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 Care Quality Commission (CQC) has launched a three-year plan for co-ordinated quality regulation of integrated NHS and social care.

The strategy creates roles for three new chief inspectors: one for hospitals, one for social care and one for integrated care.

It also outlines the new appraisal system for health and care providers, based on four Ofsted-style ratings: outstanding, good, requires improvement and inadequate.

Responding to recent criticisms of its performance by the Health Select Committee and in the Francis report, the CQC has appointed a new Chairman and Chief Executive and taken on another 200 inspectors.

The three-year plan aims to ensure more extensive inspections and clearer information for patients on the safety and quality of providers.

“This is an important moment for the CQC,” said Chairman David Prior. “We have recognised we need to change and are determined to do so swiftly.”

Mike Farrar, Chief Executive of the NHS Confederation, commented: “It is clear the CQC is working hard to regain the confidence of the NHS and the public.

“This strategy shows a strong commitment to developing a system that is responsive, specialist in its sector and provides people with the information they need about the services they use.”

The new NHS structure came into force on 1 April, with local commissioning now entrusted to clinical commissioning groups (CCGs) that combine business and clinical expertise.

The CCGs are managed by NHS England (formerly the NHS Commissioning Board) and governed by new laws that enforce a ‘level playing field’ for provider competition.

The 152 Primary Care Trusts are now abolished, and all NHS hospital trusts are required to qualify for Foundation Trust status within the next year.

NICE, renamed the National Institute for Health and Care Excellence, will set standards for both health and social care services, promoting integrated care.

The statutory role of CCGs in facilitating competition between providers of NHS services has polarised opinion, with only a third of GPs in a Pulse survey saying they felt empowered by the new system.

According to private health analysts Laing and Buisson, the NHS in England spent 11% more on services from private providers in 2012 than in 2011 – a clear sign that the provider base is already shifting.

Professor David Haslam, the new Chairman of NICE, commented: “It is a time of huge risk. We know in medical care in hospital that the greatest risk is when patients are being handed over from one person to another. It is a risky time for the system, so it is important that the big players work together.”

Mike Farrar (pictured), Chief Executive of the NHS Confederation and a long-time champion of community-based healthcare, warned that trying to improve patient safety while reducing costs would place great pressure on the new NHS.

“We need to recognise the huge challenges facing the health service,” he said. “New structures alone won’t enable us to tackle these challenges, and we should not see them as a silver bullet.”

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 ‘Nicholson challenge’ of NHS cost-cutting is being met through “short-term fixes” that block service redesign, according to the Commons Health Select Committee.

The three main methods used to reduce NHS costs have been tariff reduction, staff pay freezes and ‘salami slicing’ of providers, the MPs noted.

The Committee also observed that NHS cost savings being ‘clawed back’ by the Treasury defeated the stated aim of the savings: to create funding for service redesign that would reduce long-term costs and improve performance.

In contrast, it said, the means being used to cut £6bn each year from the NHS budget were not sustainable and harmed services.

The report found that in 2011–12, £2.4bn was saved through tariff reductions and £850m through pay freezes, with similar cuts planned for 2012–13.

It warned that these and other “short-term fixes” would be “increasingly difficult” to repeat, and that NHS commissioners needed to aim at “genuine and sustained service integration.”

Chair Stephen Dorrell said the reliance on tariff reduction “tends to have an undesirable effect of encouraging salami slicing of individual providers rather than imaginative system redesign.”

In addition, he argued, “it gives the commissioners a cop-out” when they “ought to be stage centre in the process of service re-imagination”.

The Committee warned that assuming “NHS pay will continue to fall relative to pay elsewhere in the economy” was “neither prudent nor just”.

It recommended that NHS commissioners and providers be allowed to use cash reserves to fund service change, rather than lose them to the Treasury.

Mike Farrar, Chief Executive of the NHS Confederation, commented: “We need to look beyond the short-term options and consider more radical solutions that will improve care in the long term.”

The Labour Party has outlined plans to integrate health, mental health and social care in a single system, ultimately run by local government.

