Half Day Meeting: 'The Balance of Power

- who really is the prescriber now?'

The pharmaceutical industry must build better relationships with primary care organisations, and with patients, rather than concentrating solely on the healthcare professionals who write prescriptions, if it is to maintain its position in a health system which is seeing a significant shift in the balance of prescribing power.

That was the clear message from a half-day meeting held by the Pharmaceutical Marketing Society at the Royal College of Nursing on 30th November.

Around 100 pharma marketers heard speakers from all parts of the NHS, as well as industry marketing and PR specialists, describe how the influences on prescribing decisions are dramatically shifting away from doctors and towards new prescribers such as nurses and pharmacists, and into the hands of commissioners in the PCOs.

Chairman Andy McKeon, Managing Director - Health at the Audit Commission, introduced the event by describing a shift in the balance of prescribing power within the NHS, and highlighting the importance of the impact this shift will have on the relationship between the industry and the new prescribers. He said that the distinguished array of speakers represented many of the stakeholder groups which the pharma industry will have to interact with, giving PM Society members a unique opportunity to hear points of view from across the NHS and the industry.

The PCT View
First on the podium was Chris Town, Chief executive of the Greater Peterborough Primary Care Partnership. A lead negotiator during the development of the GP contract, and involved in formulating the pharmacists' contract, Chris has a huge experience in the health service - even so, he describes what is happening now as "the greatest revolution that I've ever known happen in the NHS".

Chris outlined the various drivers for change, which include not just the new contracts, but other external and internal factors such as the European working time directive, the new IT strategy, new funding flows and increased investment, as well as clinical governance issues driven by a number of events such as Shipman and Bristol, and an increasing plurality of provision of healthcare. He pointed out that the integration of health and social care would lead to new funding, and that that money should be invested in developing new ways of delivering primary care.

In addition to all these factors, there are significant scientific and technological advances which are driving changes. Genomics and pharmacogenomics are driving illness and lifestyle management, whilst improved imaging and diagnostics, coupled with remote consultations and telemetry are changing the way that care is delivered. The lifestyle aspect of healthcare is symptomised by the shift to OTC care being delivered in the pharmacy, and by increasing self-diagnosis and self-care.

According to Chris, healthcare is in some respects a victim of its own success, with an ageing population and a reduction in communicable diseases (except for sexually transmitted diseases). But at the same time there is an increase in cardiovascular, cancer, diabetes and respiratory diseases. "There are whole rafts of changes hitting us. But government policy is only responding to what is happening in society," he said.

The new GMS contract is setting out to modernise primary care, and this is linked to other agendas, principally creating opportunities and flexibilities for PCTs, practices and other parts of the primary healthcare structure, such as pharmacists. Money is being linked to 'what is achieved' rather than who did it.

The Quality and outcomes Framework has clarified priorities, but there are some contradictions involved. A review group has now been set up to review the scheme and look at ways in which it could be enhanced in future. Chris claimed that PCTs will experience challenges in funding the achievement of the points. Nevertheless, with £1.3 billion of new money, PCTs and practices must work closely on implementation, something which will require successful team working. PCTs must also recognise that this will have an indirect impact on the prescribing and diagnostics budget.

Likewise, the new pharmacy contract will have wide implications. For the first time, there will be proper monitoring of a set of national standards, and the delivery of advanced services will require PCT accreditation of premises, and open the way for pharmacy-based medication reviews.

Chris said that he had 'no idea' what the pharmacy picture will look like in five or ten years time, because the national templates for actions and outcomes are yet to be published. However, with ten key areas (including smoking cessation, medicines assessment and compliance, and supplementary prescribing) already identified, the impact of the new pharmacy contract on prescribing behaviour will be profound.

And then there is supplementary prescribing. With an arrangement between the independent prescriber (usually the GP) and the supplementary prescriber, once treatment is initiated, it will be managed via a clinical management plan, often with minimal intervention from the GP. It will be the supplementary prescriber who monitors and adjusts the treatment in line with the plan for up to 12 months, and that is not just about repeat prescribing, but will also involved moving the patient to different medication where appropriate.

