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!

The Department of Health has agreed to withdraw and revise the current secondary legislation on competition in NHS commissioning.

New regulations, tabled in Parliament a month ago, appeared to give Monitor the power to enforce private sector tendering of virtually all NHS services.

Following protests from the Academy of Medical Royal Colleges (AMRC) and over 1,000 GPs, the DH has claimed any difference between this and the former regulations was purely “inadvertent”.

Allowing CCGs to decide which services would be put out to competitive tender was one of the modifications to NHS reform agreed following the ‘listening exercise’.

However, the new secondary legislation appeared to override the ‘discretionary’ powers of CCGs and enforce competition in all areas of care, potentially driving the contracting out of most NHS services to the private sector.

Monitor would be empowered to enforce competitive tendering except where only one qualified provider existed, which is rarely the case.

Last week, a letter signed by over 1,000 GPs was sent to the Daily Telegraph urging a full Parliamentary debate on the new regulations, which will become law by default unless actively opposed.

This weekend, the AMRC wrote to Health Minister Earl Howe expressing “considerable concern” that the regulations disregard assurances formerly given by the DH and would drive a “dangerous” fragmentation of the NHS.

The situation recalls former Health Secretary Andrew Lansley’s statement that the listening exercise had not significantly altered any aspect of the NHS reform.

However, following the protests, Health Minister Norman Lamb (pictured) said the DH had “inadvertently created confusion and generated significant concerns”, and would revise the secondary legislation to show that it was in line with existing rules.

The revised version will be “fully in line with the assurances given” to the medical professions, he said, and will confirm the power of CCGs to decide which services go out to tender.

Shadow Health Secretary Andy Burnham said the revision of the secondary legislation, less than a month before it comes into force, shows that “Coalition policy on competition in the NHS is in utter chaos.”

The new rules for tendering of NHS services have been defended by Health Minister Earl Howe and condemned by the Royal College of Midwives (RCM).

According to Earl Howe, the regulations do not enforce competitive tendering: they simply enforce patient choice.

However, the RCM is concerned that Monitor is being given the power to enforce competitive tendering in virtually all circumstances, while the promised ‘discretion’ of CCGs is abolished.

The difference in views relates to the question of which is more important to patients: the right to exercise choice, or the continuity and integration of services.

The NHS (Procurement, Patient Choice and Competition) Regulations 2013 are secondary legislation following the Health and Social Care Act, and will become law on April 1 unless actively challenged.

Following widespread criticism, Earl Howe said: “These regulations are about ensuring that when services are tendered for, whether from NHS, voluntary sector or independent providers, the rules that are applied to the process are fair.

“We have always said that competition in the NHS should never be pursued as an end in itself, but only where this is in the interests of patients. “This principle underpins the right of patients to exercise choice when accessing treatments.”

The concern of critics – including Labour peer Lord Hunt, the RCM and NHS campaign groups – is that decisions about tendering will be driven not by patient choice, but by lawyers acting for private healthcare providers.

The RCM, which represents maternity service professionals across the UK, argued that the new regulations abolish the control of local NHS commissioners over what services will be open to competitive tendering.

Expressing concern that a business-driven carve-up of the NHS franchise will damage the continuity and integration of maternity services, the RCM called for the new regulations to be debated in both Houses.

Jon Skewes, the RCM’s Director for Policy, Employment Relations and Communications, commented: “We were repeatedly assured by ministers that compulsory competitive tendering would not be imposed on organisations commissioning maternity services. The regulations as they stand will mean that this is exactly what will happen.

“Continuity of care is vital in maternity services if we are to have safe and high quality care. I fear that the fragmented service that these regulations could lead to will mean poorer care for women, babies and their families.”

New regulations for NHS procurement laid before Parliament will force CCGs to put virtually all services out to competitive tender.

The new rules, which will become law by default unless actively opposed, undo changes to the primary legislation agreed during the ‘listening exercise’.

Monitor will have powers to impose competitive tendering on any NHS contract where commissioners have maintained an existing contract or made a decision based on clinical rather than business criteria.

In February 2012, Health Secretary Andrew Lansley told the developing CCGs: “It is a fundamental principle of the Bill that you as commissioners, not the Secretary of State and not regulators, should decide when and how competition should be used to serve your patients’ interests. The healthcare regulator, Monitor, would not have the power to force you to put services out to competition.”

The new regulations make it clear that CCGs are legally obliged to put all services out to tender, and Monitor has the power to enforce that.

