NHS emergency services are facing a major breakdown this winter due to staffing and funding shortages.

Reviews by the College of Emergency Medicine and the Foundation Trust Network have warned that A&E demand is continuing to outstrip capacity.

Health Secretary Jeremy Hunt responded that better “joined-up thinking” between health and social care was necessary to reduce the demand.

A&E attendance figures have increased by 50% in the last 10 years, due to a number of factors: the ageing population, lack of out-of-hours GP services and, more recently, problems with the new 111 helpline.

The College of Emergency Medicine surveyed more than half of UK’s A&E units and concluded that a shortage of both middle-grade and senior doctors was weakening the service.

In addition, it said, as many as 30% of patients attending A&E could be treated in non-emergency settings, given better access and information.

The Foundation Trust Network (FTN) noted that some hospitals are losing millions of pounds each year due to current rules designed to reduce A&E admissions.

Where A&E admissions rise above the 2008–9 level, the hospital is only paid 30% of the normal fee for each admission.

Fining hospitals for having too many A&E patients was no way to improve services, the FTN said.

Its Chief Executive Chris Hopson argued: “Unless we can change the funding structure, the A&E system is going to fall over. We simply cannot carry on.” This winter was likely to see the collapse of the A&E system, he warned.

Health Secretary Jeremy Hunt commented that the underlying problem was “a lack of joined-up thinking between the health and social care systems which we’re sorting out”.

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 Hotel Russell, Bloomsbury, sets the scene as Detective Inspector Pinching pulls up two tan leather armchairs for another caffeine-laced exchange. The man he’s facing is GSK’s Director, Academic Liason, CBE and Harry Redknapp-tormentor, Malcolm Skingle.

It’s bloody freezing. I need a chat that’s going to warm my cold editor’s heart. I arrive, and an incredibly enthusiastic woman leads me into the upmarket reception room of this legendary bed and breakfast establishment. Malcolm has the relaxed expression of a man who has stayed in practically every hotel on Trip Advisor. It was time to talk about football, erm, I mean pharma.

Hello Malcolm, what’s your story?

I trained as a pharmacologist and this defined the first half of my career, before I eventually started running a research group. I was fortunate to be part of a great department and during my time in the labs we discovered and developed some ground-breaking medicines including, Zantac, Trandate, Salbutamol, Salmeterol, Imigran and Zofran. After 20 years of bench science, I went to work at the interface of academia and industry, and this is an area I now know well. In the past the interactions between universities, medical schools, funders and pharma were clunky, and the challenge has been to vastly improve these vital relationships.

What exactly does your job involve?

I leverage science that helps underpin what GSK is doing. That might involve a technology that the company needs to drive one of its programmes, or talking to the head of a funding agency about working together on a certain scientific topic. I’ll form collaborations with anybody, either carrying out or funding good science; this includes government departments, charities such as the Wellcome Trust, the research councils and universities. We have academic collaborations in around 50 UK universities and interact with educational institutions in over 25 other countries.

How has your role changed over the years?

Universities and pharma companies are now far more open to collaboration. Twenty years ago big pharma would work in secret and not share information and best practice. We used to be fat cats, and money wasn’t an issue, but things have changed quite dramatically as companies try to get their research budgets to stretch further. We now work together in consortia, underpinning in-house efforts. The Structural Genomics Consortium, Dundee signalling consortium and EU Innovative Medicines Initiative are all collaborations where several pharma companies fund joint projects and share information. This type of activity will increase in the future as we collectively create the new knowledge required to develop new medicines.

What is your relationship like with the ABPI?

I sit on the Innovation Board and chair their academic liaison group. GSK takes the lead in several areas and we use it to share best practice. Pooling knowledge and data is positive for the industry.

How pivotal is the ABPI’s role in terms of reform?

They’ve got big responsibilities when it comes to collating messages from different pharma companies, who may not always have identical views on certain topics. Stephen Whitehead works hard to collate and articulate a consensus view.

Where do you stand on Ben Goldacre (metaphorically speaking)?

I’ve never met him, but I’d like to. The industry gets a bit beaten up in his book, but I do agree that we need to build greater trust with both the public and media. You need radicals like Ben Goldacre to make people rethink certain issues. I joined Glaxo straight from school; did my degree and PhD through the organisation and, in 40 years, I can put my hand on my heart and swear on my children’s lives, that I have never seen anything unethical.

