Delivering the NHS quality agenda - A joint responsibility

Following the publication of Lord Darzi's report 'High quality care for all', the NHS is now focused on delivering quality. With the help of a panel of eminent speakers with a wide range of experience and expertise this half-day conference, held at the King's Fund in London, set out to discuss what delivering quality actually means and to assess the potential for the pharmaceutical industry to contribute to the process via joint working.

Delivering quality and innovation in challenging times

The journey towards delivering quality and innovation in the health service has been in three stages, according to David Colin-Thomé, National Director for Primary Care at the Department of Health. The start was greater investment, followed by the introduction of reforms aimed at achieving better performance via targets and payment by results, and culminating in the focus on systematising quality in the healthcare system as outlined the Darzi report.

Lord Darzi highlighted four key areas: patient safety, effectiveness (including clinical outcomes and patient reported outcome measures - PROMs), user experience, and innovation. He also set out a framework to enable quality improvement which is now starting to be implemented. This includes bringing clarity to quality standards (with an expanded role for NICE and NHS Evidence), developing metrics to measure quality, publishing 'quality accounts', rewarding quality via CQUIN (Commissioning for Quality Improvement), raising standards via the National Quality Board, and safeguarding quality via the Care Quality Commission.

In all these initiatives, four areas are particularly relevant: quality, innovation, productivity, and prevention - making up the so-called QIPP agenda. Various financial incentives have already been introduced via QOF (Quality and Outcomes Framework), as well as enhanced services for general practice and for community pharmacy. PCTs now have more flexibility as funders of local health services, and hospitals have the payment by results scheme to include the CQUIN quality marker.

David co-chaired the Primary and Community Care Strategy section of the Darzi review with the Ministry of Health, and key to their recommendations was that services should be shaped around individuals (the personalised approach), to include patient budgets, choice for those with long-term conditions, transforming community services, and promoting healthy lives. David noted that community services constitute one-fifth of the NHS workforce and more money is spent on them than general practice, yet prior to the review have never received major political or managerial attention in the past and there are no metrics for measuring and assessing what they do.

David's view is that population-based care provides a 'home' where the needs of both the individual and the community can be met. It will provide a home for all primary care providers (pharmacists, dentists, optometrists, community health services and social care), and home for all extended skills and services. It will of course also mean care closer to the patient's home. Ultimately it will be where the service responsibility for some of the social determinants of health can be the responsibility of one provider organisation.

Discussion

James Kingsland mentioned QIPP and whether quality should be 'warranted'. In David's view such a 'warrant' would become just another target but conceded that it would be good to reward organisations that can commit to something like QIPP. There is clearly a need to be more defined when talking about quality.

In response to a question from Patrick Hopkinson (GlaxoSmithKline) about what might happen after the election next year, David noted that while there may be a pacing and intensity issue the principles will be the same with either major party. Practice-based commissioning is about being a provider and a commissioner around a particular population. But PCTs need to increase their budgetary devolution, in David's view, to begin to extend the scope of what can be done in primary care. Most GPs are constrained by their clinical focus so they often need management help. The challenge then is for them to stay responsive to the needs of local communities as well as working in a more systematic and well managed way.

David Trevor (Allergan Ltd) asked David's view on the feasibility of increasing quality at the same time as having to take a £20 billion cut in budget. David pointed to plenty of convincing evidence that higher quality can actually be cheaper. Of course some drugs are very expensive but, looking at high-volume low-cost activity and the huge variation in how care is organised, literally billions of pounds are not currently being used wisely. If the high-volume areas such as outpatient care were to be challenged several million pounds could be saved each year.

It has been calculated that a 15-20% improvement in productivity overall would mean a saving of £15-20 million a day to the health service

Likewise, if all hospitals achieved the lengths of stay and follow-up seen in the top 25% of hospitals, this would save £2.2 billion a year. However, addressing these issues will challenge the very fabric of some organisations. It is achievable but changing the cultural mindset will be tough. James Kingsland noted that it has been calculated that a 15-20% improvement in productivity overall would mean a saving of £15-20 million a day to the health service.

Christine Baldwin (Burson-Marsteller) mentioned generic substitution and quality of patient care. David's view is that a move such as this cannot be 'top down' because that always causes arguments and political noise. It is better to give incentives locally and let the clinicians (and others) sort it out themselves.