Similarly, Health Minister Earl Howe reassured the Lords in 2012: “Clinicians will be free to commission services in the way they consider best. We intend to make it clear that commissioners will have a full range of options and that they will be under no legal obligation to create new markets, particularly where competition would not be effective in driving high standards and value for patients.” This also appears to have been untrue.

Labour Lord Philip Hunt commented on the new legislation: “Whatever was said in Parliament, it seems that the Department of Health and Monitor have just carried on as if nothing has changed. By hook or by crook, a market is being introduced.

“There is very little international evidence that a market in healthcare leads to better or more cost-effective service, in fact most suggests the opposite,” he added. “Post-Francis report, the key consideration should be quality of care.”

The Department of Health has asked NICE to develop several additional integrated health and social care quality standards.

NICE will begin work on quality standards on the care and wellbeing of both adults and children with autism and on the mental wellbeing of older people in residential care.

The DH has also requested that the Institute develop similar standards of care where no existing guidance on a topic exists.

Earl Howe, Parliamentary Under-Secretary of State for Quality said NICE’s quality standards “help define what good care looks like”.

The topics where no guidance exist and requires development are:

• Autism in adults
• Autism in children
• Child maltreatment
• Domiciliary care
• The transition between child and adult services
• The transition between health and social care, including discharge planning, admission avoidance, reducing readmissions and reducing unnecessary bed occupancy
• Mental wellbeing of older people in residential care
• Management of physical and mental co-morbidities of older people in community and residential care settings
• Medicines management in care homes

Work on two pilot health and social care quality standards is already being undertaken by NICE. Guidelines for the standard of care of people with dementia and the health and wellbeing of children in care will be published in April next year.

Dr Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE, said the Institute welcomed the request by the DH to develop the quality standards as part of its new role.

“It’s important for health and social care services to work in tandem and the standards we develop will play a vital role in ensuring services are closely aligned to ensure effective, high quality patient care is consistently achieved.”

The new Care Services Minister, Norman Lamb, was strongly critical of the Health and Social Care Bill in its original form.

His argument that the new NHS system was being “rushed into” without regard for the needs of GPs helped to stimulate amendments to the reform plans following the ‘listening exercise’.

Lamb is considered a leading Liberal Democrat spokesman on health, but political disagreements with Andrew Lansley led to his being denied a ministerial post until now.

In April 2011, Lamb threatened to resign from his position as chief political advisor to Nick Clegg if the Health and Social Care Bill was not amended.

His main concern was that the reform was not “evolutionary”: the changes were being “rushed into” without keeping GPs on board. He argued for a phased process that allowed GPs to ‘opt into’ the new system.

However, following the ‘listening exercise’, Lamb supported the amended Health Bill and said the Lib Dems had acted as a “safety valve” to allow its improvement.

Lamb’s appointment as Care Services Minister, replacing Paul Burstow, brings into the DH a major source of health expertise – potentially both a support and a counterpart to the new Health Secretary.

Other health ministers have moved on this week: Nursing and Public Health Minister Anne Milton is replaced by former journalist Anna Soubry; while Health Minister Simon Burns, promoted to Transport Minister, is replaced by former Health Select Committee member Dr Daniel Poulter.

Earl Howe, who steered the Health Bill through the House of Lords, keeps his ministerial role.

Patient feedback on GP practices, including an overall score out of 10, is now available on the NHS Choices website.

The DH claims the new online feature will empower patients both to express their views and to choose the best GP practice for their needs.

The BMA has criticised the new system for reducing multi-factorial patient experience to a single metric.

Patient feedback has been used to evaluate more than 8000 GP practices, based on several factors including ease of securing appointments, time spent waiting in reception, opening hours and communication skills of doctors and practice nurses.

The patient experience data have been gathered from responses to the annual GP Patient Survey.

Health Minister Earl Howe said: “This data will not only help patients choose the right GP surgery for them but will also give GP surgeries and the NHS new information they can use to make fresh, innovative improvements.”

A BMA spokesman commented that while enabling patients to give feedback on primary care was a good idea, the new approach failed to elicit “detailed responses” or to “take into account the differing challenges that each GP practice may face”.

Richard Vautrey, Deputy Chair of the BMA’s GP Committee, noted that the metric did not take proper account of patient priorities: “It is the quality of the consultation that is of most concern to patients.”

The Health and Social Care Bill has passed its final reading in the House of Lords and is now only days from becoming law.

The final vote in the House of Commons today will follow an emergency debate forced by the opposition.

An attempt to delay the Lords vote until the publication of the risk register for the planned NHS reforms was defeated by Conservative and Lib Dem peers.

