Maxine Vaccine interviews two directors at Bona Pharma who are brightening the grey landscape of medical sales.

I’m soaking up the cosmetically enhanced atmosphere of Battersea’s Vauxhall Tavern when the leaders of Bona Pharma flounce subtly into view.

Managing Director Julian and Sales Director Sandy have brought style and verve to the strait-laced world of the pharma industry.

“We beat that Adele to the first name only thing,” Sandy assures me. “She copied our shoes as well.”

Reassuringly, they follow industry convention in one respect: they never get a round in. I order four happy hour cocktails (two for me, one each for them), and the Q&A begins.

Pf: “These are hard times for the pharmaceutical industry. The leading drug companies have all fallen over the patent cliff. How can they drag themselves up again?”

Julian: “Trolling reps everywhere, Sophie Hipgrave is your guide – follow her through the hazardous forest of fashion choices to the emerald city of fantabulosa.”

Sandy: “Most pharma is a work of performance art in the medium of naff. The industry needs to learn that pinstripe is not the only suit.” (Shudders.)

The duo have recently returned from an antipodean business trip. We debate the relative merits of their Bushwackers and my Brandy Alexander. Maybe some day we’ll design a head-to-head clinical trial.

Pf: “Is it fair to say that your marketing has ensured Bona Pharma has a strong rep in the outback?”

Julian: “Yes indeed. We miss him though.”

Pf: “Bona Pharma is known for its niche products. What success stories did 2012 bring you?”

Sandy: “We did well with our erectile dysfunction drug abonafil. But there was one customer who claimed it had worked a bit too well. The poor omi sued us for causing him to suffer from priapism. Though it had boosted his call rates no end.”

Julian: “Didn’t stand up in court.”

Pf: “Of course, the market is changing radically, even in the UK. How has Bona Pharma responded to the shift of healthcare into the community?”

Julian: “Well, I have a check-up once a week. He’s got an extended visa.”

Sandy: “Very extended at certain times. Never vada’d the like.”

Pf: “One question our readers will be keen to hear your answer to. How useful are recruitment companies to pharma?”

Sandy (sadly): “Elton John syndrome. Great voice, nante riah.”

Pf: “What one thing about pharma would you change?”

Julian: “Its name. Every farmer I’ve met has been into market penetration in quite the wrong way.”

Another round of happy hour cocktails – my expense account covers a multitude of gins – and then it’s time for the final question.

Pf: “In an era when Parliament is voting to legalise gay marriage, is there still any need for an underworld gay dialect designed to keep secrets and spread rumours?”

Sandy: “This is pharma, dear. Secrets and rumours are the world.”

In the new Pf, Health Secretary Jeremy Hunt answers some questions from our readers. Maxine Vaccine delivers a brief audit report on his answers.

The most vital thing to remember about Jeremy Hunt is that he’s not Andrew Lansley. The older man spent nine years dreaming up a transformation of the NHS into a competitive healthcare market system, then claimed he’d had to invent it out of thin air when, as part of the new coalition government, he “saw the books” (which he’d had full access to for nine years) for the first time. Then he drove through legislation designed to break up the NHS and place its fragments on the bargain shelf of global corporate business, and mocked anyone who questioned it. Forced into a cosmetic display of ‘consultation’, he followed it up by declaring that the ‘listening period’ had been needed only to educate the ignorant doctors.

And suddenly, the Tories are faced with the prospect of losing power. Journalists are calling the Health and Social Care Act ‘Cameron’s poll tax’. Cue the new Department of Health. Exit the sneering headmaster and enter the elegantly half-smiling head boy. Who doesn’t half scrub up well, and – unlike Lansley – can say “the NHS is one of our greatest assets” without crossing his fingers behind his back. Jeremy Hunt was a contributor to Direct Democracy (2005), a Conservative Party activist guide that claimed the NHS was “no longer relevant” to modern society because it was a public sector health system. But he can say “the NHS is one of our greatest assets” because he can say anything. Lansley is a Thatcher type of politician, whereas Hunt is a Blair type.

