medical professions, insists that CCGs will have the authority to decide which services are put out to tender.

However, legal experts have stated that the decisions of CCGs will be vulnerable to legal challenges from private providers, since the ‘any qualified provider’ concept places commissioning within a business law framework.

Lord Hunt (pictured), Deputy Leader of the Opposition in the House of Lords, has tabled a ‘fatal motion’ against the new commissioning regulations that could temporarily block its passage into law.

Crossbench peer Lord Owen accused the Government of using “specious grounds of urgency” to drive through legislation that contradicts its own principle of ensuring ‘clinically led commissioning’.

According to Dr Kambiz Boomla, a GP in East London, “These regulations are likely to be the death of clinically led commissioning, and the birth of lawyer led commissioning.”

Clare Gerada, Chair of the Royal College of GPs, similarly warned that the new regulations will “remove the legal framework” for a “universal” and “democratically accountable” NHS.

NHS Dudley CCG has spent £60,000 on an online service to help adults with common mental health and wellbeing issues.

Commissioners have agreed a one-year deal with the Big White Wall, an interactive online counselling service for those in emotional or psychological distress to get support and self-manage their condition.

Dr Mona Mahfouz, NHS Dudley CCG, said the agreement made “good sense, particularly in today’s socially networked generation.”

The web-based facility provides users with a safe and anonymous service where people can access peer support, wellbeing tests and additional online resources to aid self-care and creative art and writing therapies. Counsellors are also available at all times to provide any additional support.

The Big White Wall initially launched in 2008. After its pilot year it had attracted more than 3,000 users that backed its value in improving mental wellbeing. It has since partnered with the Department of Health, the Ministry of Defence and the charity Help for Heroes to provide support to troops returning from conflict.

“When mental and psychological distress arise, getting the right sort of help and getting it early is key to recovery,” said Dr Mahfouz. “Having access to The Big White Wall is yet another tool that will provide help to those in need of it.”

The service, which is available free of charge 24/7, can be accessed by registered patients within the Dudley borough by visiting www.bigwhitewall.com.

To read more local NHS stories visit www.pfdiscovery.com.

With the NHS in flux, there has never been a better time for joint working – but pharma might need some help to negotiate the new relationships. Pf looks at the key role of third parties in bringing industry and the NHS together.

Pharmaceutical companies in the UK might be forgiven for wondering if this is really the right time to engage in joint working (JW) projects with the NHS. There seem to be a few questions in the air. What is the NHS now? Who is making decisions there? What are the real priorities? Going into partnership with the NHS might seem like dating someone with too many unresolved ‘issues’ for it to stand much chance.

However, if you keep your nerve, there has never been a better time for JW. The combination of profound structural change and austerity budgeting means that the NHS badly needs support – and the need for healthcare to shift its focus from acute to chronic illness means that the right ways to transform the care pathway are at a premium. Suddenly that mythical bird of business transactions, the win-win, has to be real.

But the opportunities for partnership are highlighting the culture gap between pharma and the NHS. Meeting on the internet and getting married on the run may be romantic, but it won’t lead to a sustainable relationship. The partners need to learn each other’s language, meet each other’s family. This is where mediators and consultants can really make a difference by providing expertise and experience.

Pf talked to two companies that are actively involved in guiding and building JW relationships – one as a facilitator, the other as an active participant. Three common points emerged from their perspectives:

1. The major changes in healthcare in the UK are creating opportunities for pharmaceutical companies to work in partnership with CCGs, local authorities and providers.

2. The payoff for the pharma company is in terms of better medicines management, leading to the company’s products being used more widely and effectively.

3. Realistic mutual understanding is critical for JW – no amount of rhetoric about values and beliefs will help unless there are shared objectives and ways of working.

Embracing the unknown

Chris Morgan of ZS Associates argues that JW does not come easily to either side: “A true appreciation of the value of partnership is still fairly rare, within both pharma and the NHS.” For years, ZS Associates has emphasised the critical importance of key account management for pharma. The current NHS reforms and the development of the JW agenda have strengthened this argument and underlined the consultancy’s role as a thought leader for pharmaceutical sales and management.

