Half Day Conference: Industry and the NHS - Recipes for Success

The NHS is undergoing a period of intense change, providing opportunities for the NHS and the pharmaceutical industry to work constructively together. It is therefore vital to identify positive and effective solutions in developing successful partnerships. This PM Society conference, held at the Royal College of Nursing, explored the recipes for successful partnership working and provided delegates with a forum to share ideas and experience.

Back row(L-R) John Procter - Pfizer; Margaret Stockham - Bedford Primary Care Trust; Angela McFarlane - HealthGain Solutions; Martin Anderson - APBI Front row(L-R) Mignon French - AstraZeneca; Judy Willits - Judy Willits Consultancy; Anna Lawson - GlaxoSmithKline

As Sandy Thomson, Chairman of the PM Society, stated in welcoming delegates, the new working practices within the NHS offer both opportunities and threats, and meeting chair Judy Willits pointed out that the distinguished panel of speakers had broad and varied experience both within the NHS and the pharmaceutical industry and in their current roles many of them work across that interface to help drive recipes for success.

Divided into three sessions, or 'courses', the 'Starters' discussed how industry and the ABPI can be involved in successful working partnerships with the NHS, as well as putting in place structures that protect the interests of all parties. The 'Main Course' highlighted a series of practical 'case studies', and 'Dessert', provided delegates with an overview of the key issues, and practical 'take-home' messages for future joint working initiatives.


The NHS and the pharmaceutical industry working together for patients
For Martin Anderson (Director of Commercial Affairs, ABPI) these are challenging and turbulent times for the NHS and industry. There is much comment and often criticism about what the pharmaceutical industry does and how. However, when Martin recently wrote to the chief executives of the top 20 most difficult to access PCTs (as assessed by ABPI members) the majority responded very positively, expressing the wish to work with the industry. In Martin's view the industry is often seen as the enemy and has a public perception problem at times he mentioned the very different perceptions of the withdrawal of Vioxx, versus the clamour to make the unlicensed Herceptin available to breast cancer patients.

As always, communication is the key. In any proposed partnership it is important to be clear in all communications and to demonstrate that industry works to a very high standard. Above all it is vital to understand each other's agendas. Since the mutual objective of any project is to bring about health improvement for individuals and the wider population, there should always be some common ground.

A Common Understanding was developed jointly by the ABPI and the Scottish Executive and published by the Executive in December 2003. It provides a checklist to consider before embarking on a joint project. The frameworks and value statements have since been used in a similar ABPI document, NHS and Pharmaceutical Industry Working Together for Patients published in 2005 and endorsed by the NHS Alliance, the NAPC and the NHS Confederation. This covers Government policy, values and principles, as well as case examples of pharma companies working with local or national NHS organisations on specific projects.

The ground rules for successful partnerships are simple and need to be openly acknowledged: trust, mutual benefit, added value, reliability, consistency and integrity. It is important to establish that everyone is happy at key stages in the process and also to be big enough if things are not going well to step back and sort matters out. Ultimately partnership is about people: building relationships and networks, agreeing and sharing objectives, playing to strengths and bringing together what industry and NHS are best at.




The changing NHS environment: opportunities for partnership working
In the view of Margaret Stockham, Chief Executive of Bedford Primary Care NHS Trust, the NHS struggles at times to keep up to date, often blinded in the headlights of change. In fact, there is less change than the media would have us believe. The future is not such a confusing place. Fundamental responsibilities will not change that much. PCTs will still be developing out-of-hospital opportunities, many with the pharmaceutical industry and professional associations. In Margaret's view the commissioning and contracting function of PCTs will strengthen.

Secondary care will remain secondary care, though some hospitals will be downsized with slightly less emphasis on diagnostics and outpatient services. Mental Health Trusts will still exist, Foundation Trusts will become more the norm, NHS Direct will continue, the Department of Health will still be there, though there will be fewer Strategic Health Authorities. Practices may well be slightly larger and some may come together like legal chambers. There will be 'one-stop shops' to offer advice and signposting without services. Local rehabilitation day services will be provided, as well as community diagnostic and treatment centres, and also envisaged are surgery centres to carry out low-risk surgery efficiently via a partnership between the independent and private sector.

In future, the power base will lie with the PCTs, who will continue to manage 75% of the NHS budget. They must establish the health needs of the population and commission services to meet these needs, and monitor contracts with pharmacists, dentists, optometrists and GPs, as well as with secondary care. The PCTs currently provide community health services, many of which might be better managed by a strategic partnership, or the voluntary or independent sector. PCTs also have a duty to integrate health and social care, particularly for those with long-term or life-limiting conditions who are currently not always well served.



While so many roles are changing, she believes this offers a great opportunity for those PCTs that want to work in partnership to drive new ways of working through the confusion. Many places around the country are doing just this, while others are entirely disabled by all the disorganisation. In her words, "don't be part of that disability, be part of the innovation".