His answers to the Pf questions are classic examples of why he has been drafted in to front NHS reform up to the next General Election, or at least part-way there. He never says the wrong thing. If he can’t say the right thing, he says nothing in a nice way. He makes you feel that anyone who disagrees with him must be insane. It’s only when you compare his words with what is actually going on that things get complicated – and you realise that, as a new lease-holder in the house that Lansley built, he has only unpacked the suitcases for two rooms: the front room and the bathroom. The rest of the house is unoccupied.

Regular Pf contributor Omar Ali asked Hunt a question about NHS rationing: how will making patients pay for services be integrated into the wider healthcare bill implementation? A good question, as this is already happening: patients in many areas are being told they cannot have cataract operations, varicose vein surgery or hip/knee replacements unless either (a) they wait until their need is greater (for example, they can have cataract surgery once they are blind) or (b) they go private. Referral management, which Sir David Nicholson is very keen on, is another form of rationing: if patients want to see a specialist in many situations, they have to go private. Hunt’s response is worth quoting in full:

Let me be absolutely clear on this – the NHS will always be free at the point of delivery and no one will be asked to pay for its services. Yes, in the future, services will be provided differently – public health services will be organised by local authorities, for example – but the founding principle of those NHS services being free, for those who need it, will never change.

Hunt is neatly splitting the hair of Omar Ali’s question. If people are paying for services they are not NHS services, they are private. But money will still be changing hands for services that used to be free. They just won’t be NHS services any more. And that “for those who need it” is significant. It has two aspects: severity of clinical need (already a moveable famine) and ability to pay (Direct Democracy suggests the NHS should become a means-tested state reimbursement of private healthcare fees). Who needs free healthcare, and what free healthcare they need, will be critical issues from now on – and legally, the Health Secretary now has no remit to influence those decisions, which will be made by autonomous CCGs and/or the autonomous Commissioning Board.

Pf reader Susan Ranch asked whether the Government’s recent announcement that it will cap individual payments for social care at twice the Dilnot-recommended level means that more NHS funding will be committed for elderly patients. Hunt replied: This is incorrect. The Government has not said this and no decision has been made. Strictly speaking, he is right. According to the BBC and three Tory-loyal newspapers (the Sunday Times, the Daily Mail and the Daily Express), journalists were briefed that setting the social care payment cap at £75k (whereas Dilnot had recommended £35k) would feature in the Government’s mid-term review. But it did not – and the critical backlash from social and healthcare experts was either unnecessary or effective, depending on your interpretation. Whatever its level, the cap appears unlikely to be implemented before the 2015 election.

Hunt went on to say: I want this country to become one of the best places in Europe to grow old and make sure people can live independent and healthier lives into old age. Which is the kind of gold-plated soundbite Lansley never delivered.

Another Pf reader, Leigh Saunders, asked how the pharmaceutical industry could work with the NHS to improve cancer survival rates. Hunt replied: The pharmaceutical industry already plays a vital role in improving the health of people with cancer. I want to improve mortality rates, where the targeting and development of medicines is becoming ever more important. I am sure the pharmaceutical industry will want to build on its work in this area and help improve cancer care.

Great stuff: that flatters the industry, expresses a decent medical aim, and then flatters the industry again. It doesn’t answer the question, but who cares?

Jeremy Hunt’s management of the Pf questions is a masterclass in accessible spin. It tells us almost nothing about Government policy, but it tells us why Hunt currently holds the lease on the house of NHS reform. He knows how to make it look good – and in politics, that’s not always easy. The pharma industry should recognise Hunt’s talents as those of marketing and sales. He’s one of us.

Maxine’s views and attitude are not necessarily those of Pf.

Fearless pharma blogger Maxine Vaccine asks whether That Cyclist is a scapegoat for our unease over the role of drugs in our everyday lives.

This week’s public loser by 2,173 miles (the length of the Tour de France) is the disgraced cyclist whose name we’re all sick of. His two-part ‘confession’ to Oprah Winfrey broke down the uneasy truce of non-admission and non-belief between him and the public. Instead, we had a carefully staged fessing up ritual that invited audiences to doubt both his full veracity and his regret.

If he’s as well versed in pharmaceuticals as we can now assume, it’s surprising that LA didn’t go the pharma CEO route and hide behind lawyers, arranging a settlement iron-clad in gagging clauses and insisting the truth is too complex for us to comprehend.

