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It has been quite a year for the NHS. We saw the departure of Dr John Reid as Secretary of State after the election and the arrival of Patricia Hewitt

The five faces of healthcare plan to provide a learning curve for pharma in 2006

It has been quite a year for the NHS. We saw the departure of Dr John Reid as Secretary of State after the election and the arrival of Patricia Hewitt.

Smoking and the public health agenda loomed large throughout the year, with Reid suggesting that a total ban on the weed would disadvantage the poorest people, who, he suggested, had few other pleasures in life.

Hewitt favoured something more draconian but had her wings clipped in Cabinet by her predecessor, leaving us
with a policy on smoking in public that is as clear as mud.

After the fags fiasco came the booze balls up. The government has waxed lyrical about yob culture and drink-related crime. Tony Blair has been keen all year to convince us that he is getting tough on yobbish behaviour and its causes.

Hoodies are banned, the use of ASBOs is on the increase and now he promises on-the-spot fines for drunken louts. Despite this, his government has moved to relax licensing laws to allow many parts of the country to enjoy 24-hour access to alcohol. Mixed messages are yet again conveyed to the electorate.

Lying in wait

The long-awaited reform of mental health law remains stuck in the long grass. In March, an all-party scrutiny committee of parliament decided to take a look at the draft Mental Health Bill.

The Bill contains controversial ideas to enforce community treatment orders on people with mental illness plus some pretty daft ideas for people with personality disorders who might be dangerous.

It has achieved something no government has achieved before, unity among nearly all key stakeholders in the mental health sector against the proposed legislation.

The health professionals, users, carers, social workers and the voluntary sector gave evidence to the parliamentary committee and rubbished the ideas suggested by the government.

The committee, chaired by Lord Carlisle QC, a human rights expert, told the government in clear terms that it needed to go back to the drawing board.

Parliamentary language is usually genteel, but the report from this committee gave the government a mauling.

What did the government do? Virtually ignored the committee and is proposing to proceed with the Bill with a few concessions. Nice to know Mr Tony is listening! Expect this story to run well into next year with high-level opposition from all key stakeholders; they are not giving up or going away.

Fuss over nothing?

The biggest non-event of the year for pharma was the review of the industry by the Health Select Committee.

Outgoing chair of the committee, David Hinchcliffe MP, stood down at the last election and many saw this inquiry as his swansong.

Hinchcliffe was highly respected across parliament and protected the integrity of the select committee fiercely, but he was also perceived by some as an old Labour leftie. Many in the industry expected him to take a swipe; and he did, but he was just as harsh on the regulators.

The report did not exactly portray the industry as a bunch of granny-murdering fiends, but did not have much to say
that was complimentary. It made a host of recommendations, most of which were ignored or neutered by the government.

AZ and GSK were called upon to face the HSC, yet very few companies had the balls to supply evidence to the committee or meet committee members; notable exceptions were Pfizer and Janssen-Cilag.

If pharma companies are not robust in presenting their case publicly and effectively then there should be no surprise if the bad press continues.

Agony of choice

Patient choice has been the key mantra through 2005 and both Labour and the Conservatives saw this as the key battleground in the May election.

The NHS is always fair game at election time, but this year was a bit different. Blair pumped record amounts of cash into the NHS on the basis that reform would follow. Yet, despite this, many parts of the service continued to run up financial deficits.

One spectacular big spender was the flagship Foundation Trust in Bradford, which saw the chair and chief executive depart swiftly. Blair and the public will rightly demand better performance for the new cash.

Blair promised the NHS more reform in the Labour manifesto and over the summer we saw the shape of that reform through a radical shake up of Strategic Health Authorities (SHAs) and Primary Care Trusts.

Sir Nigel Crisp, the top mandarin in the DoH, slipped out radical ideas in the quiet period at the end of July. One idea was to cut back PCTs, limiting them to a commissioning-only role and, therefore, allowing many more players to provide bread and butter community services, including the private sector.