Shadow Health Secretary Andy Burnham has argued that such a ‘whole person care’ approach is the only way to meet the challenges of chronic illness and the ageing population.

The current system, he argued, merely sees patients slipping in great numbers from primary care to hospital and hence to nursing homes.

Speaking to the King’s Fund health think tank, Burnham said a Labour government would legislate for “a one budget, one service approach”.

Health and social care would merge, he said, with the NHS providing social care and local authorities commissioning healthcare.

Echoing recent statements by NHS Confederation leader Mike Farrar, Burnham said that integrated care was the only way to meet the clinical and economic needs of the NHS.

To shift the balance of healthcare towards prevention, he argued, the Payment by Results tariff needed to be replaced by a ‘year of care’ payment system for patients with complex needs or chronic diseases.

The providers of integrated care might be either acute NHS trusts or primary care services, he said, but in either case both services would be combined – with mental health services brought under the same control.

Burnham said: “In the century of the ageing society the gaps are becoming dangerous. People are falling into the ever-expanding cracks between our three systems. We are paying for failure, allowing people to fail at home and drift into expensive hospital beds and from there into expensive care homes.”

However, critics will argue that local authorities lack healthcare expertise and are often the least responsible and reliable kind of politicians.

Mike Farrar, Chief Executive of the NHS Confederation, has called for a systemic shift in the NHS from acute care towards integrated, community-based services.

In his New Year message to the NHS, he argued for greater proportional investment in “primary, community, mental health and social care services”.

Farrar emphasised that NHS reform could not deliver long-term improvement if it focused on short-term cost savings.

Echoing his previous statements, Farrar said that deep cuts in acute and emergency care were necessary to build a more “sustainable” NHS that focused on helping patients to remain independent.

“The care needs of people have changed considerably since the NHS was established 65 years ago,” he said. “But the way people receive care and treatment has broadly remained the same. We need to modernise how we deliver care, where we provide it and when patients can access it.

“We know we can improve many of the routine services that patients receive so they can be provided at home or closer to home. Not only will this help relieve the growing pressure on our hospitals, but it will help people retain their independence and still be part of their local community.”

The public should demand more services that help them stay out of hospital, rather than more hospital beds, he argued, while politicians should not try to protect their seats by opposing the local consequences of their own policies: “Politicians can’t vote to limit the resources of the health service with one hand, and then resist change on the other.”

Farrar also urged clinicians and those running local services on the ground to explain and justify service changes to patients and the public; to provide accessible and comparable information on standards of care; and to support healthier lifestyles.

His core argument was that “to ensure that our health service is improving in the long term, not just running to stand still,” there needs to be deeper investment in services to keep people out of hospital, including transfer of care.

The clinical networks set up to improve cancer care have seen their budget cut by 25% in three years, with a severe impact on their performance.

Projects such as accelerating cancer diagnosis – the kind of efficiencies praised by Sir David Nicholson in his NHS review – may not be possible in future.

Clinical networks to improve stroke and heart disease treatment have also been cut back, though less dramatically.

The 28 cancer networks and 28 cardiovascular networks will be amalgamated into 24 larger networks (12 of each type) after April 2013, with the cardiovascular networks also covering diabetes.

Funding for the cancer networks has been cut by 25%, with loss of 73 staff. The heart and stroke networks have lost 12% of their funding and 38 staff.

Shadow Care Minister Liz Kendall said the feedback from clinical networks revealed them to be “in chaos”.

She noted: “Ministers have repeatedly promised to protect the funding for clinical networks.”

The clinical networks guide and support service redesign to increase clinical effectiveness and efficiency – which, NHS Confederation leader Mike Farrar argued this year, is a principle to which the NHS only pays lip service.

The clinical networks reported the cancellation of programmes that have successfully supported doctors and nurses in the past, providing specialist input into challenging areas of NHS care.

A cancer specialist from Yorkshire commented that the new Yorkshire and Humber cancer network “will be too big to be able to reflect local capabilities and needs, yet too small to have the authority of national guidelines”.

Professor Sir Mike Richards, the National Director for Cancer, said the next few weeks would be unsettling and difficult for the cancer networks as services were cancelled and staff made redundant.