Reactions to the LA statement from cyclists and sports fans have been bitter. Take this comment from Barry Richardson on the BBC website: I tried to understand this alien being, the harrowing picture of his cancer struggles always haunting me as I saw him tear the peleton apart, and spit venom at those who suspected he was cheating. And now, I still love cycling, but in a different way. It's like being divorced but knowing deep down you will always love someone... and it hurts. A lot.

Why so much disillusionment? It’s not just the sense of sporting propriety having been mocked. It’s the deadpan realpolitik of his stance: he did it to reach the “level playing field” of all the other dopers out there. It’s like he wants to take the Tour de France down with him – and even the UKIP cretins would baulk at such vandalism.

But some of that apocalyptic prospect was built into the charges levelled by the US Anti-Doping Agency, who called LA’s cycling career “the most sophisticated, professionalised and successful doping programme” ever exposed in sport. Like Watergate, this scandal is not about one infamous person: it’s about the erosion of honesty in respected professional organisations and systems.

Another source of distress is the sheer sophistication of the doping methods. LA had blood transfusions to increase his oxygen uptake – not new in sport or in other trials of endurance, but still a long way beyond the furtive necking of a few uppers.

But it’s not only those deeply involved in the world of cycling who find the LA story troubling. Even for those of us who gave up cycling when old enough to drive (the back seat of a bicycle offers limited romantic possibilities), the episode leaves a bad taste in the mouth. It’s the taste of medicine.

Competitive sport may be the only profession where taking drugs to improve your performance is not acceptable. In the midst of our technically and chemically mediated lives, sport is framed as a return to the innocence of a younger life, and a younger world, where we relied on our unaided (but trained) bodies and minds for everything.

Let’s put that in a modern working context. In the last few years I have taken the following drugs specifically to enhance (or enable) my performance at work, either directly or indirectly: nicotine, caffeine, paracetamol, phenylephrine, guaifenesin, dextromethorphan, aspirin, ibuprofen, codeine, valerian, loperamide, menthol, loratidine, cortisone, fluoxetine and diazepam. There may have been others. The first two were purchased in general shops; the last two were prescribed; the rest were bought OTC from a pharmacist. Nearly all of them are banned in athletic sports.

In all other jobs you take medicines if you feel tired, if you are upset, if you feel sick, if you have a cold, a cough, a sore, a headache, period pains, backache or worries. You might even take medication when you feel fine – just to make sure you stay that way. But if your job is sport (though interestingly, football is an exception), you have to suffer whatever ails you without medical relief – or go on forced sick leave.

Is that fair? Are we making sporting professionals suffer unnecessarily in order to maintain a fantasy of some Elysian fields where young men and women run, jump, throw, swim, cycle and dance without access to the routine meds the rest of us rely on? How much longer can we keep sport in a state of innocence the rest of modern life doesn’t even want? Perhaps we can’t and never could.

But would I have a blood transfusion to make me a better key account manager? Sorry, but no. That’s the paradox of LA. He’s put more effort into cheating than most of us do into playing by the rules.

Blogging elf Maxine Vaccine pays tribute to the ABPI, looks forward to the office party, and asks Pf readers a crucial question about the future.

Maxine’s attitude got her in trouble again. It must be Thursday.

A mildly snarky comment about the ABPI and its ‘the honeymoon is over’ stance on value-based pricing, and look what happens – Pf gets an e-mail from Stephen Whitehead, Chief Executive of the pharma industry’s trade association. Most shaming of all, it wasn’t a snarky response. It was a reasonable and sensible response explaining that the ABPI has always regarded the VBP concept as complex and has tried to ensure that, if it becomes the UK pharma sector’s currency, it is not devalued.

Which left your humble correspondent looking immature and shamed. Which hasn’t happened since the morning after the last office Xmas party. More about that later.

Meanwhile, I wanted to tell Stephen Whitehead – whose role as the industry’s voice I praised a few months back – that I apologise for any offence caused. It’s part of my role to voice objections that might arise in the mind of the average pharmaceutical sales professional and require an answer. And as my manager will tell you, ‘average’ is very much the word – indeed, she commented at the last staff Xmas party (of which more later) that ‘average’ was more aspirational than descriptive – in my case.