How important is transparency and sharing information?

Companies are at different stages of wanting to share. Our Chief Executive, Andrew Witty, is a great leader and the sort of guy you would follow over the wall into battle. He was the first pharma chief exec to say that we’re going to publish all our clinical trial data. Some other companies aren’t quite there yet, but I am sure they will come around in the near future. It is vitally important to share data with other scientists, so that it can be validated.

GSK seems like an organisation that likes to be ‘out there’

We’re easily the most visible pharma company at the academic-industry interface and we have more collaborations than anyone in the country. This includes, not only pharma, but also companies from other sectors like aerospace and energy. Every two years the ABPI collect the data from all UK pharma, and GSK publish it. Part of my mission is to go around talking about what we do and I am passionate about GSK being transparent, our great science and being a good partner.

What partnership venture are you most excited about?

We’ve got an open access lab in Tres Cantos, Madrid, working on diseases in the developing world. This includes high containment facilities for pathogens, 120 GSK scientists and the capacity to take an additional 60 outsiders. The open access agreements mean that if someone has a bright idea for treating malaria or TB, for example, you can go there and have access to our chemistry and drug development technology. We’re serious about making a difference.

What successes have emerged from this project?

Five of our scientists screened two million compounds, by hand, in order to find leads against the deadliest malaria parasites. We then published a database last year containing all the 13,500 structures, which anybody can access as potential leads. Over 80% of these were proprietary and discovered by GSK. We want to share, as we can’t possibly carry out all the science connected with something like malaria on our own, so we stimulate interest in order to take a drug through. It’s been so successful that MMV (Medicines for Malaria Venture) has provided our compounds to more than 100 labs around the world. People feel proud to work for the company because of that.

Tell me more about what you’re doing with the universities

The most fruitful thing we do is post-doc collaborations that involve intellectual inputs from both the academics and us. We will also, at any one time, have around 250 PhDm studentships, which we co-fund with the research councils.

Are GSK keen to continue operating in the UK?

We’ve got a chief executive who is British, he’s Chancellor of Nottingham University and we’ve got our headquarters in Brentford. Does that sound like a company that’s just about to bugger off to New Jersey?

Malcolm, you’re clearly on the road a lot how do you strike the old work/life balance?

My wife is very understanding – I earn reasonable money and she’s good at spending it – and I’ve got two wonderful daughters. I love sport and used to play semi-pro football in the Isthmian League, and that has helped me to apply myself 100% to everything I do.

Hold on, who did you play for?

Firstly, Bishop Stortford – my home town – then Borehamwood for six years, before the company moved me to Greenford, and I joined Kingstonian. When they moved me back again, I played for Hertford. We had a few cup runs at Borehamwood, drawing at home with Swindon Town in the FA Cup, and losing the replay 2-0; we also won the league with 103 points. I don’t think that total has ever been beaten.

What position did you play?

I was a winger and also used to score goals, playing off a big man. When I got slower I drifted into central midfield.

Did you encounter any big names?

Yeah, I would regularly play against people, either on their way up or coming back down, like Gordon Hill, who was at Southall and went on to play for Manchester United and England. Sometimes I think I’m dreaming it, but when Bobby Moore finished playing and West Ham more or less dumped him, he managed the Oxford City team that I scored against. I remember it was pouring down with rain that day and Harry Redknapp was playing for them, just before his managerial career took off.

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.”

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.

Vaccines are the most important breakthrough in modern medicine: the jewel in the crown of the pharma industry. What can the success of vaccines teach us about healthcare and the industry’s commercial model?

Out of the virus immunity comes.

Killing Joke’s lyric uses vaccines as a metaphor for the human ability to find a positive meaning in the darkest threat. The history of medicine has shown, time and again, that every disease holds the seeds of its own treatment – but to find the answer, you have to look deep inside the problem.

It has been said that no other health initiative, with the exception of clean drinking water, has done as much as vaccines to improve public health. Medical sales professionals love selling vaccines, for two reasons. Firstly, their potential to protect the young and the old against highly dangerous diseases is beyond reasonable doubt. Secondly, the sales model for vaccines is as dramatic as its medical impact: the supplier becomes responsible for securing the immunity of a population.

Yet, on the face of it, the public might wonder what the fuss is about. Vaccines are one-off medical treatments that protect against specific infections. Many are prophylactic: they don’t work if you have the disease. They are not 100% reliable, since pandemic infections have many competing strains. And they can have harmful side effects. So why should healthy people bother?