Asked how the productivity element of the QIPP agenda will be squared with the need to decommission and with allowing patients a stronger voice, David agreed that patients will never like the idea of decommissioning if it is presented as a 'macro' decision - a sudden announcement always causes negative reaction. But if the clinicians involved first put the alternatives to patients, namely that to receive more and better services locally hospitals might have to become smaller or even close, this will help in getting patients to accept the decision. As more and better care is provided in community settings, patients will become engaged in the process. However, if hospital-based services are going to be moved and if there is then also a move to centralise local GPs; that would be a political disaster. The GP being local but better organised is a good counter balance, in David's view.

Geoff Frew (Pharma Times) raised the question of patient budgets. David noted that there will be an academic evaluation of the 70 pilots currently under way in this area. The fact that these initiatives are pilots has allowed the safety to try some very imaginative solutions, including actually giving the money to the patient.

Developments at NICE – Implications for industry

Presenting an overview of ongoing developments at NICE and putting these in the context of what they might mean to industry, Gillian Leng (Deputy Chief Executive, NICE, and Chief Operating Office for NHS Evidence) began by discussing the aspect that NICE is perhaps best known for since its inception in 1999 - appraising new drugs. Gillian pointed out that because each new appraisal carries a mandatory three-month funding directive, NICE have been able to support the uptake of new drugs, such as herceptin.

Gillian Leng, Deputy Chief Executive at NICE, and the Chief Operating Officer for NHS Evidence

Within the single technology appraisal (STA) programme the threshold range for cost effectiveness has evolved over time. NICE generally accept a drug which costs below £20,000/QALY, and those costing over £30,000/QALY will normally be rejected (though this is not automatic, and depends on other factors). Additional advice was added this year to cover drugs likely to give at least three months' additional life expectancy at the end of life, meaning four drugs have been accepted that would not otherwise have been. Gillian acknowledged that there have been many negative headlines regarding NICE decisions, but earlier this year NICE held a workshop with stakeholders, which concluded that the existing threshold is as good as it can be, though it will be reviewed on a regular basis.

With regard to new developments at NICE, an initiative to create a single horizon scanning database has now been approved which will be managed within NICE/NHS Evidence and up and running by June 2010. Individual companies will directly upload data to the database, to which key clients will have direct access via a secure system.

NICE has also established PASLU (the Patient Access Scheme Liaison Unit) and also, following a pilot with Novartis, the NICE Scientific Advice Programme began this year, where for a fee NICE respond to questions from individual companies through a face-to-face meeting, supported by a formal report. This aims to provide advice during phase II studies to help companies plan future work (covering trial designs, comparators, outcome data etc).

An initiative to create a single horizon scanning database has now been approved which will be managed within NICE/NHS Evidence and up and running by June 2010

Gillian also outlined that the Office of Life Sciences (OLS) report published earlier this year has generated a number of changes to the process around technology appraisals with aim of helping pharmaceutical companies work with NICE more effectively. For example industry will now have the opportunity to respond to questions from the committee during appraisal meetings, and also be able to meet NICE post appraisal to discuss the reasons behind a negative NICE decision. Also out for consultation is the idea of the 'innovation pass', which will identify potentially important new drugs that can be supported initially in the NHS for a period of three years, after which the products will only then need to go through a NICE technology appraisal.

In the post-Darzi quality landscape NICE has begun setting out key quality markers. Unlike the Care Quality Commission standards (which are the benchmark at the bottom end) these quality standards will be at the top end of the quality curve. Four disease areas are currently being piloted - neonatal care, dementia, stroke and venous thromboembolism - and the plan is to cover 20-30 areas a year to complete a library of 150 quality standards in total.

QOF is a powerful driver of change in primary care and Gillian outlined the NICE role in developing indicators for health improvement, and also in reviewing the current QOF indicators and making recommendations about 'retiring' them. NICE are not involved in negotiating which indicators should be included or dropped, however.

In an age when we suffer from too much information and finding the right data is a challenge, another Darzi announcement was to aid access to clinical and non-clinical evidence from multiple sources. To this end, NHS Evidence has created a simple search facility. Information is prioritised so the most relevant data source appears at the top of the list, with an indication as to whether that source has been accredited as reliable. This facility was launched 30 April 2009, and information is added on an ongoing basis. The aim is also to include drugs, devices and diagnostics in the pipeline. Gillian also outlined another QIPP information resource portal (presented in a standard template) will be available on the NHS Evidence website from 2 December 2009.