By way of reparation, and to show that I do read the ABPI press releases, here’s a short verse celebrating the Association’s hard-working and boat-rocking leadership:

Stephen Whitehead, the industry’s voice,
Said patients should have far more choice –
But the strictures of QIPP
Were a hole in the ship
Though the DH was chanting ‘Rejoice!’

Remember, this is meant to be an interactive blog. We’re keen to read your feedback on the issues raised here. Please send your comments to the Pf editor, John Pinching, at john.pinching@healthpublishing.co.uk with the subject heading ‘WTF is that Maxine talking about?’ It’s already a substantial file, as my line manager at Munchkin Pharma can attest.

In particular, we want your feedback on one of the key questions that any pharmaceutical sales professional will need to consider in 2013 as we emerge from winter into spring: Would you date a colleague?

To address the tangled theme of office romance in the issue of Pf that will be in your otherwise empty hands on Valentine’s Day, the journal called on its most creative and insightful journalist. But she was not available and the second choice was busy with NHS reform and the third choice was drunk, so they tried a few other options (including the caretaker) and finally, in desperation, called me.

So: assuming you had some time on your hands and were free (or could arrange to be on a timeshare basis), would you engage in a ‘special project partnership’ with someone from your industry, your company, and your team? Would that be the perfect prescription or a formula for disaster? Would you sell each other a vision of happiness or down the river?

Please give it some thought while munching mince pies and imbibing sweet sherry like the diabetes crisis was still a century away. Then e-mail the Pf editor (see above) with your verdict and the reason why. Thank you!

(If you work with me, there’s no need to reply. I know the answer, and I know why. It has to do with the office Xmas party. But I’m on a word limit here and there’s no space to explain.)

Have a restful Yuletide break – and look after your elf.

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

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

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

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

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

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

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

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

Or maybe the antibiotics are making me dream.

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

Maxine Vaccine asks whether the current horse-trading between health and social care is a version of trading in derivatives. How much of this theoretical money ends up providing real care?

Everyone supports the principle of integrated care. The more closely healthcare and social care teams work together, the more effectively the needs of communities – and especially, the growing elderly population – can be met. Putting local government in charge of public health aligns it with social care, strengthening the role of both services in promoting and protecting health, and thereby reducing the clinical and economic burden on the NHS.

That was the basis of Duncan Selbie’s recent statement that local government could make a better job of improving public health than the NHS. The new head of Public Health England was arguing that councils have “a much broader view of the world” through their long-term role in such functions as education, housing and sanitation. Some might question, of course, whether councillors – who owe their jobs to the murky world of local politics – can really compare with a workforce of dedicated health specialists. But in principle, public health can only benefit from being seen in the right context: the actual lives of communities, where and how people get along from day to day.

The problem starts when you ask: who is investing in the social care that will provide the basis of a stronger public health strategy, while reducing the burden on the NHS? That has been a major concern from the early days of this Government, which declared it would not reduce NHS funding but then conceded that the NHS would have to make up for the drastic cuts in social care funding. If you spread salmon paste too thin it becomes tuna. If integrated care means passing the buck of austerity obsessively back and forth between CCGs and councils, all that will be shared is pain.

Just as the DH has drafted legislation that will force CCGs to give contracts to private sector health providers if the latter tick ‘efficiency’ boxes defined by the Government, it has drafted legislation to expand the market for private sector providers of social care – and backed it up with the Developing Care Markets for Quality and Choice programme, which helps local authorities to shape the social care market.

Meanwhile, the Dilnot proposals for enabling more elderly people to afford the care they need have become a political liability. The Government has expressed support for the principle of capping individual contributions, but will not commit to a figure or a funding mechanism for it. There is talk of funding it by cutting £2bn out of the NHS budget – which, understandably, has horrified the NHS Confederation. Finding a workable solution to the challenge of social care is hard enough for a government that believes the market can solve everything, without some pesky economist telling it to spend money.

And now former Social Care Minister Paul Burstow has accused George Osborne of trying to put the Dilnot proposals “in the trash bin”. I’m gutted that he has not provided photographic evidence of this. Burstow claimed that detailed plans were drawn up to implement the Dilnot proposals, but Osborne refused to sign off the funding. He also accused his own leader of having failed to recognise the popular support that Dilnot commands.