The key to all the changes is putting patients first. Patient-centred care has been talked about endlessly but does not always happen. What is needed is to provide personalised care while at the same time caring for the population as a whole. This requires real innovation, not just revising, reviewing and tinkering at the edges of the services already provided. This can only be achieved by good relations and shared vision, by having fewer national targets and more space for local developments, and by service modernisation.

With regard to governance, critical appraisal and evaluation is important and PCTs must demonstrate that fair and balanced consideration has been given to all companies. Decisions should be based on best practice and Margaret strongly advises documenting the reasoning behind decisions, particularly if recommending one company over another. She also recommends exchanging governance documentation and agreeing to work to ABPI and NICE guidelines.

Finally, Margaret firmly believes that in order to improve patient care is it essential that the industry and the NHS work together. Commissioning and the drive for a patient-led NHS provide opportunities to make real changes in relationships for the benefit of patients.




Engaging with the NHS in a transparent manner: the ingredients for success
Back in the days of fundholding Angela McFarlane, Managing Director of HealthGain Solutions, was not convinced that partnership could exist between industry and the NHS. But times have changed and the NHS is now much more open to finding innovative solutions to address the particular challenges it now faces.

One of the biggest barriers to implementation of integrated healthcare pathways is getting the NHS to recognise that in an appropriate managed-care environment, patient outcomes can actually be improved.

Industry knows that if the best interests of the patient are kept at the centre then the best interests for the industry will follow, but it is important to be aware of the context in which the NHS is working. The Government puts a lot of money into the private sector to ensure that waiting times do not go up: £3 billion will be spent on private sector treatment over five years to pay for 1.7 million operations. These public/private partnerships are causing tensions however very few PCTs have had much choice about the private sector organisations commissioned to build services and capacity in their area.

How then do we facilitate successful partnership working? One of the critical success factors is to test any concept with the NHS before it goes to market, possibly via advisory boards, and if the concept is not robust then have the courage to abandon it. Protect the concept with attention to detail and think about the local health economy and not just projects in isolation. Other drivers should be considered, such as the Caldicott Guardian that safeguards patient confidentiality.

Angela went on to highlight the successful Alzheimer's Dementia Project conducted with Shire and Janssen-Cilag with which she was involved. A joint Advisory Board including all the interested parties came up with the plan to employ a mental health nurse to work as a link between the carer, the GP practice, and social services where necessary, and undertake not just an Alzheimer's review but a full medicines review. Heads of Agreement (or contracts) between everyone involved were critical so that everyone involved understood what was expected from the provider, the practice, and the PCT. Another good example is a pilot medicines management project for older people with long-term medical conditions across 10 PCTs with 42 GP practices and reviewing the medications of over 9000 individual patients.

In Angela's view, most important for partnership working is to engender trust and confidence so that everyone involved feels that they are 'swimming with the dolphins rather than the sharks'. It is vital to be open and transparent, provide clear documentation to identify the role and responsibilities of all parties, and to be flexible in implementation.




Talking Points
Asked for her views on the need for more 'joined up' working between PCTs and social services, particularly for the elderly population, Margaret Stockham felt that a merger between the two is not realistic at this stage, though there has to be some degree of integration. This requires a shared vision and shared purpose locally to ensure that the focus is on the end user - the patient. Margaret also pointed out that the NHS as a whole is not ready for partnership working so it is important for the industry to identify those areas of the NHS that are ready to participate. Martin Anderson added that while some pharmaceutical companies are ready and willing to enter into partnerships, others are not. Judy Willits felt that because the process of change in the NHS is so rapid something that did not work six months ago might actually work now. Be brave and go for it!

Asked who in the PCT to approach with a partnership proposal Margaret stressed there is no one-size fits all answer. Generally the industry should use existing relationships. If no relationship exists the best place to start is with the most senior clinician (either the Director of Public Health or the Clinical Director) who can quickly get together a suitably senior group to make a decision on the proposal.

Answering a question as to whether the industry could ever take over the management of a PCT, Margaret felt it would be fraught with difficulties. However, it would be exciting and challenging and perhaps a better solution than simply franchising or merging high-performing PCTs with low-performing ones.

On the question of product-based risk-share projects Martin Anderson explained that this is an interesting business model where a PCT commits to using certain volume of a medicine at a certain price and the cost is refunded if the medicine does not meet the clinical needs of patients. Commercially this approach can be risky, however, if the patient mix in a particular area is not as anticipated.