Discussion

James Kingsland asked whether industry has any part to play in the development of indicators for QOF. Gillian stated QOF is an important tool for getting things into practice and industry are well placed to inform that process as they know what is effective and what can drive change.

Asked by David Trevor (Allergan Ltd) to comment on the NICE role in 'value-based pricing' in the new PPRS, Gillian noted that currently NICE is involved specifically in the patient access scheme (PASLU). However she is not close enough to the detail of the other options within the PPRS to comment.

Patrick Hopkinson (GlaxoSmithKline) asked about NICE's links to the regulatory authorities to ensure uniform and consistent scientific advice. Gillian stressed that discussions are ongoing with other agencies to ensure there is no duplication of effort but, unlike the other bodies, NICE's work is very much around cost-effectiveness.

Asked by James Kingsland how she feels when NICE appears to deny a patient group a new therapy Gillian conceded that it is difficult, especially when NICE are challenged very publicly. On an individual basis obviously she understands what it is like for that patient but NICE have the difficult job of considering funding across a whole population and balancing the budget. All health economies around the world have to deal with this difficult question. In her experience medical students now grasp the fact that there is a limited budget and that there therefore has to be some prioritisation. Also, the extensive media discussion around these issues means that the public now understand that not everything can be afforded.

Quality and innovation – what is the role of industry?

We live in times characterised by incredible change, in the view of Patrick Hopkinson (Director of Portfolio Partnership Marketing at GlaxoSmithKline), both for the NHS and also for industry. However Patrick is optimistic for the future, believing that through partnership (particularly via joint working) a model can be developed that will benefit patients, the NHS and pharmaceutical companies.

Clearly whatever the outcome of next year's election there will be significant financial challenges in the future with regard to NHS budgeting. Also the pharmaceutical industry is itself going through massive reorganisation and restructuring, and every company is responding different ways. The implications for industry are across the board (R&D, emerging markets, etc) and getting a drug to market presents a considerable challenge in terms of both resources and effort. However, Patrick's view is that there is now senior macroenvironmental commitment to address this issue and improve both uptake and the relationship between pharmaceutical (and device) companies and the NHS.

One output of this has been the Department of Health/ABPI Joint Working Guidance. The toolkit for joint working has been in development for 6-7 years, and aims for a more business-to-business relationship to create a framework to build trust and transparency. It is now recognised by the NHS that industry can bring much more value than it currently does, for example in terms of capacity, resources, capability, skills etc.  From a pharma point of view, companies can now be clear and transparent about the benefit that they expect to get from a project – fundamental in terms of building trust. For the pharmaceutical industry, rather than driving market share it is now a question of market expansion - by getting more patients through the system in line with NICE guidance and therefore more patients being appropriately treated. For the NHS, the opportunity is to bring in extra resources and capability to improve services, to achieve targets, to move towards integrated patient pathways and to move patients out into primary care.

The key concept behind joint working is a pooling of resources. Projects are co-funded 50:50 between PCTs and industry. Patrick conceded that governance has been a problem for some companies whose legal teams are based outside the UK, so legal aspects have been complex in some cases but there are tools and templates on the ABPI website that can assist in this.

What is the future for the pharmaceutical industry? The view at GlaxoSmithKline is that there must be a move away from the supplier model to a partnership model, from brand sell to solution sell, from a brand-led focus to a more customer-led focus across the patient pathway to deliver disease improvement. That model, underpinned by joint working, is both sustainable and acceptable on all sides.

As an example of helping the NHS deliver their agenda, GlaxoSmithKline provide a patient audit system to GP practices allowing the practice to monitor and audit patients against a national standard to improve patient care - the 'Points' system. Another joint project between the company and the NHS in Salford aims to improve COPD management and GlaxoSmithKline have put in their Points system, as well as nurse resource, educational support etc. Some early results from the PCT show a reduction in length of stay, reduced hospital expenditure in terms of admissions avoided and in terms of patients diagnosed and treated.

Patrick stressed that joint working partnerships are not for every part of the pharma business. Sponsorship still exists, MEGS (medical and educational good and services) are still appropriate, but these are separate from joint working. Key differentiators are that for joint working both sides put in resources (both finance and people), there is a detailed and legally binding agreement, and outcomes must be measured.