The NHS Confederation has appointed Michael O’Higgins as its new chair.

Mr O’Higgins replaces Sir Keith Pearson who departed in June 2012 to take up a similar position with Health Education England.

The new chair said he has “long admired the work of the NHS Confederation” and is “excited about making the most of this position to speak on behalf of the NHS.”

He joins the Confederation with immediate effect after leaving as chair of The Pensions Regulatory. Mr O’Higgins has previously held similar high-profile roles at the Audit Commission and the Treasury Group Audit Committee.

Mike Farrar, NHS Confed Chief Executive, said the new recruit is a highly respected figure following his work within the NHS and local government. “His extensive knowledge of the health and social care sector means that he will be invaluable in developing our relationships right across the wider care sector.”

Maxine Vaccine raises an eyebrow at the ABPI’s declaration that the ‘social contract’ between the pharma industry and the NHS has broken down. What do they think has been going on for the last few years?

Hi folks. Sorry I’ve been quiet on the blog front for a while. Bit of a busy time. Also, I’ve been struggling with a seasonal respiratory infection. Being mindful that overuse of antibiotics dilutes their long-term effectiveness, I left it a fortnight before dragging my shivering self to the local medical centre and asking for some.

My GP offered me a week’s worth of generic amoxicillin – the Special Brew of antibiotics, cheap but potent – but I held out for the more refined (and branded) huletthemycin from Munchkin Pharmaceuticals. Anticipating my argument that GPs should not be refusing NICE-approved medicines to patients on grounds of cost, my GP did a quick search and tilted the screen towards me so I could read the relevant NICE appraisal. To focus my reading, he had highlighted the phrase “worthless crap”. I told him they had meant to say it was “reassuringly expensive”. He made a kind of “harrumph” sound and dutifully applied his healing hands to the keyboard.

A week later, I was back at my desk in the comfy offices of Munchkin Pharmaceuticals, sipping coffee and reading the latest ABPI press release. Stephen Whitehead told the Association’s annual conference that the “social contract” between the pharma industry and the NHS, which has lasted for decades, has now “broken down”. Companies can no longer trust the NHS to buy gold standard medicines that they have spent blood, sweat and tears in developing. Austerity was not only damaging patients but damaging the industry, which had lost 16,000 jobs in the UK in four years.

If I weren’t at risk of another coughing fit, I would laugh out loud. I’m sorry, Stephen, but where have you been the last four years? We’re in the depths of the worst economic collapse since the 1930s. Companies everywhere are going down like ash forests hit by fungal blight. So many people are out of work that the Government is trying to find new ways of not paying them any benefit – as if that would make millions of new jobs appear. Does the ABPI expect a telegram from George Osborne saying “There, there”?

But when he talks about the “social contract” between the NHS and the pharma industry being broken, Whitehead is genuinely rocking the boat. Where was the ABPI when the social contract between the NHS and the people was being torn up? Standing in the gallery, applauding. Now it’s realised that breaking up the NHS and reshaping it as a competitive market takes away the structures that, for decades, gave pharma companies some stability and traction at a national level. Now, local prescribers and commissioners are free to seek the lowest bidder – and not free to do anything else.

The ABPI is learning that when you wave goodbye to the planned, Keynesian version of capitalism, you get what Ted Heath called its “unacceptable face”. In a deregulated, competitive healthcare market, there is no role for the ABPI, because there is no court of appeal for it to turn to and no shared ethos for it to refer to. The message for pharma companies, NHS organisations and patients is: You’re on your own.

But maybe the tide is turning. Whitehead’s speech reveals a nostalgia for the Darzi version of NHS reform: service redesign for long-term sustainability and effectiveness, as opposed to brutal cost-cutting with no element of service redesign. Jim Easton may have quit, but Mike Farrar is still making the case for a coherent and planned NHS that does things better. Perhaps the pharma industry is realising that you can’t have a social contract if, as Margaret Thatcher put it, there is no such thing as society. And it’s beginning to ask whether there could be a different approach.

Or maybe the antibiotics are making me dream.

Maxine’s views are not necessarily those of Pharmaceutical Field.