And that's not the end of it. Lord Warner has already talked of independent prescribing powers for pharmacists by the end of 2005, and the pharmacy contract seems sure to evolve - and the march towards OTC seems sure to continue.

So what of the future? Chris set out a vision combining all of these new developments, whereby case management will involve a mixture of community matrons, nurses and social services; where care management will be mainly run by nurses, especially district nurses; where pharmacists will undertake medication reviews and adjustments; and where self-care will play an increasingly important role, backed by support from practices and pharmacists.

The issues therefore are myriad: what will the real impact be of the new contracts; will the new prescribers behave differently to doctors; will foundation hospitals and the private sector use new drugs if the treatment tariff price remains the same; will greater patient involvement in running what Chris called 'the business' challenge traditional marketing techniques for the industry; will foundation trusts and PCTs place more limits on prescribing, or create new incentives to comply with the formulary; and will choice have an impact, including offering non-drug alternatives to medication?

The GP's View
This view of a raft of influencers shaping patients' care was challenged by Walsall GP Dr Denys Wells, who said that the point to remember was: "Who is in charge of my case?" He claimed that the explosion in treatments has brought disjointed care to modern healthcare, with a pressing need for one person to take charge of an individual's care.

He pointed out that in the average ten minute consultation, a GP has to delve into the patient's history, conduct the examination, and prescribe treatment - and so to do this properly it is inevitable that other people will need to get involved.

Denys pointed out the pressing issue of concordance, with the fact being that people don't want to take medicines for ever. He said that doctors have not been very good at listening to patients, and that even if medicines were safe, effective and available, they weren't necessarily acceptable, an important factor in driving compliance.

Praising the work of practice pharmacists, whom he described as "hugely beneficial to our work", Denys reserved his scorn for 'experts', who, he said, "are the banes of our lives. They're always telling what to do, but they've never had to do it." He also questioned the level of experience of nurse prescribers.

The NHS structure in which GPs work also came in for some criticism. Contracts, he said, did not give rewards which were in line with best healthcare practice, constant change in the NHS and Primary Care commissioning was leading to ignorance on the part of the patient about who they should be turning to.

Denys set out an ideal situation in which the doctor diagnoses and the pharmacist prescribes. "I'm not very interested in what tablets are used by the patient; I'm interested in the outcome."

All of which made for a situation in which there is a team-based approach to patient care, with diagnosis, chronic disease management, shared care and stabilisation all playing a role. But, said Denys, there is a need for a co-ordinating role, a 'captain of the ship'. And that captain can only be the doctor, no matter how skilled the crew.

The Nurse's View
Matt Griffiths, Joint Prescribing & Medicines Management Advisor at the Royal College of Nursing, posed the question as to whether nurses were shifting from being an influencer to a fully-empowered prescriber.

There seems little debate that nurses are already an important influencer in prescribing decisions. With around half a million practising nurses in the UK, with many involved in chronic disease management, the influence is clear. And in acute care, the influence they have could be argued to be actual prescribing.

The 'new breed' of nurses developing new skills, running clinics and leading services, is much more akin to proper prescribers.

Various reports over the 1990s and 2000s, from the Cumberledge Report of 1996, through the two Crown Reports, to the introduction of Independent and Supplementary Prescribing in 2002/3, have driven this process forward. And government has put money where its mouth is, by providing £10 million over three years to support the education of nurse prescribers.

And now that funding has been increased, with £27 million available, and a target (or at least an 'aspiration') to have 10,000 qualified nurse prescribers by the end of 2005.

Meanwhile, the question of controlled drugs has also been tackled. But the shadow of Shipman still looms. Computer generated scripts are also not being implemented as quickly as they could be and so many nurses still print out prescriptions in the doctor's name to save administration.

Nevertheless less, with 27,000 district nurse and health visitors prescribers (albeit on a very limited formulary), 3,200 extended independent prescribers and 2,800 supplementary prescribing nurses (as well as around 250 supplementary prescribing pharmacists), and there are now more non-medical prescribers than medical ones.