The answer lies in the list of deadly and disabling diseases that once cast a shadow over human life, but now are preventable: smallpox, polio, tuberculosis, measles, mumps, chickenpox, typhoid, cholera, bubonic plague, rabies, tetanus, diphtheria and pneumonia. For some viral infections, vaccines are the only effective treatment.

Vaccination programmes demand collaboration across disciplines and borders to protect populations and share medical innovations.  This collaboration model meets with scepticism on two sides: those who mistrust public health provision and those who mistrust the pharma industry. It’s not surprising, therefore, that vaccines meet with antagonistic campaigns and conspiracy theories from a coalition of unreason.

The body’s weapons

Vaccines are different from conventional medicines because they do not directly attack the disease: they provoke the body’s natural immune response against the disease, like a mock-invasion used as a military training exercise. A vaccine dose consists of dead or inactivated disease organisms, or biochemical agents derived from them. In designing a vaccine, scientists trade off risks and benefits.

The first vaccination was conducted by the rural English physician Edward Jenner in 1796. Hearing that local milkmaids who contracted a minor infection called cowpox never seemed to contract the deadly smallpox, he deliberately infected a farm lad with cowpox and then, when he had recovered, with smallpox. (Medical research ethics have improved somewhat since then.) The use of a live disease culture for immunisation is now called inoculation.

The first use of an artificial vaccine was conducted by Louis Pasteur in 1885, using a vaccine developed by his colleague Emile Roux by dessicating the spinal tissue of rabies-infected rabbits. Pasteur gave the vaccine to a boy who had been mauled by a rabid dog. He came to no harm.

Vaccines are still news, with global mobility and shifting demographics making the challenge of immunity more complex and urgent than before. In 2012, new vaccines were developed to treat meningitis, shingles, rotavirus (a cause of infant diarrhoea) and whooping cough. Vaccination against HPV, the cause of cervical cancer, is a new priority for health systems. The GAVI Alliance, dedicated to providing vaccination programmes for children in the developing world, has funding from the Bill & Melinda Gates Foundation and the support of many pharma companies.

A vaccine coalition

A leading company in the European vaccines field (and the only specialist firm) is Sanofi Pasteur MSD, a collaboration between two major pharma companies with a long history of investment in immunity. Sanofi Pasteur is founded on the work of the Pasteur Institute, while Merck’s Dr Maurice Hilleman developed vaccines for measles, mumps, hepatitis A and B, chickenpox, meningitis and pneumonia. The joint company protects half a billion European people against 20 major diseases.

Paul Hardiman, Communications Manager for Sanofi Pasteur MSD, told Pf about the company’s unique role in the European immunity landscape. There are three reasons for the collaboration, he explains: “It avoids a duplication of effort in the drive to develop new and innovative vaccines. It also allows a focus on the strengths and suitability of vaccines for different markets from both companies’ portfolios. This in turn gives flexibility and supports public health priorities.”

The two parent companies are both deeply involved in the global project of the GAVI Alliance. Both Sanofi Pasteur and MSD “use a policy of tiered pricing (linked to a country’s ability to pay) to enable access to vaccines in GAVI-eligible countries. This has included significantly reduced prices on vaccines against HPV and rotavirus and a pentavalent childhood vaccine against diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type B.”

In the UK, Sanofi Pasteur MSD plays a major role in public health immunisation programmes for children, young adults and elderly people. These “are secured through competitive national tenders, requiring the consistent and timely supply of large volumes of high-quality vaccines”. The company has dedicated vaccine representatives selling directly to pharmacies and GP practices.

“Every year, the Joint Committee on Vaccination and Immunisation (JCVI) carries out a horizon scanning exercise to identify all potential new vaccines expected from manufacturers that may have an impact on public health over the following five years.”

As public health in the UK shifts to local authority provision, vaccine suppliers need to be fully aware of the economics and logistics of immunity. Sanofi Pasteur MSD’s UK sales force are “vaccine experts, engaging with practice nurses and GPs to support them in the areas of vaccine supply, campaign organisation and communication, and the education of vaccinating HCPs.”