Of course, Burstow was speaking during that surreal week in the LibDem calendar when the party exchanges the Orange Book for the Little Red Book in an attempt to convince its membership at conference that it believes in ‘liberal’ values. Like Clegg’s talk of a mansions tax, Burstow’s accusations of a Dilnot-dustbin interface will shortly be forgotten when the LibDems resume their coalition role of voting through everything the Chancellor suggests.

All this talk of social care reform, public health reform and (let us not forget) NHS reform helps to keep the private sector interested in the services that are currently being franchised. The funding promises and the ‘partnerships’ they attach to are closely allied to the derivatives that keep ‘wealth creators’ involved in finance. The more the money goes round from the NHS to local government and back again, the more can be hived off into the accounts of investors – and the less there is to pay for actual care. Whether it’s healthcare or social care doesn’t matter when the game is austerity: nothing split two ways still doesn’t come to much.

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

Maxine Vaccine casts a sceptical eye over the media strategy of the new DH and asks: is this new openness just another phase of a closing door?

There’s something about the new Department of Health team I can’t quite put my finger on, not that I would want to. Something airbrushed. Like a pop group just past its sell-by date. Jeremy Hunt exudes boyish sales exec glamour, Anna Soubry has the kind of sculptured fringe Kate Winslet would die for, Dan Poulter’s chest muscles are breaking through his silk shirt, and even Norman Lamb – the token oldster – has hair so reminiscent of Lembit Opik it makes you wonder whether the Lib Dem HQ gives its MPs haircuts as well as packed lunches and updates on their current beliefs.

Along with this faux-youthful rebranding of the DH goes a charm offensive so deliberate you can smell the cologne even on Twitter. It’s all about openness. Norman Lamb openly admits that he had issues with the way the original Health and Social Care Bill tried to force rapid changes on GPs. He even threatened to resign his post as chief political advisor to Nick Clegg if the Bill went through unchanged. But, he says, the ‘listening exercise’ fully addressed his concerns. That may be news to the GPs.

And now, Anna Soubry does a ‘private’ Q&A with the press to talk about what went wrong with the reform legislation. Asked to comment on how the DH had dealt with medical professionals and Royal Colleges, she says: “We screwed up.”

That is superb. For a start, it’s a tidy euphemism that won’t cause trouble in the press or get the likes of us shut out of our own website by the firewall. The phrase suggests literally screwing up a piece of paper – though it would have taken the entire duration of the ‘listening exercise’ to do that to the Health and Social Care Bill – but it has a darkly emotive undertone: after all, screwing means ****ing.

Later, Soubry explained: “We could have done more when the plans were set out initially to explain the benefits for patients, and encourage the support of health professionals. That is exactly why we took the rare step last year of pausing the legislation and holding a listening exercise. We ensured we took on people’s concerns and improved our plans.”

My, that’s good. It aligns with Norman Lamb’s praise for the ‘listening exercise’ and positions the DH neatly as people who sing the same words as before, but have improved the tune to appeal to a mass audience.

Can this be the same ‘listening exercise’ that Andrew Lansley said in April had not led to any substantive changes in the NHS reform legislation? Its purpose, he said, had been only to explain the Bill and “give further reassurance” to those GPs who had either “not read it” or “not really understood it”. That was a calculated insult to the BMA, who swiftly rose to the bait.

Could it be that bad hair is not the only reason why Lansley has been moved off the page in time for his replacement to defuse the medical profession’s anger? While Hunt is certainly no less right-wing than Lansley, he’s unlikely to lash out in that way at people whose support – or at least acquiescence – he needs to implement the reforms.

The former DH was in the Thatcher mould: dogmatic, bold, impatient with dissent. The new DH is in the Blair mould: open, feeling your pain, anxious to share… but underneath that, just as determined to set the agenda and keep to it.

As any sales professional knows, sometimes a door is opened just so it can be slammed in your face.

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

The new ‘semi-disgraced’ Health Secretary arrives with trouble already packed in his suitcase. Does that mean he’s in for a difficult time? Not necessarily, says Maxine Vaccine.