“The established relationship between pharma and the NHS can be pretty toxic,” Morgan says. “ There isn’t a whole lot of trust established there. Before we can partner, we have to earn that trust.” He gives the example of a company ZS worked with that had spent six months piloting a new service idea with a PCT. “The PCT loved it, it worked well for the company, the patients loved it – and then they packaged it up and gave it to all their other account execs to sell, and a year later they had sold none.”

Why was that? “The first time they sold it, they thought they were developing a service – but what they were actually developing over six months was the trust required for the customer to buy that service. Then, when they showed up to every other PCT subsequently, the response was ‘Who the hell are you?’”

Too often in pharma, ‘trust’ is interpreted as meaning ‘goodwill’. That might work when the culture is the same on both sides, but between pharma and the NHS it won’t hold. Morgan explains that without clear mutual understanding “it’s not clear who is living up to their end of the deal, and it’s not even clear to you whether you’re living up to what the other person perceives as being your end of the deal.”

In addition, he argues, “those circumstances for partnership where it’s clear that everyone has something to gain end up being easier to defend, and more ethical, than those JW situations where there’s no apparent gain for the pharma company.” If a company sponsors an initiative in a therapy area where it has no products, two questions arise: does the company have the expertise needed, and what are its motives? JW has to be about “genuine mutual interest”. Quid pro quo agreements are not only non-compliant, but make no business sense: “I can sell you £10 notes for a fiver all day. There is no rational economic reason why you should reciprocate to a value greater than what I’ve just given you.” JW has to generate value, to the objective benefit of both sides.

Another key issue is defining who the customer is, and here Morgan illustrates the value of the KAM approach. “Too often we try and define the customer as being the doctor, the patient or the payer – but the only time you find genuine mutual value is when you think about all three stakeholders together.” Pharma companies need to involve providers as well as commissioners in JW projects, since the most successful providers “are actively going out and engaging with commissioners” to redesign care pathways – and thus are already on the JW road.

The best JW projects, Morgan says, often involve “care pathway re-engineering”. An area ripe for partnership is diabetes care, as its problems are well-known: poor service integration, poor medication compliance, high levels of complications. The JW opportunity is for the pharma company to help commissioners and providers improve care by improving diagnosis, monitoring or compliance, thereby reducing complications and hospital admissions. “The pharma company benefits as well because its product is used earlier, more persistently or in a larger or more appropriate group of patients.” The win-win is not only real, it is flying.

A time of change

Karen Bell, Business Manager at Ashfield In2Focus, argues that a window of opportunity exists now for pharma in terms of JW, and that there’s no time to waste. Ashfield In2Focus provides a range of services to pharmaceutical companies to help them develop and implement JW relationships with the NHS. Most importantly, it provides quality healthcare development managers (HDMs) and key account managers (KAMs), many of whom have NHS backgrounds, to mediate between the two sides and facilitate the process.

There are three reasons why this is a crucial time for JW, Bell explains. Firstly, the drive towards more patient-centred care, the QIPP agenda and the increasing role of private provider competition are all making the NHS engage with industry in new ways. Secondly, the Department of Health and ABPI guidance around JW have made the NHS “less nervous about working with industry and more open to win-win types of partnership”. Thirdly, its new emphasis on innovation has made the NHS more aware of its weaknesses in that area, and more ready to involve people with different experience.

The focus of JW projects is closely linked to the NHS’ need for increased patient throughput, especially in primary and community-based healthcare. “Typically the JW projects which we tend to see succeeding are in CHD, diabetes, women’s health, mental health – really any long-term condition, and also where there’s a drive to keep patients out of hospital” – while “for the sponsoring pharma company it means more patients going into the total patient pool for their product”.

However, the current business climate does not reward risks. Aren’t those pharma companies who decide to wait until things settle down being sensible? Bell’s response is emphatic: “They’ll miss the boat. Because we are now in a time of change or flux, with innovation and efficiency high on the agenda, the NHS is very open to hearing about and indeed engaging in new ways of doing things. Those pharmaceutical companies who go out there and talk about these initiatives now, and those NHS organisations who engage with them, will be the ones who will capitalise in the longer term.”