The company is now supplying Gardasil for a schools-based vaccination programme to protect teenage girls against HPV and hence against cervical cancer. It is also preparing to supply Zostavax for a national programme, starting later this year, to immunise senior citizens against shingles. In the future, the company hopes to target, cancers, allergies, addictions and diseases of the central nervous system.

Immunisation programmes deliver savings both in the short term (by reducing the need for acute treatment) and in the long term (by reducing disability and chronic illness). As the focus of healthcare shifts further into the community, vaccines are increasingly crucial weapons in the HCP’s armoury. Their value, the company maintains, can be expressed in both health and economic terms.

Diplomatic immunity

In February 2013, nine female health workers responsible for delivering polio vaccination programmes in the Kano province of Kenya were murdered by gunmen after a local preacher condemned the vaccine as a plot to cause infertility. Similar killings have happened in Pakistan. In the US, ideologues opposed to public health programmes have accused the Obama government of spreading disease in order to experiment on the public with dangerous biological agents. The internet has given these conspiracy theorists a large audience.

In the UK, a spurious panic was created around the MMR vaccine by Andrew Wakefield’s article in The Lancet in 1998, which claimed the vaccine was a cause of autism. As the BMJ has recently reported, the article was scientifically discredited within a year, and has since been exposed as an “elaborate fraud” based on research that never took place. However, Wakefield’s claims are still declared to be accurate by the Daily Mail and its bizarre columnist Melanie Phillips.

Why do vaccines inspire so much mistrust? The reasons are complex. Some people believe that harnessing the body’s immune response is ‘interfering’ with nature. Others maintain that public health programmes violate the responsibility of the individual to determine their own healthcare. Still others claim that immunisation programmes are a form of covert surveillance, or even of biological warfare.

Paul Hardiman argues that vaccination may be a victim of its own success: “Anti-vaccine sentiment is thought to arise when people no longer fear the disease for which they are being encouraged to accept vaccination. As vaccine coverage increases, serious disease starts to disappear along with people’s fear of the disease. As people lose sight of the threat, so anti-vaccine sentiment may replace the good reasons for vaccinating – raising concerns in people’s minds.”

Doctor and writer Ben Goldacre, whose book Bad Science is strongly critical of anti-vaccine conspiracy theories, argues that the industry is not blameless: “I think it’s fair to say that anti-vaccine conspiracy theories are a kind of poetic response to the obvious regulatory failure in medicine and in the pharmaceutical industry. People know that there is something a little bit wrong here.”

For example, he notes, the recent murders in Nigeria took place in the same province where Pfizer had run the Trovan antibiotic trial in 1996 – a trial whose controversial nature led to Pfizer paying the Nigerian government £75 million to settle out of court, and inspired John le Carré’s novel The Constant Gardener.

Goldacre comments: “There’s something interesting happening when a very destructive anti-vaccine conspiracy theory built around fear and anxiety that drug companies are behaving badly arises in the same very small province in northern Nigeria where Pfizer have been running a trial which many regard as unethical.”

When I arrive at our agreed location (14 minutes early), I notice that the PM Society’s Anneliese Cameron (General Manager) and Carys Thomas Ampofo (Communications) have already had a coffee and been perusing the last two editions of the rebooted Pf mag. It’s a relief to know these ladies are alert and of uncommonly good taste. As I undrape my burgundy scarf, I realise that I am on the threshold of something rather wonderful. I order more coffee (the card machine is broken and the till guy is unapologetic – I rise above it) and begin the interrogation.

What do you think of the relaunched Pf ?
Carys: How much are you paying us?
As much as it takes.
Anneliese: I think it’s really refreshing to see a pharma mag with a consumer feel to it, and it’s lovely to focus on individuals. It’s got a real community feel.

Enough about me. What role will pharma play, as reform starts to unfold?
Carys: There are opportunities for all the healthcare industries to really help the reform process by not just providing and supporting treatments, but bringing experience from the private sector in order to understand processes, especially at a local level and with joint working.
Anneliese: It’s all about perception and, ultimately, we’re all patients. In the mainstream press there is a lot of negativity but, actually, pharma does a hell of a lot of good and that will continue to emerge in the next few years.

What does pharma need to do, in order to start hanging out with the NHS on equal terms?
Carys: Pharma needs to get smarter. Pharma personnel have to establish the same level of knowledge as the people they are talking to within the NHS. They must understand local needs, the role they can play in improving patient outcomes and how their product might fit into the bigger picture. One of the biggest challenges in the UK is where companies are expected to deliver campaigns that have been developed at a global level. There is no such thing as one size fits all now.