Ivor Eisenstadt, MGP Ltd. and PM Society

Discussion

Alan Naismith (Epic Consultancy) is conscious that joint working is being driven by the industry towards the NHS and asked what mechanisms can be put in place to support PCOs and other organisations that want to reciprocate and initiate joint working with industry. Patrick stressed that the ABPI joint working task force and the Department of Health have worked hard to publicise joint working to the NHS, as has the Office of Life Sciences. The hope is once the concept is proved by the initiatives currently under way, the demand will mushroom. The challenge then for pharma is how to scale up the response to this need because the resource implications are huge.

Asked whether smaller companies are at a disadvantage in joint working Patrick pointed out that the membership of the joint working task force is from both large and small companies. The NHS often asks for multiple company proposals and this is a way for smaller companies to work on bigger projects. GlaxoSmithKline have projects under way in COPD where four or five companies are involved and there is no reason why a smaller company should not be involved. However the challenge for all companies, large and small, is that they must bring something to the table which is more than the brand - quite a challenge for companies whose management may have been in sales and marketing 15 years ago and have to change mindset.

James Kingsland is a great supporter of joint working projects, but his concern is not to lose sight of the brand - industry has to make a profit otherwise it cannot reinvest. Patrick stressed that joint working is not about companies becoming charitable organisations, rather about changing the way they work. In Patrick's view the current model is no longer fit for purpose ?industry has to change fundamentally.

Advancing Quality in the North West

Having been part of the Advancing Quality programme in the north west since its inception 2-3 years ago, Alan Horne (Advancing Quality Director, NHS North West) spoke about the data the programme produces for both providers and PCTs. Advancing Quality is owned by all the PCTs in the area, who each pay 0.01% of their budget into the pot, totalling £10.6 million. Alan stressed that the programme is more than just measures and metrics. It is a driver for quality and service improvement. And Advancing Quality have entered into a partnership with Pfizer around the way data is presented, which meets all the joint working criteria already set out.

Within the programme performance can be benchmarked between hospitals in the northwest and elsewhere in the UK. The data is triangularised against three different measure sets: clinical outcome; patient reported outcomes that measure quality of life; and patient experience. There are 29 Advancing Quality clinical measures across five clinical focus areas: community-acquired pneumonia; hip and knee replacement; acute MI; CABG; and heart failure.

The North West was the first health system in the UK to introduce patient reported outcome measures (PROMs), with PROMs for hip and knee replacement, and much information is already available around quality of life post-surgery.

With regard to patient reported outcome measures (PROMs) the North West was the first health system in the UK to introduce these from 1 January 2009, with PROMs for hip and knee replacement, and much information is already available around quality of life post-surgery. Patient experience measures (PEMs) have been slower to get under way, but are now being measured in a specific and standardised way. The aim is to report publicly in April 2010 (depending on the time of the election).

Feedback so far is good from both providers and PCTs and Alan stressed that a wealth of information intelligence has been produced. By comparing this to population data, for example the socio-demographic make up of acute MI patients, it will be possible to equate whether deprivation correlates with appropriate care. What is clear is that this is no longer simple data but clinically relevant intelligence.

Advancing quality also facilitates system-wide quality improvement via collaborative learning and knowledge sharing. There is also an electronic portal to share best practice and intensive support for Trusts via 'jump start consulting'. New networks have been established as a result of Advancing Quality – for the first time there is now an orthopaedic network across the northwest. However, developing the measures and metrics is expensive (about £500,000 per measure/metric). It therefore makes sense to work together in a systematic way to share the costs, and to use evidence already assembled, for example by NICE.

The key learning in Alan's view is that there are no 'antibodies' to such an initiative in the system. At a programme level there has been no resistance, though at hospital level mindsets have had to change. Quality becomes contagious and spreads to other clinical focus areas. When best-care practice is the objective organisational boundaries have broken down. Much is being learned and it is important to share this experience as widely as possible.

Discussion
Asked which is the one single factor that affected changes in behaviour throughout the programme, Alan felt this to be the fact that the clinicians believed in it. Clinical leaders were appointed for each of the clinical focus areas, and agreement was obtained from the BMA and NICE to ensure everything conformed to guidelines. And though it sounds boring, the process around data quality is very rigorous meaning that clinicians believe the data.

Alan Horne, Advancing Quality Director - NHS North West

It was pointed out that the NHS is not renowned for good joined-up information. Alan explained that the basic record is from SUS (Secondary Uses Service), the common dataset used by all commissioners. Then the clinical indicator information is attached to the denominator (patient population) information. This means all the data is produced by Trusts themselves by marrying the clinical information with the SUS information within a benchmarking tool. It can be laborious but it pays dividends because everyone is signed into the data and is confident it is telling a true story.