And it won't stop there: as Chief Nursing officer Sarah Mullally said at the end of 2002, "There will be no legal limit on the conditions that may be included in supplementary prescribing. Supplementary prescribers will be able to prescribe all medicines currently prescribable by doctors, with the exceptions only of unlicensed medicines (except in specific circumstances) and, currently, of controlled drugs."

Matt said that non-medical prescribing was integral to the NHS Plan, to the new GMS and Pharmacy contracts, and the PMS pilots. In fact, it is in many cases simply legitimising what has been happening for years - 'back-door' prescribing has been commonplace for a long time.

"We have to improve the service to patients in accessing medications, improve the concordance in medications, helping cost and clinical effectiveness, and we have to reduce time-wasting, with professionals waiting for scripts," he said.

So what do nurses need to achieve all of this - and how can the industry help? First and foremost if validated CPD, which is high quality, accessible, robust and non-promotional. And that means non-biased, non-commercial. Matt posed the question: can this be provided by the industry?

So are nurses influencers or prescribers? "They are both," said Matt. "There are already huge numbers of influencers, and we are now seeing a growing number of real prescribers."

The Pharmacist's View
Beth Taylor, Principal Pharmacist, Community Health at London Specialist Pharmacy Services, and a member of the NHS Modernisation Board, put the point of view of the pharmacists. Setting out the context in which pharmacist supplementary prescribing was evolving, she drew attention to the wider picture, with PGDs and medicines management, as well as political pressure, all playing an influencing role. She spoke about new PCTs being keen on innovation, but lacking infrastructure and constrained by capacity - what she called the "real issues".

In London, the approach has been through a lead Workforce Development Confederation, to set up a three year project to support the implementation of supplementary pharmacist prescribing for all sectors (primary, secondary and community).

The group identified a number of tasks which needed tackling, including communication, infrastructure and systems, as well as support for the education and application process.

The results have been encouraging. So far there are 85 pharmacists in the capital who are qualified or in training, with three universities in London and five in the south-east offering SPP courses in 2004.

Beth outlined a number of case studies where pharmacists have worked as part of the clinical team (mainly in secondary care) to optimise drug therapy, working to agreed protocols. In one case, at a high-risk medication management clinic at a London teaching hospital, demonstrable benefits included improved patient experience, increased clinic capacity - by 20%, reduced medication risks and better patient communication and education.

She also outlined how a PCT employed pharmacist can see patients to discuss and individualise therapy (once initial diagnosis is made). Using their ability as a pharmacist who reviews therapy in patients with long-term conditions allows prescribing without having to request the GP to make changes to medications.

So what is holding pharmacists back? One aspect is the doctors; they are often very unsupportive, but may not grasp exactly what the supplementary prescribing model is until some way into the training process. Another key issue is that in the context of nGMS, GPs seem unwilling to fund non-practice staff to deliver core chronic disease management work. And like everyone else, according to Beth, IT is a hindrance, but we hope this will change!

Beth asked a key question: "Do GPs want to share prescribing responsibility, or delegate it?" She maintained that where pharmacist prescribers have trusting relationships with medical prescribers, supplementary pharmacist prescribing can work well. But the model can cause a drawing back from the delegated model of extended prescribers.

Referring to Denys Wells' 'Captain of the ship' analogy, Beth said that pharmacists do have a 'navigating' role to play. In fact, much like nurses, their role is two-fold: as prescribers in their own right, and as advisers, dispensing prescriptions for other practitioners.

"Supplementary prescribing is a new tool, not a new service in its own right," suggested Beth. Its best use may be to enhance a service, taking shared responsibility for drug treatment, and improving therapy that is relatively less well-managed.

"After only two years gestation, pharmacist prescribers are a reality in all sectors," she said. "We need to take the learning so far into debates about independent prescribing models for pharmacy."

The Industry View
Carsten Edwards, Customer Marketing Manager at Bristol Myers Squibb Pharmaceuticals, asked the simple question: Who is the new prescriber? He said that prescribing decisions are no longer the sole domain of the person with the pen and prescription pad - mainly hospital doctors and GPs. Instead, he maintained that PCOs are the 'common denominator' who 'permits' prescribing. It is these bodies who are responsible for implementing guidelines at a local level.