What is the PM Society doing to help people improve their performance?
Anneliese: The PM Society has undergone a period of modernisation in the last 12 months. It has identified some key areas of healthcare marketing that are hot topics at the moment, including market access, NHS partnerships, personal career development, digital platforms and patient engagement. With an interest group in each of these areas, led by an expert in the field, we are looking at providing the information, content and education which tackles those challenges. The role of today’s marketer has changed; there needs to be a much more fundamental understanding of all aspects of the industry, whatever role you work in.
Carys: It’s really important to get everyone that is involved in the drug development process switched on to health technology and marketing needs early on in the trial stages. You will then get the information that is appropriate to support the product, when you actually bring it to market. When the marketers at a national or global level release promotional material they also need to appreciate that the sales rep needs flexibility in how they canvas the information. This requires a significant cultural change.

Can changing a company’s ethos get results?
Carys: The most forward-thinking companies I have worked with in healthcare communications are those that bring everyone around the table, as part of a brand planning team, allowing contributions from all areas of the business and developing a strategy that suits everyone. I worked on one project with Daiichi Sankyo where this approach was put into practice brilliantly.
Anneliese: Yes, they’ve also really embraced info-sharing technology and all its sales staff have an iPad. It’s about presentation; doctors like to see how medication actually works, and what the benefits are for their practice and patients. This is much more exciting if it comes from an iPad rather than a flip chart. These days marketers need to be digital pioneers.

What have been the notable landmarks for the PM Society in the last year?
Anneliese: Personally speaking it would be taking the role of General Manager; a position that the PM Society has never had before. The organisation has been around for 30 years, but it needed to change from primarily a social entity into a forwardthinking, innovative organisation with a solid grounding in business.
Carys: It was a question of drawing a line in the sand, saying, ‘how can we meet our members’ needs in 2013, not 1983’, and preparing the Society for the next 30 years. We now offer greater flexibility, more visibility and, since 2005, marketing-specific modern training programmes, which really make a difference.
Anneliese: In the past we were perceived as bit of a club. But now we are a valued, completely independent organisation run by a voluntary executive committee and dynamic office team.

Do pharma employees regard the PM Society as a support system for their development?
Anneliese: Very much so. We are a none profit organisation, so they don’t feel like there is any pressure from a corporation. We provide impartial advice without charging a fortune for events and content. For me, it’s about making a positive difference during this exciting new phase. Members will also benefit from a partnership agreement we have just signed with the ABPI, which recognises the opportunities to communicate with pharma professionals at all levels.

Your recent market access gig, which I attended, was refreshingly enthusiastic about the possibilities of joint working and breaking down boundaries.
Carys: The meeting was a great example of how the PM Society can help pharma companies develop their skills to meet the changing market. The key experts and experienced speakers from the NHS made pharma employees start thinking about the possibilities of working with public sector colleagues. People attending definitely demonstrated a desire to form positive partnerships; they want to make things happen. It’s also about spreading the word, because inspirational partnerships between the NHS and pharma companies are already happening.

Your awards tend to recognise companies that have demonstrated positivity and teamwork.
Anneliese: The Advertising Awards are about creativity, but it’s also deeper. We examine the campaigns and look at what the outcomes were for both the companies and patients, and how effective those campaigns were in capturing public imagination and making a difference. We also have the only healthcare-specific Digital Media Awards, which last year saw a 30 per-cent increase in entries.

What nuts are you looking forward to cracking in the next 12 months?
Anneliese: I want us to dig deeper into pharma and raise awareness, not to a few individuals in a company, but the entire workforce. We’re very ambitious about creating a real community, which embraces all areas of healthcare. We’re also really keen to introduce ABPI members to our services.

Right ladies, I’m bringing the tone down. You both have high-pressured jobs, what do you do to relax?
Carys: I don’t really have much time to relax! I have three daughters, of six years and under, and have also found myself Chair of the Parent Staff Association (PSA) at their school.

Is that much different to the the PM Society?
Carys: Yes, but the politics are 100 times worse! Being a mother is very much part of who I am; it’s a really difficult balance, as a working woman; giving quality time to your family and also working productively. Intellectual stimulation is really important; I think I’d go mad if I had to spend every day with my children! In the future it would be great to see more professional flexibility for women.