Case study 1
Chronic disease management partnership:
Pfizer and Haringey Teaching Primary Care Trust (TPCT)
As an example of how partnership can work, John Procter, head of UK Pfizer Health Solutions, discussed the Haringey Project, a pilot begun in February 2004 which arose out of discussions between Pfizer's Hank McKinnell and Alan Milburn at the DOH. The project primarily aimed to test the model that Pfizer had already developed in the US for a pro-active and systematic telephone-based support service for patients with long-term conditions, with the primary focus around supporting individuals to improve their capability to self care and to use this as a driver for the more appropriate use of healthcare services. Learnings from the project would be identified and ultimately shared across the NHS. In undertaking the project Pfizer's objectives were to demonstrate how the company could work in a public-private partnership for the benefit of patients.

Originally planned to last 16 months the project has been extended to the end of November 2005 to enable more detailed evaluation of the 600 patients in the intervention group and the 150 in the comparator group. The original budget of £250,000 has been extended to £470,000 (split 50:50 between Pfizer and the DOH). While the DOH has provided a funding commitment they have otherwise been a silent partner, though they are kept regularly informed on progress. The primary work is done by Pfizer and Haringey PCT. It is important to have clarity about each partner's responsibilities and a very strong governance structure involving the right people. There is also a rigorous and independent evaluation process, something which John strongly recommends.

The service is delivered via care managers who are employed by the PCT and work with patients primarily over the telephone. They are trained to provide information, education, motivation, support, and skills to help patients gain greater control over their condition and have a positive impact on their long-term prognosis.

The Plan-Do-Study-Act (PDSA) cycle has also been helpful in evolving and developing the project. The value of PDSA is that it promotes a learning approach, working together on solutions to issues that arise and developing understanding together.

Findings will be reported in March 2007 but learnings have been shared amongst the partners on an ongoing basis. In terms of national awareness for what is really quite a small project the Haringey project has punched well beyond its weight. Over the last three months John Procter and Pfizer have spoken to 30% of all PCTs in England at the PCTs' invitation.

Haringey has offered exciting opportunities for Pfizer who have gained recognition as a private company that can bring expertise into the NHS. UK Pfizer Health Solutions has now been set up to promote the supported self care model and offer it to other PCTs as a commissioned service. The first deal has just been signed with North and Eastern Birmingham PCT and NHS Direct to provide a similar service for 2000 patients in the West Midlands.




Talking points
Asked about profit models, market opportunity and ROI John Procter stated that the Haringey project essentially budgeted to cover the cost of delivering the service. Each new project will be quite different Birmingham for example will be on a fee-for-service basis. In John's view the Haringey project has been a good investment so far and up to now there has been no problem separating Health Solutions from Pfizer product sales.
Margaret Stockham stressed that the Haringey Project is an excellent practical example demonstrating that if projects are set up with transparency and honesty and with the patient in mind then all the traditional barriers just fade away.



Case study II
Working in partnership with the NHS:
Delivering sustainable improvements for severe mental illness sufferers
Partnerships come in all shapes and sizes but for Mignon French, Mental Health Strategic Partnership Lead with AstraZeneca, there are two vital questions: will the partnership improve the patient's treatment and experience of the service and will it be mutually beneficial for both the industry and the NHS. Partnerships are built on trust. Unless all parties are transparent and open the partnership will fail, but when a relationship is successful this leads to sustainability and ongoing commitment for future partnership. Most important, in Mignon French's view, is to identify a common goal, understand each other's perspective and to be flexible.

The NHS and Pharmaceutical Industry Working Together for Patients document contains the following case study started 18 months ago implementing the National Service Framework for mental health in Slough. The aim of the project was to achieve the NSF targets and implement other up-to-date policies, including the new GMS contract around mental health and the NICE guidance for schizophrenia and depression.



The steering group consisted of Berkshire Healthcare Trust, AstraZeneca and all other key stakeholders that the project touched, i.e. healthcare professionals, pharmacists and patients. The project was truly collaborative, with very clear objectives and responsibilities within the group, and also regularly peer reviewed. The collaborative approach enabled sharing of best practice through networking and using the varied and extensive knowledge base of all agencies involved, as well as helping to bridge the gap between NSF guidance and implementation at a local level.

The objectives were to:

• Improve the referral process
  
• Provide up-to-date information and advice for healthcare professionals, patients and carers
  
• Highlight the physical health needs of patients with mental illness
  
• Signpost services within the local community
  
• Provide information for patients enabling informed choice
  
• Facilitate early recognition, assessment and diagnosis of psychosis in primary care and faster access to secondary care
  
• Provide evidence-based advice for prescribing and treatment.

The work has now been extended and adapted locally, and other pharmaceutical companies have come on board (Wyeth and Janssen-Cilag) to provide guidance for the whole of Buckinghamshire. It is also being developed in Oxfordshire. The work has been cited as an excellent example of multi-agency working to promote and enhance good practice which can only help improve services to mental health service users and their families.