With regard to productivity, Alan was asked whether the North West Strategic Health Authority is in better position to deliver its QIPP promise as a result of the Advancing Quality scheme. Alan emphasised that the scheme provides the information to add to quality accounts, to formulate regional CQUINs, and most recently to add to the QIPP agenda. He added that the North West experience has so far been shared with four other SHAs who all aspire to something similar, so effectively the Advancing Quality idea will soon be applied across half the country. Implementing initiatives across areas on a systematic scale will ultimately save both time and money.

Joint working and the new quality agenda – an integrated care pilot view

Pulling together many of the strands already discussed, Paul Midgley (Community Director, Principia) presented a practical example of partnership working between a group of GP practices and a pharmaceutical company. Paul is a patient representative on the Board of Principia, a PBC cluster of 16 GP practices in Nottinghamshire, which has set up an integrated care pilot around COPD. From the outset the idea behind Principia was for it to be a mutual company which involved the community in developing healthcare with clinicians. It is therefore a community interest not-for-profit company. Integrated care in long-term conditions therefore sits well with the Principia ethos, as well as with the patient population.


Paul Midgley, Community Director, Principia

The 16 practices of Principia support 120,000 patients across south Nottinghamshire (a reasonably affluent area but with a large elderly population with a lot of long-term conditions). The practice cluster had good relationships with the respiratory department of Nottingham University Hospitals Trust. In 2006 a COPD nurse specialist was moved out of that unit into the community within the cluster and this provided the impetus for the Principia COPD initiative. Existing good relations with other stakeholders e.g. community services, were also helpful.

The initiative became an ICO pilot in April 2009 and, in the six months so far, three community wards have been successfully rolled out across the 16 practices. This allows community services (respiratory specialist nurses, respiratory physiotherapists, pulmonary rehabilitation services) to work more closely with individual practices. A variety of other posts have been set up to support the community ward philosophy and one of the university hospital consultants now runs a clinic in one of the health centres. The feedback from this is excellent. The nurse specialists sit in the clinic with the consultant, helping their confidence and also allowing patients to be more confident in the specialist nurse.

Monthly multidisciplinary team meetings are becoming standard practice for GP surgeries where patients with complex care needs are discussed, with the aim of avoiding hospital admissions. Community matron training has improved, and social services are also fully involved. A wide range of patient support information is available, including simple things like fridge magnets and credit cards alerting anyone attending that the patient is part of the community ward. Patients will also be supplied with electronic devices at home, for example to monitor their peak flow. In addition, an end-of-life care pathway for COPD has been implemented right across Nottinghamshire.

With the help of Astra Zeneca metrics have been identified to ensure everything is being done in the right way and can therefore be transposed onto other health economies when the pilot is written up. A dedicated webpage for the community ward and for COPD is on the website. It is still too early to say definitively how the integrated care plan is working but since the introduction of the respiratory care nurse in the community there has already been a reduction in bed days in hospital.

In terms of the collaboration with Astra Zeneca, joint working has been a slow but comfortable process. In Paul's view it has worked because sharing best practice is helpful to clinicians. It has also focused community-based physicians on metrics and improved their ability to provide better care. Joint funding has allowed the provision of more nurses, for more patients to be treated at home, and reduced the waiting time for pulmonary rehabilitation. The benefits have filtered through to every practice and improved the confidence of practice nurses who see the majority of patients, with a resulting improvement in diagnosis. It is clear already that patients are delighted to have stronger community support.

Getting everything in place was admittedly a lengthy process and Principia have already implemented a second six-month project around diabetes with Takeda, and Astra Zeneca are also working with Principia on a heart failure project.

Key lessons have been learned, most notably that the pharmaceutical industry can be extremely helpful and are trustworthy. There are some issues around employment contracts when posts are part paid by the NHS and part by a company but these can be overcome. It is also important to have an open mind and be prepared to allow a pharma company to become fully engaged and involved in decision making, in Paul's view.

Matt Lilley (Integrated Healthcare Specialist with Astra Zeneca) then discussed integrated care and the Nottinghamshire COPD pilot from the point of view of the company. Astra Zeneca's background in joint working goes back as far as disease management strategies in 1994, through to formulating strategy for delivering effective healthcare in today's NHS via joint working.