How do you chillax, Anneliese?
Anneliese: I love rugby. I’m a big supporter of Dorking Rugby Club, who my son plays for. My partner is Welsh, so my allegiances have switched a bit, and last year I went to the Millenium Stadium for the first time, to watch Wales vs Italy [John’s internal voice – ‘Traitor!’] I’ve got two dogs and I love walking in the Surrey Hills. My partner recently launched Tillingbourne Brewery, so I help to promote cask ale in my spare time.

Will you be drinking the profits?
Anneliese: There’ll be plenty of market research!

On that note, do you think it’s important that pharma recruits more people from the ‘outside’?
Anneliese: I spent 15 years in the music business. I worked for Polygram [now Universal], on the classical side, during the ‘Three Tenors’ period. Although I didn’t know much about pharma and healthcare when I started, I knew a lot about marketing. I remember in my first year of running the PMEA, at a reception with Rob Wood (then a director at AstraZeneca). He asked me where I came from and, when I told him, he said, ‘that’s fantastic, we need more people from different industries’. Nowadays pharma is bringing talent from other sectors, and that’s really important, because they provide such a range of different attributes. Marketing, advertising and PR skills can always be adapted to a new environment.

You don’t necessarily need to know the secret ‘pharma’ handshake anymore.
Carys: I think it’s changed for the better, and it’s brought fresh thinking. If you only have people from a regulated system it can hinder creativity. Some of the best people I’ve worked with, in pharma, have come from outside, with fresh, exciting perspectives.

To get involved with the PM Society go to www.pmsociety.org.uk.

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.

The ABPI sets out to deliver tailored support and advice to healthcare providers on the medicines its member companies produce. Kevin Blakemore, NHS Partnerships Manager at the Association of the British Pharmaceutical Industry, discusses the advantage of partnerships in healthcare.

The pharmaceutical industry has experienced tremendous change and, as part of that evolution, forming successful partnerships in healthcare has become integral to our way of working. The NHS delivers outstanding care to patients – utilising the innovative medicines the pharmaceutical industry produces – so it makes perfect sense for us to work together, ensuring the best possible outcomes for patients. There are some points, however, to consider when embarking on ‘joint working’ ventures – these partnerships must be managed and guided to ensure that the process is efficient, seamless and offers patients maximum benefit.

Often these partnerships can result in patients spending less time in secondary care settings, and can deliver significant savings. Patients benefit most when those with a stake in their care work effectively, enthusiastically and efficiently together.

Joint working describes situations where, for the benefit of patients, NHS and industry, organisations pool skills, experiences and resources for the joint development and implementation of patient centred projects and a shared commitment to creating a streamlined, joined-up care pathway, where patients are kept at the heart.

Flexible joints
Joint working has already benefited thousands of patients across the UK and to help achieve greater outcomes, the Association of the British Pharmaceutical Industry (ABPI) has developed the ‘NHS Partnerships Team’. My dedicated team work with healthcare providers up and down the country, providing specialist advice and support, while facilitating successful working relationships.

The NHS Partnerships team is made up of eight individuals, each responsible for a different area of England. Their knowledge and expertise includes experience of working within the pharmaceutical industry and the NHS. They also bring their knowledge of innovative and effective medicines created by the industry, and this can be utilised for the benefit of patients. The central focus of the team is improving the healthcare environment in order to increase access to and uptake of innovative products. The team consists of Diana Vegh, Karen Thomas, Carol Blount, Harriet Lewis, Andy Riley, Mike Ringe, Angela Logun and myself.

Diana Vegh started her career in the pharmaceutical industry within regulatory affairs in AstraZeneca, working in scientific roles of increasing seniority. She then moved to the NHS where she held senior positions in the Strategic Health Authority, two PCTs and a Foundation Trust in the South West.
Diana returned to industry in a commercial capacity at UCB Pharma, working in market access for products. She has extensive networks across the industry and the NHS, and a wealth of practical, positive experience.

Veteran’s parade
Karen Thomas – a recent addition to the NHS Partnerships Team – has extensive experience of working in the pharmaceutical industry, and for the past 12 years Karen has worked for Bristol Myers Squibb, where her roles spanned finances, sales, commercial and market access, covering several therapeutic disease areas. Karen joined the ABPI in November 2012 as the Regional Partnership Manager for London.