The unions, the NHS and Labour MPs have gone ballistic. This particular incident gives us a fascinating glimpse of the actual power of ministers versus civil servants. A prominent pro-Blair backbencher was spitting tacks
to me about Crisp and DoH top brass.

His view was that the Chancellor had demanded efficiency savings from the DoH and the NHS. Crisp and the mandarins, he suggested, were damned if they were going to face any cuts, so they dreamt up the NHS restructure on the basis of cutting management costs, hence leaving the centre relatively pain free.

What the mandarins did not read was a massive backlash against the health reforms proposed by Crisp.

We now await a White Paper on social care and care outside hospitals, but in the dying months of 2005 we are seeing signs that Hewitt is backing off from the original ideas espoused by Crisp.

We will see far more flexible ideas in the White Paper and a new-look primary care in England next year. If a patch can get MPs and local politicians to agree to a reconfiguration of PCTs, then it is likely to go ahead; where such consensus is absent things are likely to stay as they are.

If Hewitt tries to carve up community provision and allow the private sector a free hand in the White Paper, she may well find the Labour backbenchers will have none of it. The consequence is likely to be another defeat for Blair in the commons.

dr n. urse

The next big part of the choice agenda involves non-doctor prescribing. In November, Hewitt announced far greater prescribing powers for nurses and pharmacists. Those who have been independent, or supplementary prescribers, have been working to a limited formulary stifled by agreed guidelines for each individual patient.

By early 2006, it is proposed that nurses and pharmacists who are already prescribers will undertake an additional 34-day training period and will then be allowed to prescribe any medicines in the British National Formulary (BNF), apart from controlled drugs. The nurses and the pharmacists' representative bodies seem to welcome this role expansion but the British Medical Association (BMA) is very anxious, and so it should be.

The GP contract allowed practitioners to opt out of providing out-of-hours services. In many parts of the country, a wide range of providers now offer cover and some bring doctors over from the EU to provide weekend cover. It is expensive.

A recent series of public consultations around the country have shown that the public sees this aspect of service in primary care as hugely important. As a result, the government suggests that a patient might register with more than one GP (ie, one in the place of residence and another in their work location).

NHS walk-in centres, staffed by experienced nurses with wider prescribing powers will be able to expand patient choice rapidly. In addition, advanced nurse practitioners and prescribing pharmacists could offer totally new ways for patients to access treatment and support more easily.

Entrepreneurial nurses, pharmacists, and private providers could put together all kinds of service models to either complement or challenge GP services.

Moving goal posts

This all makes 2006 very unpredictable for the pharma sector. Just as firms were getting on top of their NHS customer base, the ground shifted. How many PCOs will there be in England? Will all or some of them be providers? Will private providers in primary care become new customers? At the moment, we just do not know.

What is clear is that marketing and sales teams will need to keep an eagle eye on PCO structures and track the evolving picture closely, bearing in mind that different parts of the country may opt for different solutions. The one-size-fits-all PCO is likely to become history.

If the new prescribing powers for nurses and pharmacists are as wide ranging as Hewitt suggests, it is clear that a wholly different customer base will emerge. The industry will need to think hard about how to engage these new prescribers.

I would venture that the traditional ways in which the industry talked to doctors will not work with nurses and pharmacists. It is clear that new prescribers will be seeking support for enhanced training, and high quality and well-targeted educational events are likely to be welcomed.

Other big issues will centre on avian flu. If a pandemic unfolds, share prices in companies developing vaccines are going to do well. As the market becomes more global and health systems keep up the pressure on cost containment, life will be tougher for the pharma industry.

Undoubtedly, the push for mergers on a grand scale will be a key feature during 2006 and we could well see some household names hooking up.

Merger mania will be on a lot of minds as we enter a challenging and less predictable new year. Have a happy one!

2nd September 2008


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