Timing is a crucial factor in politics. If Andrew Lansley had been replaced as Health Secretary when the Health and Social Care Bill had not yet been passed, that would have been interpreted as an admission that the reforms were misconceived. If it had happened just after the Bill had become law, that would have been taken to mean that Lansley’s personal handling of the reforms had been poor. If it had happened shortly before the next General Election, that would have been a blatant electoral ploy to replace an unpopular veteran with a fresh-faced Cameron clone. Happening now, the replacement doesn’t exactly have any of those meanings. It gives Jeremy Hunt the opportunity, over nearly three years, to adapt his course according to how the wind is blowing.

From 1 October, the health service will be run by the NHS Commissioning Board, which in turn will entrust it to CCGs at a local level. Legislation is under way to make CCGs play the game according to the ‘any capable provider’ rules, ensuring that the role of the private sector in NHS service provision continues to accelerate. The public spending budget will continue to shrink as the second-wave recession deepens, ensuring that austerity is the name of the NHS game for another decade. The finely-tuned machinery of Lansley’s NHS revolution will continue to turn – and, as Lansley promised, it doesn’t need any Government intervention to ensure that it delivers a competitive healthcare market. All Hunt needs to do, safely domiciled in the house that Lansley built, is wave from the balcony.

The most important thing to understand about Hunt as Health Secretary is that he is a longtime opponent of the NHS. He was a contributor to Direct Democracy (2005), a book co-authored by 23 Conservative Party members that claimed the NHS was “no longer relevant” to modern society. Its problems was not “one of resources”, the book argued, but one of adherence to a public sector model. Its proposed solution was: “We should fund patients, either through the tax system or by way of universal insurance, to purchase health care from the provider of their choice. Those without means should have their contributions supplemented or paid for by the state.”

That’s an accurate description of the ‘Panel’ health funding system that prevailed before the Second World War. Does the 21st century demand its revival? The Times reported back in July that Hunt, as Culture Secretary, had tried to get the NHS tribute taken out of the Olympic Games opening ceremony. However, it’s very unlikely that Hunt will start his time as Health Secretary by saying “It’s time to wave goodbye to the NHS.” Rather, he will put his weight behind the reforms and let the process take its course.

What Direct Democracy and its two sequels, which Hunt has endorsed, show is that the plan to ‘de-nationalise’ the NHS existed well before the 2010 election. Stripped of the stark phrasing that the Conservatives use when talking to each other rather than to the media, Direct Democracy predicts the Lansley reforms – and those steps immediately beyond it that the BMA and other clinician groups have warned against. The book cannot embarrass Hunt: there is nothing scandalous about it, unless your view of Conservative policy is based on the naïve assumption that the party supports the NHS.

The recent Leveson enquiry blighted public trust in Hunt to some extent – hence the recent description of him in the Guardian as ‘semi-disgraced’. But it also showed that he can walk through trouble without losing his cool or naming names. His statements in support of homeopathic medicine, however alarming to NHS and pharma industry professionals who believe in evidence-based medicine, also show that he is not afraid of controversy.

It’s a safe prediction, therefore, that opponents to the NHS reforms in the medical professions or the public sector unions will achieve little by dragging Hunt into the briar patch of controversy. He was born and bred in a briar patch. He will be passive or active on NHS reform depending on circumstances and the Government’s mood – but he will not backtrack on the reform agenda. While his gestures and hairstyle may suggest a genial public-school clown, only the most naïve critic would fail to take him seriously.

Maxine Vaccine wonders whether reports of the death of top-down NHS control have been exaggerated.

The Government has been very clear that its slogan ‘Liberating the NHS’ means just that. It wants to liberate the NHS – by which it means clinicians – from bureaucracy and political interference. That’s why it has given control of local commissioning to CCGs, which are GP-led and represent both clinical expertise and local experience.

With that in mind, the new DH consultation document Securing best value for NHS patients makes interesting reading. It presents a draft of regulations to ensure that CCGs observe “choice and competition” in their commissioning decisions.

A particularly striking observation is: “We will not be able to enforce non-statutory, administrative rules in the reformed system, where commissioners and other organisations have greater autonomy… We need to put the rules on a statutory footing so that they are binding on the new commissioning organisations.”

In other words, what had been top-down guidance will no longer be binding on the autonomous commissioners, so the law must be used to ensure they don’t misuse their freedom. It won’t be top-down guidance then, it will be the law of the land.