Harriet Lewis has been a pharmacist for over 20 years. She has worked in a wide range of healthcare sectors including industry, community, hospital and primary care. Before joining the ABPI, Harriet’s most recent role was Associate Director for Medicines Advice with the National Institute for Health and Clinical Excellence (NICE). Harriet has led on a number of NHS support programmes, including local formularies, local decision making, controlled drugs, accountable officers and ‘specials’. She has authored several key documents for NPC and NICE. Harriet is the Regional Partnership Manager for the North.

Most recent additions to the team are Andy Riley and Mike Ringe. Andy joins us as the ABPI Regional NHS Partnership Manager for Midlands and East. He qualified as a pharmacist in 1987 and has held posts in hospitals, community pharmacies and health authorities in London, the North West and the West Midlands. Mike joins us as the ABPI Group Therapy Manager directly from the NHS, and previously held the position of Chief Operating Officer at Luton Clinical Commissioning Group.

My role is the NHS Partnerships Manager and I manage the team. Previously, I have worked in the pharmaceutical industry for over 25 years – at UCB and GlaxoSmithKline (GSK) – and I have been responsible for developing national level methodologies and frameworks to support patient and market access programmes.

Bonded by blood
The ABPI recently undertook a joint working project at a hospital trust in the North of England looking at epistaxis – one of the most common ENT emergencies in England, with over 27,000 patients presented to secondary care between 2008 and 2011. In 2009/10 the trust admitted 250 patients presenting the condition, with the average length of stay at over two days, costing a minimum of £400 per patient per day.

Like many other hospitals, the trust had limited specialist ENT experience in their emergency departments, and as a consequence nasal packing was frequently used as a first line treatment – even for small volume bleeding – when a more conservative or targeted approach would have been safe and effective. There was a clear opportunity here for the patient pathway to be revised and a different approach taken.

Through the ABPI, a joint working project was instigated between a local pharmaceutical company and the trust. They jointly agreed – through a joint working agreement – to truly address the challenges within the current treatment regime and completely redesign the service. Consequently, it addressed the training requirements within A&E and junior doctors.

The new treatment pathway encouraged clinicians to identify the bleeding point, if possible, and in cases of continued bleeding, to consider the use of a product manufactured by the local company – thereby avoiding unnecessary hospital admissions. The company and trust continued to work in partnership to develop training materials in order to develop the new treatment pathway and introduce the use of the medicine where possible.

This venture resulted in a number of positive outcomes, which included a reduction in hospital stays, improving productivity and cost savings. But most importantly, when compared with the three preceding years, the audit of the venture showed that the total number of bed days due to epistaxis, was reduced by 30 per cent and length of stay was reduced by 21 per cent. Additionally, staff were motivated to consider an alternative to immediate nasal packing/admission, which also resulted in a reduction in the length of stay.

QIPP while ahead
Working with the Department of Health and the NHS, we have developed a toolkit on successful joint working. Joint working is a relatively new concept for many, but has already shown tangible benefits to patients, the NHS and industry. For example:

East Lincolnshire Primary Care Trust (PCT) reduced hospital admissions for Chronic Obstructive Pulmonary Disease (COPD) by 23%, through working with three companies to target and screen patients, train clinicians and set up specific COPD clinics.

In Ashton Leigh and Wigan the PCT is tackling low life expectancy, high rates of heart disease and diabetes by working with industry on a ‘Find and Treat’ strategy.

The innovative approach to patient care adopted by that trust was aligned with the Quality, Innovation, Productivity and Prevention (QIPP) programme. QIPP is an NHS initiative to improve the quality of care it delivers, while at the same time making savings that can be reinvested into the service. It engages with staff from across the NHS, at local and regional level, and is supported by QIPP plans and work streams that provide guidance and tools.

The NHS also works with a range of partners to deliver QIPP, one of which is the pharmaceutical industry. Apart from supplying medicines that improve the quality of patients’ lives and outcomes, the industry can contribute business skills and expertise, as well as extensive knowledge of the therapy areas relevant to its medicines.

Joint working is the foundation for creating, developing and implementing innovative healthcare solutions which can lead to better health outcomes. We believe this is the way forward in healthcare and both the NHS and industry must seek out more opportunities to work together.

In the first of a new series, Pf’s John Pinching meets Novartis’ Senior Brand Manager and Pf reader, Caroline Armstrong. A franchise coffee house in Farnham sets the scene, as she orders an exotic latte, while he opts for an invigorating Americano (with three sugars).