During the final Lords debate, 25 protests against the Health Bill took place across the UK.

A motion tabled by Labour peer Baroness Thornton called for the Bill to be dropped because it did not have the support of patients, clinicians or the public and would drive the “fragmentation and marketisation” of the health service.

It was defeated by 269 votes to 174, with the support of only one Lib Dem peer.

A further motion by crossbench peer Lord Owen, calling for the Bill’s third Lords reading to be delayed pending the publication of the NHS transition risk register, was defeated by 328 votes to 213.

The Freedom of Information Tribunal recently upheld the decision by the Information Commissioner that the risk register, which the Government has now withheld for 15 months, must be published.

Shadow Health Secretary Andy Burnham commented that it was “highly unsatisfactory” for the information about the risks of the Bill’s implementation to be denied to MPs until after their final vote.

“Parliament has a right to know, before it is asked to make a final judgment that will have huge implications for every person in this country,” he said.

However, Health Minister Earl Howe (pictured) told the Lords that considering the transition risk register to offer some “deep insight into what this bill means for the NHS” was “an absurd proposition”.

Labour has forced a 90-minute emergency debate today on whether MPs can approve the Bill before the risk assessment has been published.

If approved by the Commons today, the Bill could receive Royal Assent and become law later this week.

The Government has again made amendments to its Health and Social Care Bill as it attempts to address Liberal Democrat concerns.

Further safeguards have been added over private patient income and to clarify and extend the compliance powers of Monitor over foundation trusts.

Health Minister Earl Howe hopes the amendments will provide “ongoing reassurance that the NHS will always operate in the interests of patients”.

However, the series of amendments which have been added to the Bill during its passage through Lords are still not enough for certain Liberal Democrats. Activists are aiming to hold a vote to axe the reforms at the party’s spring conference later this week.

The amendments to the powers of Monitor will now see it able to direct foundation trusts to change their boards when there are concerns it “will fail to comply with the conditions of its licence”, said Earl Howe.

Although it will not maintain its existing compliance regime over trusts, it will mean the regulator continues its extensive powers over foundation trusts until the health secretary makes a parliamentary order.

Changes have also been made on the issue of trusts benefiting from income from private patients. The amendments will now mean trusts will have to declare annual plans to increase non-NHS income. If these plans aim to increase income by five percentage points of overall income, the Department of Health would then have to agree to the proposals.

“The principles of our modernisation plans – doctors and nurses making decisions, patients being at the heart of the health system, and less bureaucracy – have always been at the core of the Bill,” said Earl Howe.

“These principles are widely accepted according to the independent NHS Future Forum. We will continue to work with peers to provide the reassurance and clarity necessary as the Health Bill progresses through Parliament.”

The controversial Health Bill returns to the Lords this afternoon.

Changes to the Health and Social Care Bill have been announced in response to emerging cross-party opposition in the House of Lords.

According to Health Minister Earl Howe (pictured), the Department of Health will table amendments that preserve the responsibility of the Health Secretary to maintain the NHS as a comprehensive public service.

A further amendment will prevent CCGs from withholding care from certain patient groups on the basis of ‘lifestyle’.

The decision follows statements by the Royal College of Radiologists and the Royal College of Psychiatrists of their opposition to the Bill, joining the BMA, the Royal College of Surgeons and the Royal College of Nurses.

With the College of Emergency Medicine and the Royal College of Physicians also expressing serious concerns, Health Secretary Andrew Lansley’s repeated claim that the reforms have the broad support of the medical profession is looking increasingly exposed.

Recent criticisms of the Health Bill in the House of Lords have been led by the LibDem peer Baroness Williams and the Conservative peer Lord Mackay of Clashfern, as well as Labour’s Baroness Thornton.

The latter described the new amendments as a “massive climbdown” by Andrew Lansley, but said that attention still needed to be paid to the part of the Bill dealing with competition.

Concern has focused on the potential fragmentation of the NHS: both the scaling down of provision from a ‘comprehensive’ service to a ‘basic’ service, and the wholesale conversion of NHS services into private franchises reimbursed by the NHS.

In a letter to a group of peers, Earl Howe commented: “There seems to be an emerging consensus about how the bill can be improved in order to put beyond doubt the secretary of state’s accountability for the health service.”

Organisations representing hospital doctors and A&E doctors appear likely to add to the clinical opposition to the reforms. The members of the Royal College of Physicians have called for an emergency general meeting to condemn the Bill, while the College of Emergency Medicine has expressed serious concerns.