The principles behind joint working require the industry to be open and transparent - also the patient has to be at the heart of any scheme.

The principles behind joint working require the industry to be open and transparent - also the patient has to be at the heart of any scheme. The joint working toolkit already mentioned provides a business case template which gives details of the background and metrics that need to be in place. This helps both parties in terms of probity. Matt emphasised that everything undertaken is backed up by the ABPI Code of Practice, which states precisely what a company can and cannot do.

Principia were identified as a potential partner for Astra Zeneca for a number of reasons. There was a clear clinical need around COPD - the cluster had 1100 patients on the COPD register, yet Principia reckoned there to be 1700 patients in the area, so clearly there was a gap. In addition, Principia was proactive across the 16 practices and Astra Zeneca already had an established relationship with the GPs involved who were keen to work with the company in this way.

As to the benefits, for the NHS better use of resources for COPD releases funds for other disease areas, for Astra Zeneca the benefit is around more patients being treated appropriately and for the patient it means more effective care. Ultimately it is very much about a win-win-win relationship for all involved.

Internally for Astra Zeneca this means delivering valued medicines but around a customer-centric and patient-centric mindset rather than around Astra Zeneca. Matt stressed that it has also been about becoming partner of choice. The success of the work with Principia is borne out by whether it adds value to the NHS, the patient and the company. If this can be achieved, then this is how Astra Zeneca will look to work with the NHS in the future.

Discussion

James Kingsland asked what Astra Zeneca's involvement brought to the project that could not otherwise have been delivered, and whether Principia would have been comfortable working with other companies. Paul stressed that for Principia priming the nurse post by Astra Zeneca was the initial attraction - one nurse was already in place and working effectively but more were needed. Also the existing relationship between Astra Zeneca and some of the clinicians was important, as well as the experience they brought from outside which speeded up the adoption of ideas. Matt added that Astra Zeneca were very comfortable with their role, adding that with Nottingham City PCT the company are now working on a project in COPD with Pfizer, GSK, Bohringer and Nycomed. Each company has its own sign-off procedure however, and this can slow the process when multiple companies are involved. Clearly though, having several companies on board helps in terms of the resources available.

Asked which departments in Astra Zeneca got involved in the project and how the sales/marketing relationship was managed, Matt noted that the department most involved was clinical services. They already had expertise in building services around NHS needs. They had also done some work in Lincolnshire along similar lines so the Principia were able to meet those in Lincolnshire to learn from their experience. As for sales and marketing, Matt himself is from the sales side, though there has not been much input from marketing on this particular project.

Patrick Hopkinson mentioned that as a company GlaxoSmithKline started small initially, aiming to have ten joint working projects up and running by the end of the year. He stressed that the governance must to be right however, and initially this has taken considerable involvement from the legal and medical teams. It has also required senior management endorsement. Now that the framework is set up the process will be more straightforward in the future.

Ivor Eisenstedt asked what the main barriers encountered were and whether the focus of commissioners and medicines management were different. Paul noted that medicines management are closely involved in the Principia scheme. Also one of the metrics adopted is to measure market share to ensure that Astra Zeneca do not gain any advantage. In terms of barriers, Paul noted that these were more around the PCT. Because Principia is a PBC group with an indicative budget but no real budget, any contracts must be agreed by the PCT. Principia therefore had to go through its own internal governance and then persuade the PCT (who had never been involved in a joint working project with pharma before). This did slow down the process somewhat.

Matt agreed that one of the barriers for Astra Zeneca was the time involved. One key learning from the project is in future to be clearer about time scales.

Matt Lilley, Integrated Healthcare Specialist, Astra Zeneca

Drawing the meeting to a close, chair James Kingsland noted that the presentations had provided valuable insight into delivering the NHS quality agenda, which clearly has to be a joint responsibility between the NHS and the industry. The wide-ranging debate identified significant opportunities for the pharmaceutical industry and in James's view the environment is now perfect for the industry to partner the NHS, both in terms of the current financial uncertainty, and in terms of the groundwork developed over the last 7-8 years to promote joint working. It is also clear from NICE that there is also the opportunity, if not to directly influence QOF, then to help develop it. Now, with the focus on the quality agenda, there is the opportunity to partner the NHS in new ways. The time is right for industry to seize that opportunity.
 

Held on: 24/11/2009