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Working in harmony

They both rely on each other to survive, but the pharmaceutical industry and the NHS can only improve healthcare together if they break their current deadlock.

ButterflyThe history of partnerships between the NHS and the pharma industry is patchy. The NHS desires the best possible outcomes for all its patients and, inevitably in the 21st Century, much of this is medicines-dependent. Pharma, on the other hand, is ultimately commercial and must sell the results of its heavy investment in research and development in order to survive.

While the two parties may appear to be on divergent courses, their aims are by no means incompatible. The NHS and pharma don't always share the same perspective, of that we can be sure, but they need each other, they're good for each other and they share the same aims.

They need to work together to survive and achieve the desired outcome successfully - better public health through disease prevention, safer and more effective treatment for patients, and, of course, patient choice.

Sweet nothings?
In 2000, the NHS Plan recognised that the deadlock between pharma and the NHS was not to anyone's benefit - least of all the patients - and stated clearly the government's commitment to creating a mutually beneficial bond.

'For decades there has been a stand-off between the NHS and the private sector providers of healthcare. This has to end. Ideological boundaries, or institutional barriers, should not stand in the way of better care for NHS patients,' it stated.

The Plan was heralded as a new era for joint working, when the present government stated its wish to harness the input and resources of private, as well as voluntary, organisations. Yet, there is still scepticism that nothing is really being done on a governmental level to encourage true joint working.

Anthony Harrison, researcher at the King's Fund and author of Getting the Right Medicines?, says: The current government has set up a number of bodies, for example the Pharmaceutical Industry Competitiveness Taskforce, but their work is designed primarily to promote the interests of the pharmaceutical industry, rather than to address the needs of those patients neglected by current private and public research priorities.

Practical beginnings
In recognition that a helping hand was needed the Association of the British Pharmaceutical Industry (ABPI) and the NHS Alliance have produced a framework designed specifically to help the two sides work together for the benefit of patients.

Launched last year, NHS and Pharmaceutical Industry Working Together for Patients, was so successful that a follow up publication focusing on partnerships in Wales was launched.

The move was timely following publication of the Wanless Report, which advised that the Welsh NHS is unsustainable in its present form and would need new ways of delivering care: a situation that could be eased by private sector involvement.

Jeremy Felvus, Pfizer's head of corporate affairs Wales, found that the NHS in Wales was slow to take up partnerships with the private sector. Though hopefully, the recent publication of a new document, Welsh Health Circular (2005) - laying out how these partnerships can work - will improve this situation, he adds.

Pfizer is currently involved in several partnership projects in Wales. Of particular importance is Chronic Disease Management, in partnership with the Welsh NHS Confederation.

Working with Mike Ponton, director of the Welsh NHS Confederation, Felvus' team has visited and evaluated many global chronic disease management projects to assess what could be learned to transfer to Wales. A final report is due to be presented to the Welsh Assembly government and the Confederation's members this month.

Working together 
Can the industry and the NHS really work together? There are certainly some who would argue that the two cannot work together effectively. Ben Hayes, the ABPI's director of public affairs, is pretty upbeat about the creation of a successful working relationship between industry and the NHS.

It's [Working Together] been a huge success and is already the most requested of our publications. It was developed as a result of a survey of PCOs that flagged up a real wish for opportunities to work with industry. We wanted to point out to everyone that the opportunities are there, and give people a starting point and a framework for establishing best practice for working together, he says.

It would seem that the old, sceptical and wary relationship the industry has had with the NHS is slowly changing. In recent years, both sides have certainly worked hard at self-improvement with a clear focus on patient benefits and choice.

The new patient-centred NHS has a significant emphasis on the case management of individual patients with chronic conditions and on patient choice in all things for all its users. This kind of information provision, patient care and service delivery will not be an overnight change and it's clear that the new NHS will not succeed in achieving its aims without help from those that supply its services, medicines and devices.

National Clinical Director for Primary Care, David Colin-Thome, is only too aware that partnerships with pharma and non-governmental organisations are crucial to the development of the new NHS. 'Only by working in partnerships with other public services, the private and voluntary sectors, will we in the NHS deliver on the daunting yet achievable task set for us,' he stated in the foreword to Working Together.

Local heroes
Joint working has produced some incredible success stories. Yet, these beacon projects, where both sides work altruistically to realise genuine patient benefits, often remain hidden. This may be largely based on the fact that the most successful projects are direct local initiatives.

Local level projects can often work better and this is particularly true of initiatives that support a case management approach, because at a national level things are usually organised into age group, or disease, silos. Localised projects are, more often than not, much more successful - particularly in chronic disease areas - than national schemes.

Dr Roger Boyle, National Clinical Director for heart disease, believes that localised solutions could be the way forward.

It is expensive to run national measures; localised projects that could be rolled out nationally can be very effective in helping to ensure that efficient models of delivery are developed. They can really help with chronic disease management in terms of getting treatment more systematic, he notes.

