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 NHS is limiting patient care by reducing access to medicines in order to achieve short-term cost control targets, the ABPI has said.

At its annual conference, the industry association emphasised that France, Spain and Germany spend three times as much per patient on new medicines as the UK.

While it focused on medicines, the ABPI statement echoed comments from the NHS Confederation on the way that ‘salami slicing’ of healthcare is being used as a short-term financial solution.

Both organisations are calling for service redesign to shift healthcare from the hospital to the community, rather than further cutbacks to existing services.

In particular, the ABPI noted, denying patients access to new medicines on grounds of cost is holding back the treatment of long-term conditions within the community, while giving hospitals more work.

Spending on new medicines is set to rise by only 1.3% by 2015 – half the projected increase in total NHS spend, and far below the rate of inflation.

The UK spends 74p per person per day on medicines, compared to over £1 in Spain, Germany and France. It spends only 7p per person per day on new medicines, compared to over 20p per day in those countries.

Stephen Whitehead, Chief Executive of the ABPI, said: “Our healthcare system needs to focus much more on caring for patients in their own homes and much less on treatment in expensive hospitals. Investing in new, innovative medicines will be absolutely key to this.

“By 2015, the new medicines which are being launched now will make up just 2.5% of the entire medicines budget, and yet it is these treatments which are able to transform the way many diseases are treated.”

The rapid pace of NHS reform means that the pharmaceutical industry needs new strategies for joint working to create and sustain commercial opportunities. Diana Vegh, NHS Partnership Manager at the ABPI, describes how the Association is working to develop a joined-up partnership strategy across the new NHS landscape.

The NHS has been going through one of the largest reorganisations since its inception – Sir David Nicholson famously describing it as “so big, you can see it from space” – and the implications for the pharmaceutical industry, particularly regarding the joint working agenda, are significant. So much so that the ABPI has established an NHS Partnerships Team, led by Kevin Blakemore, with one senior manager covering each of the four NHS England regional offices. The concept has been driven by Stephen Whitehead, our CEO, and was piloted several years ago as the ABPI Outreach Team – which made constructive inroads in the South-West, a challenging health economy to work in.

I am one of those regional managers, ex-NHS and industry, based in Devon, and covering a territory that stretches from Penzance to Margate. The population is 13.4 million, with a budget of £21.1 billion and 110 NHS organisations. There are 1,873 GP practices, 34 local authorities (with three unitaries), four clinical senates, five Academic Health Science Networks, seven Area Teams, three specialised commissioning hubs and 51 CCGs. And it’s a 14-hour return journey from one end to the other. Plus we’re a trade association, with limited resources. With such a large number of potential customers and new organisations, how do we make the best use of our time?

RIGS strike oil

Each of us has produced a regional business plan, aligned to member company priorities, broadly supporting our themes of value and partnership, and clustered around 11 core corporate objectives. These have all been discussed and agreed by our Board of Management, which is made up of member company executives. The most important objective for my team is improving the environment for access and uptake of innovative medicines. We’ve segmented our rapidly evolving customer base and developed stakeholder maps for engagement. But pivotal to helping us navigate this complex structure has been the establishment of our Regional Industry Groups or RIGs, one per region, which meet monthly. General managers of our member companies have nominated senior representatives to sit on these groups, and we are adding associates who will join us virtually, i.e. online, via WebEx and telephone conferencing.

My RIG is chaired by Lisa Rosewarne from MSD, and our deputy Chair is James Steed from Pfizer. We have agreed our Terms of Reference and work plan for 2013, with a series of five workstreams and virtual task and finish groups led by RIG members, focusing on industry-wide issues from medicines optimisation to the Formularies Good Practice Guide. We often have external speakers who may not meet with single companies but are happy to talk to a group – such as Steve Sparks from NICE, who manages the field-based Implementation Team, and who recently gave an excellent presentation at one of our meetings. We also connect our RIG to the national policy work we do, and communicate across the other ABPI teams.

We’ve had a number of ‘bids’ from the NHS and healthcare companies who are interested in working with the pharmaceutical that there is a need for external organisations to understand better what joint working truly means in terms of the ‘Moving Beyond Sponsorship’ work done by the ABPI and the Department of Health in 2010. Our key tool for this has been the Joint Working Guide, and in particular the sections on pages 7 and 8. One of our RIG workstreams is to use these guidelines to engage with potential partners in order to share constructive feedback and highlight examples of best practice that we are collecting from member companies.

We showcased this at a conference with the NHS Confederation in February this year, in London. We have a Memorandum of Understanding with the NHS Confederation and the ABHI to work on the Innovation, Health and Wealth agenda collectively; and this national policy work is essentially what we’re putting into practice in our regions.

Rules of engagement

In my day-to-day job and in my meetings with NHS stakeholders, I work to promote the whole pharmaceutical industry and a more mature working relationship with us. The majority of my discussions have been very positive, with a clear desire to move away from the old models of promotional metrics and explore a new way of working. Some CCGs, such as Torbay and South Devon, are striving to be ahead of the curve. Others are more conservative and prefer to agree a new policy on joint working first, and we’re trying to encourage the use of our toolkit and case studies.