Partnership works because solutions are co-owned by both parties, and the relationships created are sustainable and valued. Trust is gained through transparency allowing people to work creatively together. Mignon French is passionate about ensuring that the expertise that exists across the pharmaceutical industry is used more productively in this way.



Talking points
Judy Willits saw the Slough project an excellent example of a partnership project in a difficult therapeutic area. On the question of how smaller organisations should approach partnerships, Mignon French stressed that most important is to build trust between partners, irrespective of company size.


Healthy Alliance:
Collaboration between GlaxoSmithKline and the Parkinson's Disease Society
Healthy Alliance is a non-promotional service brand for GSK, providing education and training directly to the Parkinson's disease nurse specialist working in the NHS. What makes it unique, according to Anna Lawson (Parkinson's Disease Nurse Adviser for GSK) is collaboration with the Parkinson's Disease Society, as well as the RCN and the Parkinson's Disease Nurse Specialist Association (PDNSA).

GSK has a heritage in Parkinson's disease, with the drug ropinirole (Requip) one of four dopamine agonists on the market. Back in 2002 GSK was perceived by those involved in caring for patients with Parkinson's disease to be an aggressive and unsupportive organisation something GSK were anxious to reverse. The objectives of Healthy Alliance were therefore to establish GSK as the pharmaceutical partner of choice in Parkinson's disease, and to support the development of Parkinson's disease Nurse Specialists to improve service provision and reach more patients.

Nurses are pivotal in the coordination of care in Parkinson's disease, particularly in medicines management. When Healthy Alliance was set up the Parkinson's Disease Society had pledged to create 240 Parkinson's disease nurse specialists around the UK, pump priming these posts with £30,000 for each nurse. However the nurses appointed received inadequate training and were leaving as quickly as they were put in place, thus haemorrhaging money. GSK saw this as an opportunity and employed Anna Lawson as an independent nurse adviser to improve both nurse and service development.

Together the stakeholders defined Anna's role, which has four key areas: service development (GSK's primary objective), a nurse induction programme (the Parkinson's Disease Society's objective), audit (the key issue for the PDNSA), and professional skills (key for the RCN). From this framework three silos of nurse development were developed: clinical, service and professional. The clinical silo consists of induction programmes, nurse prescribing meetings, and Healthy Alliance Conferences. The service silo has proven to be one of the most successful areas providing regional development workshops for nurses. The professional silo covers resources such as teaching packs on CD-Rom, care pathways, protocols for setting up and running clinics, as well as professional skills workshops such as time management, presentation skills and influencing skills.

For GSK, perceived in 2002 as aggressive, pushy and unfeeling, research from 2005 has shown that GSK is now considered the best pharmaceutical partner for Parkinson's disease in the UK a great result for GSK in such a relationship driven market. Healthy Alliance is supporting the development of services for people with Parkinson's disease. For Anna Lawson this is what is important: to improve service provision, encourage best practice and reach more patients.

As to the future, nurse prescribing represents an enormous opportunity for every pharmaceutical company, regardless of size. Practice-based commissioning will provide other opportunities, as will pharmacy prescribing. The NHS is changing rapidly and who knows what will happen in future. One thing is certain, however: GSK will continue to support Healthy Alliance.



Talking points
Asked why so few nurses actually take on prescribing Anna Lawson stressed that the barriers need to be broken down, in particular how nurses secure a prescribing budget. It is important that everything in place before the nurse goes on the prescribing course so they can hit the ground running on their return from the course. Anna also pointed out that because nurses are aware of Healthy Alliance it opens doors for GSK where previously they had been firmly closed.


Chairman's summary:
The pay off - joint working initiatives and how to make them work for you
Summarising the conference, Judy Willits (Healthcare Consultant) stressed that with so much change going on in the NHS, this creates exciting opportunities. The issues discussed managing demand, service redesign, new contracts, reconfiguration, new customers, focus on patients and choice, as well as IT developments all offer great opportunities to move thinking ahead. Everything that has been attempted in the past is now coming alive.

In Judy's view, the question for delegates and their organisations is whether to be a leader or a follower?

The principle lessons and take home points are:

• Focus on our customers' agendas
  
• Acknowledge the expertise that can be brought to the table
  
• It isn't always about money, but about skills, resources, and facilitation
  
• Evaluate the learnings and share them across the NHS
  
• Honour agreements, set out what needs to be achieved and deliver on it
  
• Set up criteria for success and evaluate them.

Remember to walk in your customer's shoes and keep on top of what is happening: understand your customer's agenda and issues (no one-size solution fits all); find the common ground; identify what you can offer. It is vital to develop a shared and transparent framework for partnership working and deliver your side of the bargain. So it's up to you. If you are on the front foot and really drive these partnerships then there is everything to gain.

Held on: 15/11/2005