Working Together flags up just such successful local projects that have worked in a number of different areas. The document is an enthusiastic and optimistic overview of utopian partnerships, yet its common sense approach to establishing protocols makes essential reading for anyone planning to embark on a partnership.

The Haringey pilot is a manifestation of the NHS' growing desire to work constructively in partnership with the private sector. This unique partnership, which focuses on coronary heart disease, heart failure and diabetes, is run and funded jointly by Haringey Primary Care Trust and Pfizer. It is also supported by the National Primary and Care Trust Development Programme (NatPaCT), as part of the Transformational Change Programme.

The aim of this is to help patients get the best possible healthcare outcomes from their treatments, as agreed between them and their GP. The programme will enable patients to take a more active and informed role in their health and help them understand what is important, says Sally Goodenough at Pfizer.

The project's care managers reinforce the care provided by GPs and hospital doctors and their role is to empower people with long-term illness via telephone-based information and support to enable them to better understand and manage their health.

This includes advice for patients on understanding their symptoms, guidance on when it is necessary to engage with local health services and thoughts on leading a healthier life, as well as ensuring they are following the medicine-based treatment recommended by their GP.

Embracing change
There is clear agreement from all stakeholders that the industry needs to be aware of changes taking place as the NHS evolves, and will have to respond to this in a way that adds value. The first port of call is primary care. As the 'gatekeepers' to hospital specialists and other healthcare professionals in secondary care, this is where patients will go first.

However, with the exception of sales reps and a few medical education programmes, the pharma industry has little or no interface with primary care - a point that Dr Boyle believes needs addressing.

Primary care is really where the cookie crumbles, as nine out of 10 interactions are at primary care level. The hospital prescribing element is quite minor in the great scheme of things, as hospitals are about short term rather than long term management.

The industry has traditionally focused on the hospital setting, as hospitals can take up new drugs rapidly. We have a long way to go in improving prescribing in primary care and the industry could help here with education and awareness, he continues.

Information age
Another area where joint working would produce increased patient benefits is in the provision of information.

Information and disease awareness are key to prevention. This is particularly relevant at a time when most random killer diseases have been eradicated by modern medicines, and the majority of ill people need treatments for diseases that develop as a result of poor lifestyle choices.

There is a big opportunity to work with primary care to identify risk and ensure that the concept of risk is better understood so that more people with a multitude of risk factors consider modifying them themselves and that primary care physicians consider treating raised blood pressure, cholesterol and diabetes, Dr Boyle comments.

Research and development carried out by the pharmaceutical industry has improved immeasurably our understanding of diseases and their progression. This information can go a long way towards helping people to understand fully the risks of poor lifestyle choices, such as smoking, bad diet and lack of exercise - and the diseases associated with them - and ensure that they change their risk-taking behaviour.

Avoiding the obvious
To work together in partnership, the industry needs to start thinking in new ways and go beyond obvious, short term product marketing. The Primary Care Organisation survey which spawned Working Together, flagged up medicines management as one key area where the NHS needs the input and expertise of the pharmaceutical industry.

The time is ripe for the industry to stop being simply a tablet-producer and start researching new approaches, according to Colin-Thome. There are two examples I can think of where industry is doing just that, one is a phone call review system for PCTs on how patients progress and continue with their medication and another is the active support of the provision of GPs with a special interest. There are opportunities to look beyond the provision of therapeutic drugs.

Working together for public health may also involve issues of research and provision of the data necessary to protect subsections of the population.

Two of the most vulnerable groups in society are children and those with multiple conditions taking drug combinations. Many drugs remain unlicensed in children and many commonly used drug combinations have not been tested together.

This also needs addressing and it can only happen where drug companies and the NHS work together in a public-private partnership. Both groups need to work together to make the research happen, says Harrison at the King's Fund.

Happy ever after?
Setting out the aims and boundaries of the project from the outset is absolutely necessary, and the guidance in Working Together is an excellent starting point. As with any partnership, however, it is vital that both sides know what they want from the relationship and are aware of what will be required of them in return.

I have found the most important step in partnership working is to be very clear at the outset what is in it for each party and what each will contribute, says Felvus at Pfizer.

This exploration of each other's objectives and finding the areas of common interest can often take a long time, but does produce an enduring mutual trust and transparency, he continues.

With clear project guidelines, a patient focus and an emphasis on key areas, such as local initiatives and medicines management, the relationship could be a long and happy marriage that goes beyond a single product's life cycle. Companies that were quick to recognise this are already reaping the benefits.

As with all good relationships, the public-private partnership of the industry and the NHS needs to be genuinely two-way to work well. This will require a level of openness and honesty, and a common desire to provide true patient benefits. Many of the projects started in the new spirit of togetherness are only just beginning to come to fruition and the evaluations of these early starters will provide key learnings for the future.

The Author
Liz Shanahan is managing director of SantÈ Communications and chair of GlobalHealthPR.

2nd September 2008

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