When I meet Caroline – winner of the prestigious Joint Working Award at the Pf Awards 2012 no less – she exudes confidence, charm and style. Indeed, she immediately draws my attention to a famous local sculpture and points out that, viewed from a certain angle, it resembles something entirely unexpected.  I conclude that it must be ‘attention to detail’, which sets this career-climber apart.

What is your background, Caroline? I come from Newcastle and did a degree in Biomedical Science at the University of Newcastle Upon Tyne. During my time there I worked in a lab at Proctor and Gamble. After approximately five minutes I knew it wasn’t the career for me! I needed to do more than just take microscope slides out of a washing machine for the rest of my life.

How did you embark on a career in the selling side of pharmaceutical drugs?
I attended a recruitment drive, was impressed with the potential opportunities and became a medical sales representative, first at AmDel, then Altana Pharma. I know it’s a cliché, but in order to fulfil my ambitions I had to be out there, ‘carrying the bag’; it’s the best way to build a network and discover how the industry really works.

Do you remember your first gig? Yes, it was pretty nerve-wracking. As soon as I arrived at the surgery, I was taken straight to the GP, without any time to compose myself. It was a steep learning curve, but I soon gained confidence and was able to apply my personality when describing products. Showing your human side in medical sales is vital.

How did that enable you to progress further? I joined Novartis initially as a Vaccine Account Manager, before getting the chance to go on a marketing secondment. I really felt like the company believed in my ability and this ultimately led to my roles as the UK Influenza Brand Manager and Travel Vaccines Senior Brand Manager.

What were the most satisfying aspects of your new Novartis ventures?  Getting involved in really broad campaigns was very exciting. With influenza it’s not just a case of painting patient pictures, you are convincing people to purchase products there and then; sign on the dotted line. From a marketing view, delivering an effective strategy is essential, but from a sales view, you’ve effectively got twenty minutes in front of a healthcare professional to deliver, not just a generic pitch, but one that demonstrates empathy, understanding and confidence in your proposition. There’s only one chance, so you have to make every interaction count.

Does it make you appreciate the impact you’re having on society? It’s pretty amazing to think that last year the number of vaccines given through pharmacy alone could fill St. James’s Park. That really puts the number into perspective.

Do you support Newcastle United, by any chance? Yes, I used to go with my dad, when David Ginola was playing (judging by the wistful expression, I think Caroline may have been a great admirer of the aforementioned Frenchman).

I digress, what programmes are you putting into place in preparation for the dreaded reform act? We have been very passionate about implementing vaccination programmes, which enable a more community-based approach to health. We’re training pharmacists to vaccinate in local pharmacies, enabling many more thousands of people to access healthcare. It will certainly relieve some of the pressure from GPs. People will have the convenience of being able to pick up their weekly shop and a vaccine, all in one place.

How do big companies react to changes enforced by new political policies? From an industry perspective you can’t plan too far in advance because you simply don’t know what the NHS will look like in a few years. If Labour get in all the changes might be reversed and we’ll end up going round in circles.

You’re still young, but seem to have ascended up the ranks rapidly I enjoy what I do and like to do it well; then I’m ready for the next challenge. When you reach milestones in your career it’s so important that you have a story to tell, making sure that it’s as fulfilling and successful as it can be. Some people are satisfied to do the same thing for years, but I want each chapter to represent a new adventure and an opportunity to make a difference.

What does the future hold for you? I’m starting a new job in Basel! (Caroline is making the pilgrimage to Switzerland and she’ll be working as Business Franchise Manager in Novatis’ Ophthalmology business unit – which is nice).

That’ll be incredible Yes, I’m going there with my partner and it will certainly be a great experience. It’s a global role so it will be really interesting to see how other health services, like Australia and Canada, operate compare to ours. I hope they don’t have as many acronyms.

There’ll also be some cultural differences in Switzerland too? Yep, for a start, they only serve wine in 100ml measures and that will take some getting used to!

What will you miss? The higher your position, the greater potential there is for you to be removed from the ‘patient’.  I think I will miss the daily coal face interaction you get when you work in a local market, close to the actual health provision. That is why I think it is so important to remember what it is like when you are on the road, bringing products to life. Ultimately, whether you are in a local or a global role, everything you do is still for the patient.