At the recent industry conference – ‘Looking Ahead to 2009/10: engaging with a changing NHS’ – a detailed storyboard on the post-Darzi NHS world was played out to an audience of pharma managers. The aim of the conference was to examine the wider implications for pharma going forward.
Chris Ham, professor of health policy and management at the University of Birmingham’s health services management centre, set the scene and delivered a strong take-home message: with lower NHS funding increases to come in the future, the ‘party’ is indeed over and the rationing debate can no longer be contained on the back burner.
We have certainly seen this to be true recently with the top-up debate.
Regarding market access, Professor Ham pointed out that independent assessments indicate NICE has done a good job and, as such, the industry should not expect it to be going anywhere soon. In a world of overt priority setting, politicians need an expert body like NICE to take some of the flak over unpopular decisions.
Professor Ham also wondered whether the NHS might be on the threshold of a new era in primary care, with a focus on increasing its capacity. It is not surprising then that the industry has stared paying greater attention to hospitals.
Looking at Lord Darzi’s primary and community care strategy, Professor Ham concluded that the NHS has moved out of critical care and is now in active rehabilitation. He claimed, however, there is still some way to go to becoming a world-class organisation.
Life on the NHS frontline
Sophia Christie, chief executive of Birmingham East and North PCT, never shy of presenting her thoughts in the Health Service Journal, gave an impassioned view of life on the NHS frontline.
Reviewing the competencies of world-class commissioning, Christie said that NHS managers would have to think harder about investment for health gain using data on patterns of disease, service investment and the resulting outcomes. More attention, she said, would have to be paid to commissioning primary care. PCTs would have to prioritise local health needs, and this is where tax payers’ money comes in. Money should not be spent on what pharma wants, nor on what hospitals want, she claimed.
Quality of healthcare
Nigel Edwards, policy director at the NHS Confederation, reviewed high-quality care for all, which charges the NHS with improving the quality of healthcare. He stressed that good data are needed to make better decisions (delegates would probably not have failed to noticed the NHS Information Centre stand in the exhibition hall boasting big plans for world-class information).
Edwards also pointed out that Darzi was consistent with existing policy, but that many of the proposals put forward in the Darzi review had been seen in earlier policy documents. He added that in his opinion, the big opportunities for pharma lie in contributing to prevention strategies and working with NHS organisations to develop care pathways and commissioning.
The emphasis on giving more managerial responsibility to physicians will give pharma some important new people to talk to. Opportunities also exist around the proposed NHS Constitution insofar as it relates to NICE approved drugs.
The future of NICE
Dr Carole Longson, director of the Health Technology Evaluation Centre at NICE, reflected on ‘Being NICE’ as the organisation nears its 10th anniversary. She stated that although there was still some scepticism among companies, generally speaking, perceptions had changed for the good since 1999.
Longson did say, however, that in the post-Darzi world, NICE would be an even bigger and possibly more problematic organisation to deal with than in the past.
Darzi has had a lot to say about NICE, including that the institute needs to get more involved in the quality agenda by setting a range of new/updated clinical quality standards (the national service frameworks are starting to run out), have a central role in further development of the QOF (less process and more outcomes) and use ‘NHS evidence’ to bring together under one roof the evidence that NHS decision-makers will need.
NHS evidence is envisaged as a kind of ‘google’ portal through which people will be able to access ‘kitemarked’ clinical and non-clinical evidence and best practice.
Dr Longson stressed that engagement with industry is key to NICE’s effectiveness and a new (voluntary) programme of closer working is being implemented to offer scientific advice to companies on HTA evidence plans prior to the commencement of phase III studies.
Programme budgeting
Dr Peter Brambleby, director of public health, North Yorkshire and York PCT and North Yorkshire County Council, presented on matching scarce resource spend to local healthcare needs. If you didn’t know, the Department of Health collects data from PCTs on healthcare expenditure and cuts this into clinical areas, including mental health, cancer and cardiovascular disease. Analysis of this ‘programme budgeting’ data can be used to plot spend against health benefits and can, thus, be used to decide local priorities as well as identify possible areas of disinvestment/new investment.
Dr Brambleby feels that programme budgeting allows PCTs to look at healthcare spend in a completely different way, and allows new questions to be asked of providers in primary, secondary and tertiary care.
New kinds of questions (eg how much does a PCT spend in total on cancer and what does this investment achieve?) tend to give new kinds of answers to old problems surrounding variations in care and the mismatch between healthcare need and expenditure. Not asking new questions means that we will keep getting the same old answers.
In terms of closer working with the industry, many of Dr Brambleby’s comments echoed those given by Sophia Christie, reinforcing the notion that it is important to listen to what is coming from such frontline NHS customers before coming to them with answers.
New models
Dr Richard Barker closed the conference by saying that pharma is trying to adapt to this rapidly changing environment, but still has deep-rooted challenges to address. He said the traditional R&D and marketing models are probably broken for good, so it is imperative that companies establish new kinds of relationships with the NHS. Pharma also needs to learn to regard the highly influential new organisations as new customers (some were in the exhibition hall) and find new ways of engaging.
The issue that seemed to worry Dr Barker the most is the continuing deep-seated distrust of the industry felt by some NHS staff. Finding ways of helping NHS organisations improve service quality will not only allow the industry to make progress, but also to rebuild trust, he said.
In the area of joint working, Dr Barker announced that an ABPI working group had revised the Code of Practice guidance after members reported it placed unnecessary restrictions on projects, and that this would be published shortly.
Conclusion
The industry needs to understand local priorities as well as the national picture (refer to the 2009/10 NHS Operating Framework).
In terms of joint working, pharma is advised to develop only those things that the NHS needs, rather than what it thinks the NHS wants.
Post-Darzi, SHAs are likely to be the big winners in all of this, with new kinds of customers appearing. But are you fit-for-purpose and ready to cover these developing organisations?
As always after such meetings, there are as many questions as answers. For instance, EL (94) 94 has been revoked so does this mean that companies should again look at being healthcare delivery providers in chronic disease?
Meeting chair, Roy Lilley, was very sceptical about providing such services and thinks the industry should return to basics.
But that’s the problem Mr Lilley, it’s the basics that are broken… things like when marketing has all the budget, how can one persuade it to move away from focusing soley on brand plans?
Although the air is currently filled with doom and gloom over the economy, following this meeting, one could in fact predict that a significant window of opportunity is opening for the industry. Are you brave enough to take it?
The Author:
Alan Jones is a consultant and independent healthcare policy analyst