Given the myriad of NHS agendas, none of which stand alone, the key to successful communication with PCOs, and subsequent brand prescription at both primary and secondary care level, is to align relevant (to the brand) agendas - the industry's role should be to facilitate prescribing. Therefore stakeholders need targeting with brand and disease messages which are appropriate to their job function. As Carsten put it, "ads of penguins in swimming pools may work for a GP, but they don't work for a Prescribing Advisor".

He set out a comprehensive list of the new prescribers, demonstrating the dilution of audiences which the industry has to get to grips with. But all are united by the current NHS agendas, which Carsten introduced one by one.

Management of long-term conditions is very high on the agenda, because it's very costly. 60% of adults report some form of chronic condition, and 80% of GP consultations are associated with their treatment. The importance for the NHS is demonstrated by the fact that patients with chronic conditions are more likely to be admitted as in-patients and stay on hospital longer.

The NHS Improvement Plan has identified many targets for service delivery, including indicative practice commissioning budgets, as well as the rollout of the Expert Patient Programme, something which Carsten said would be very influential. In addition, patients referred by their GP will be able to choose any provider able to meet NHS standards and to deliver care at tariff.

He explained how the Kaiser model could be used to develop local implementation strategies, with three levels: level one, where self-management accounted for 70-80% of patients; level three, where patients with highly complex conditions were managed; and sandwiched in between, level two, where disease management was a truly shared agenda between the industry and PCOs. It is here that there is a potentially more direct link to products.

The pharmacy contract gives the industry "a huge role to partner with Pharmacy," according to Carsten. "It's time we woke up to the role of our community pharmacists. Again, there is a big role for PCOs, who must provide funding for enhanced services, and who need to plan for the development of community pharmacy services in their area.

Payment by Results is a big incentive for PCO initiatives. It should encourage innovation, improve efficiency and choice, and support devolution to local decision-makers. It also links resource costs to clinical outcomes. Alongside this, practice-based commissioning recognises that local knowledge is essential to the successful development of local services in the community.

So how should the industry be approaching this new world? The first thing to recognise, according to Carsten, is that local customer insights are essential. "One size will not fit all. We must empower local teams to interact with PCOs - but they have to be projects which fit our own agenda.

"All of our communications and brand plans have to have the PCO as the pivotal part. The PCO is king."

Brian Gunson, Chairman of Munro and Forster Communications, and a non-executive director of St Albans and Harpenden PCT, was optimistic about the future. "There is a will to encourage a new level of co-operation that brings together the industry, policy makers, practitioners and above all the patients and public," he said.

Claiming that the market is increasingly de-stabilised, with many pulls and priorities, Brian said that current strategies will require serious re-evaluation; with the findings fed back into organisational and business development processes internally and into new relationship management approaches that support 'reverse engineered' visions for local markets - all the way down the value chain to R&D.

Brian outlined four 'strategic pillars' to consider. First is to shift from the concept of patients to 'citizen-consumers', with the recognition that not all will engage with the process of self-management. Second is the increasing multidisciplinarity of the market. Third is the shift of the industry from product suppliers to service solution providers, the importance of providing the right medicine, with the right management at the right time cannot be underestimated. Finally, there is the opportunity to innovate modern information and communications.

So what tactics should the industry be embracing? Brian made a number of suggestions to mull over: should we be changing the business model; should we be exploring risk-sharing; should we encourage a new dynamic producer/provider/patient relationship (which would mean engaging in a new relationship ourselves); should we be educating and informing a wider range of stakeholders, both traditional and non-traditional; should we understand the culture, drivers and priorities of commissioners better?

Should we be researching the demography of the patient, especially on a local level, and better manage patient expectations (by realistic communications with patients)? Should we, as an industry, be encouraging public involvement in the planning and provision and review of services? And certainly we should be focussing on relationship management.

"The industry is a very important partner in creating healthy futures," said Brian. "We must have the internal agility to work within a constantly changing market!"

Held on: 30/11/2004