Even so, why is a mediator needed – isn’t that one partner too many? Bell argues that as a service provider already working with the NHS and industry, Ashfield In2Focus is a key link between the two cultures. It provides experience of working on both sides and knowledge of the regulations around the provision of NHS services. Any service it provides is backed up with the necessary documentation to “protect the NHS, the patient and the pharmaceutical company”.

In addition, Bell argues, Ashfield In2Focus is well placed to bridge the culture gap between the NHS and pharma: “When our HDM teams talk to an NHS customer, they can often be having a peer to peer conversation, and that facilitates the whole partnership process, building engagement, mutual understanding and trust from the start. As many of them have come from that background (we employ a number of ex-commissioners or Department of Health personnel), they understand the world of the NHS, and they can more effectively identify and implement a solution.”

JW projects require the right people to engage with “the new NHS stakeholders” and “to develop and carry through these initiatives and make them sustainable”.  They also need to be able to influence local authorities and Health and Wellbeing Boards, and to “talk coherently around the joint strategic needs assessment process”.

In classical mythology, Hermes was the messenger between worlds. Bell uses a similar image: “People sometimes see our staff as being one step removed from pharma – working for us on behalf of a pharmaceutical company, but not directly for them. Our nursing services are a perfect example of this.” In addition, she says, Ashfield In2Focus attracts and recruits quality personnel for these roles, through its vast database and network of contacts, by offering a permanent contract of employment to potential employees in uncertain times – reafirming the value of the third-party role for pharma and the NHS.

Hospital ratings and a “duty of candour” for the NHS are among the measures announced by the Department of Health in its response to the Francis report.

A new Chief Inspector of Hospitals will be appointed to manage the appraisal of all hospitals, as well as individual hospital departments.

Health secretary Jeremy Hunt said the new measures would help to create a “zero harm” culture in the NHS, ensuring that the Mid Staffs tragedy was not repeated in other Foundation Trusts.

However, the Royal College of Nursing (RCN) drew attention to the dangers of systematic understaffing of hospitals.

All NHS staff will have a statutory duty to be honest about mistakes, and managers who fail in that duty will be barred from management roles – though the DH will not make it a criminal offence to cover up errors (as Francis recommended).

Hunt argued that it was necessary to strike a balance between ensuring “candour” and not creating a “culture of fear”. However, he claimed, the new review of patient safety would mean “a radical overhaul” focused on “high quality care and compassion”.

A code of conduct and minimum training standards for healthcare assistants will be developed, and nurses will have to work for a year as healthcare assistants before being funded for an NHS nursing degree.

In accordance with recent recommendations from the Nuffield Trust, a ratings system will be developed to assess hospital departments, with each hospital receiving an overall rating of ‘outstanding’, ‘good’, ‘requiring improvement’ or ‘poor’.

Peter Carter, General Secretary of the RCN, warned that understaffing was a fundamental issue that the review did not address.

However, Mike Farrar, Chief Executive of the NHS Confederation, said the DH had struck “the right balance between external assurance measures and internal changes focused on transforming the NHS culture.”

The Department of Health has launched a “vision and strategy” to support and develop the contribution of all nurses to the care of dementia patients.

The strategy, published as the Prime Minister’s Dementia Challenge reached its first anniversary, describes what is expected of general, “dementia skilled” and specialist nurses working across all care settings.

Significantly for industry, the strategy requires nurses to be “research aware and committed to delivering evidence-based care”.

Listing the values and behaviours necessary for nurses involved in dementia treatment and care, the strategy includes:

• recognising that dementia “brings cognitive, behavioural and physical changes”

• supporting advance care planning

• promoting patient choice and focusing on “strengths and unmet need”

• using “all available resources including networking, technology and social media to improve care and access to services”.

A pyramid of nursing care is outlined, with all nurses providing “usual care and support”, dementia skilled nurses providing “assisted care or care management”, and dementia specialist nurses providing “intensive or case management”.

Emphasis is placed on the need for “seamless” integrated care across a range of settings: home, community and hospital.

The strategy addresses the responsibilities of nurses not only in the NHS but also in social care, the prison service and the private and voluntary sectors.

Pauline Watts, DH Nurse Lead for Dementia Care, commented on the launch of the strategy: “Dementia is every nurse’s business – with a change in mindset, practice, commissioning and education, nurses can make a real difference to people living with dementia and their carers and families.”