The DH states the core responsibility of local commissioners: “to secure best value from limited resources”. It wants CCGs “to have flexibility to decide how to respond to these challenges”. However, it says, in the past NHS commissioners have limited their own flexibility through “bureaucratic processes” and “inappropriate criteria”. These must be prohibited. Where the commissioners are not flexible enough, flexibility must be imposed upon them.

What is required is that CCGs “carry out an objective assessment of different options” according to the Government’s criteria, not their own. In particular, they must choose providers with “quality and efficiency” in mind, without any preference being shown for public sector providers over voluntary or private sector ones. They will have to maintain records for audit by Monitor to show that they have followed the correct procedure at every stage.

In other words, it is not the CCG that decides what “quality and efficiency” is, it is the Government. The CCG must follow a detailed, transparent procedure to ensure that its commissioning choices are in line with those “objective” criteria. It will now be a criminal offence for a CCG to “prevent, restrict or distort competition” unless that can be proven “indispensable” to patient benefit in the face of a legal challenge.

This means that ‘clinical commissioning’ is being brought into the framework of company law, a battleground for commercial and legal forces. Are GPs really being ‘liberated’ by this? Or are they being reduced to a lower-level bureaucratic role where they carry out decisions made by lawyers and financial managers, with private healthcare corporations pulling the strings?

And is that why most GPs are staying out of the local commissioning game?

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

Sir Michael Rawlins wants campaigners to take legal action against trusts that deny patients access to NICE-recommended drugs. Maxine Vaccine asks whether this is a powerful strike against bureaucracy or a pointless fit of sulking.

It’s not easy being NICE. When you decide a drug is not cost-effective, the manufacturer contacts a bunch of patient groups on Facebook and passes on soundbites to the press that make you out to be the most heartless despot since King Herod. When you decide a drug is cost-effective, the NHS quietly ignores you.

The Government says it will force trusts to make NICE-approved treatments available to patients – but at the same time, the recession comes back for whatever it forgot to wreck the first time, and the NHS is told it has to make deep spending cuts for the foreseeable future. Andrew Lansley first praises the NHS for hacking nearly £6 billion from its budget, then says rationing of NHS treatments is “unacceptable”. Simon Burns tells Radio Five Live that Monitor will sack CCG leaders who ration services, then the DH shamefacedly explains that he meant to say the Commissioning Board would do that.

And just to make matters worse, if you’re Sir Michael Rawlins, people confuse you with Sir Andrew Dillon and vice versa. Is it your fault that you both look exactly like 1970s newsreaders? Having good taste in neckwear wasn’t part of your job description. And you both have something of the knight about you. It’s time you stood up for yourself.

At least, that’s my rationalisation of why Rawlins went on the HSJ website and revealed that he encouraged the RNIB to take legal action against the NHS. I could be wrong, however. He may have had a touch of the sun, or a bout of lansley that his GP wasn’t allowed to prescribe for.

Whatever the reasons, his blog was in the awesome NICE tradition of standing on the moral high ground and waxing ironic over those below. He recommended that patient groups should use legal measures to “blow the whistle” on trusts that use “delaying tactics” to save money – thereby forcing them to put in place “appropriate financial arrangements” for the drugs in question to be provided. Then came his parting shot: “That would be a much better use of the time of formulary committees than trying to pretend they have the knowledge and skills of a NICE appraisal committee.”

Strangely enough, that didn’t go down too well with the NHS. David Stout, Chief Executive of the NHS Confederation, responded with an air of wounded dignity: “We must remember the reality is that every NHS organisation has a finite amount of money available. Every new treatment covered and funded under a NICE technology appraisal means fewer resources for other treatments.

“The issue raised by Sir Michael Rawlins leads us on to the wider debate that we need to have about the fact that the NHS is facing an unprecedented financial challenge,” he continued. “We need to be open and honest with the public about what the consequences of this financial challenge are, and the fact that trade-offs will be required if we are to improve standards of care while keeping the NHS affordable.”

That is rather good – and it cuts through the DH’s excuses like a scalpel through the contents of an inflamed colorectal tract. We need a public debate about NHS rationing – its economics, its democratic basis, its medical and social impact – not confused denials that such activity was ever dreamt of. If it was Rawlins’ intention to force that debate into the public space, he did well.

Bring it on.

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