But one thing I’m very clear to emphasise is that my team isn’t ‘the’ route into pharmaceutical companies. If an NHS organisation wishes to work directly with a company, of course it can. We are not competing with market access teams – we are enablers and facilitators – and the ABPI Code of Practice gives the NHS assurances about governance and conduct. But some organisations remain difficult to reach. I’m using good examples of joint working elsewhere in the NHS, or pragmatic discussions in other parts of the organisation, to overcome those barriers.

After all, partnership isn’t about pretending that everything’s fine and there aren’t any problems. But it is about moving to a place where you can agree to disagree, and solve your problems together even if you have differences. . e table above shows the framework I base my work on.

On the whole, projects seem to fall into three categories. The first category is disease specific projects, which often relate to long-term conditions such as COPD, diabetes or vascular health. Some of these can be quite broad, while others can be about specific service redesign projects in a particular health economy and relate to implementing new national guidance. The second category is projects that relate to an NHS priority, such as reducing inequalities, where industry expertise in social marketing and media has been put to excellent use. The final category, and the one expanding most rapidly, is where we have shared aims: improving patient safety, reducing medicines wastage, better adherence, realising the benefits of treatments – i.e. the medicines optimisation agenda.

Moving the goalposts

Those of you with a lot of experience may be reading this with a sceptical eye. Hasn’t this all been done before? Talked about before?

Yes. But this time, there are some key differences. The clinical voice is louder, and often in a leadership position. Attention is far more on quality than in the past, and the sanctions are greater. And while our austere financial climate is squeezing medicines spending, increasingly senior people are seeing that it is disingenuous to look at medicines solely as a cost pressure, and far more beneficial to see them as a means of improving health outcomes – on which the NHS is now being more tightly measured. New organisations also have a legal duty to innovate, which is now in primary legislation as part of the Health and Social Care Act. The new Academic Health Science Networks have been set up as companies, and though many focus on the earlier part of the medicines life cycle they will all be looking for new partnerships.

Pharmaceutical companies are also changing. We’ve gone from Share of Voice to Key Account Management, and the skills and competency mix of pharmaceutical field teams is very different from how it was a few years ago. When I’m out and about I’m meeting people with new roles, such as service development managers, NHS business managers and strategic account managers. And there have been a lot of redundancies in the NHS which have seen knowledge and skills move into the pharmaceutical industry. Today I had an email from a CCG asking me how they could second someone into an ABPI member company.

We are in a ‘perfect storm’ of policy, and the organisational turbulence we’ve all experienced is bringing some very forward-thinking and creative people into senior positions. Let’s make the most of that, and work together to get better outcomes for the populations that we live in and for the organisations that employ us.

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 focus of NHS investment needs to shift from large acute hospitals to community and home-based services, according to the NHS Confederation.

A new report, Transforming Local Care, argued that “significant” investment in making the community the “default setting” of healthcare is needed to meet the combined pressures of increasing demand and shrinking budgets.

Hospital inpatient services can be reserved for complex surgery and treatment of life-threatening conditions, the report said – but major and visible improvements in community-based care need to take place at the same time.

The NHS Confederation, which represents commissioner and provider organisations, called for long-term condition management to be shifted decisively out of the hospital framework.

It highlighted the proven value of strategies such as home monitoring, mobile diagnostics and medication adjustment in helping to keep people out of hospital.

While these strategies were recommended by Lord Darzi’s NHS review in 2008, the “unprecedented” economic pressures have made them urgent priorities for national adoption, the report argued.

Calling on the NHS Commissioning Board to “facilitate the necessary shift in the financing of care”, the Confederation outlined the need for payment incentives to promote prevention, early intervention and early supported discharge.

Crucially, it added, efficiency savings must be reinvested in community-based services, instead of being claimed by the Treasury (as currently happens).

“It is time we started thinking differently and making sure investment supports innovative service delivery that supports patients’ independence and recovery,” said Jo Webber (pictured), the NHS Confederation’s interim Director of Policy.

“For too long, the default setting when we think about healthcare or support is to think of a hospital. But in reality, acute hospitals are rarely the best place for someone who needs ongoing treatment.”

Health and wellbeing boards (HWBs) across the country will have to work closely with local providers of health and care services if they are to be successful, a new report warns.

The NHS Confederation’s report argues that the new responsibilities of the boards, such as creating joint strategic needs assessments and health and wellbeing strategies, can only be met effectively with the help of local assistance.

Jo Webber, Interim Director of Policy at the NHS Confederation, said HWBs would need to take a flexible approach to working with local providers if they are to successfully tackle regional priorities.

The report, Stronger together: how health and wellbeing boards can work effectively with local providers, outlines how local providers must be engaged with to build and establish strong links for service users.

“Over the past year (with funding from the Department of Health) we’ve produced a toolbox of resources to support newly-established health and wellbeing boards,” said Jo Webber. “With this latest publication, all the learning and advice from those with direct experience of engaging with health service providers – from big acute trusts, community service providers, and voluntary sector organisations – is being shared throughout the system, so the new boards can make use of the best tools for their local needs.”

The report was developed as part of the National Learning Network for health and wellbeing boards, which was funded by the DH and supported by the NHS Confed, the Local Government Association and the NHS Institute for Innovation and Improvement with the aim to share the learning and support of well-functioning HWBs.

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.