NHS joint working initiatives - how to achieve win-win

PM Society Half-Day Conference

The time has never been better for the pharmaceutical industry and NHS to collaborate on joint initiatives. Policy documents such as the Department of Health's Best Practice Guidance on Joint Working, together with the Best Practice Toolkit on Joint Working confirm the positive transformation that has taken place in working relationships between industry and the health service.  However...

• What do you really understand by 'joint working' with the NHS?
• What are the real benefits to industry of joint working initiatives with our NHS colleagues?
• And can we really achieve 'win-win' outcomes?

To address these and many other issues, this half-day conference chaired by Chris Town (an independent healthcare consultant and former PCT Chief Executive) took a detailed look at joint working, giving insight into the real value from both the industry and NHS perspectives. A number of 'real-life' case studies provide examples of how it can be done and demonstrate the development and roll-out of successful joint working initiatives, as well and highlighting the issues and pitfalls involved.

The value of joint working to the industry

Michael Warren (Head of Primary Care at Pfizer UK Ltd) began by asking whether the pharmaceutical industry should care about joint working at all. It is his view that the industry should be bothered because joint working is coming, and it is coming now. Pfizer have had both good and bad experiences of joint working. When Mike Warren joined Pfizer the 'old-school' approach was that if you threw enough 'love' at the customer (that is, at NHS GPs) the 'love-o-meter' would move and things would just happen. The 'new-school' approach is via 'collaboration', a word which Mike Warren prefers to partnership.

Collaboration means mutual benefit, but that mutuality starts with the patient. Can we deliver a benefit jointly to patients and also to the NHS and to the wider community? And can industry help the NHS deliver world class status? The answer is yes, we can. And in doing so we can deliver benefit to the industry and to individual companies. Mike Warren's view is that industry should be proud about what it can offer ? there is nothing wrong with doing something to benefit someone else and getting a benefit for yourself, and nothing wrong in being commercial to get a commercial return. What is important is how this is described and how it is fronted.

The key word is honesty. Working in collaboration requires honesty. It requires you to say 'we want to work with you because...' but it also requires you say 'I don't want to work with you because... we don't have a mutual interest'.

Collaboration takes time, however. There is no quick win for anybody. Collaboration is driven by willingness, but that willingness can be confounded by the reality of the day job on both sides. Within the industry people change jobs, which means that continuity within a project may be affected for the customer. The same is true within the NHS where there is constant churn that confounds everybody's willingness. You may sign up to collaborate with someone in the NHS who is keen to work with the industry only for him to be replaced by someone who is cynical about the industry and has no driver to complete the project. How to manage this sort of situation has been a real learning curve.

Within Pfizer, Pfizer Health Solutions is a separate commercial entity built entirely out of financial return from providing services to the NHS. It has been hugely successful. In Birmingham, Pfizer are running, together with NHS Direct, a complete service for long-term conditions. It has required massive investment with a massive lead time. There is no quick return: Pfizer Health Solutions is now in year 4 and only now showing a profit.

Talent is an important element. Once you have talented people in your organisation and in the NHS then it is vital to play to those talents, to utilise the skills of someone who can speak the same local language as his colleague. Similarly skill sharing has been very successful – taking somebody from Pfizer, putting them in a PCT and getting them to use their commercial acumen to sort out a problem. There has been even better success having someone from the NHS working in Pfizer. Being able to see each other's worlds can have huge rewards.

Most important in joint working however is predicating any plan on meeting customer needs. Customers need operating plans, help in meeting targets, achieving QOFs etc. If the industry can bring business skills to bear on meeting those needs then success can be achieved. It is vital to find good people and get them talking the right language in the right place.

Mike Warren pointed out that there have been some disasters in joint working, however and cited the example of Pfizer's support for a baby massage clinic when the company has no interest in paediatrics or something with absolutely no relevance to the company's therapy areas. Pfizer also produced a fabulous brochure on health and safety for GP practices, solving a problem that practices did not know they had. This was a completely unwanted Christmas present, not joint working.

Finally, on the subject of compliance, i.e. legal approval, the contractual approach adopted by Pfizer in the early days was very off-putting to the NHS. The emphasis now is getting compliance in an honest, truthful and ethical way.

So should you as a company be bothered with joint working? Yes, otherwise you will lose your place in the market. Also, it is about changing perceptions of the pharmaceutical industry, which is frankly somewhat chequered: some people rank Pharma alongside arms dealers, politicians and the tobacco industry. Doing what we have always done in the way we have always done it is not mutually beneficial. But Mike Warren believes that Pharma makes a massive contribution to patient benefit in terms of medications and interventions that help keep them alive. The pharmaceutical industry should be proud of this. Joint working can demonstrate that the industry is part of the health community.

The value of joint working to the NHS

In the view of Dr James Kingsland (GP and Chairman of the National Association of Primary Care – NAPC) the 'shout theory' is still felt to predominate in the National Health Service. It is the main way that the customer base – GPs – feel that the industry approaches the healthcare professions. This is the old-school approach outlined above by Mike Warren. The new school approach of collaboration is absolutely vital. But within this arena, do you know who your customers are and if you do, do you know what they want?

Mutual benefit means recognising that the industry wants to sell its products to the NHS but that the product has to be packaged in a different programme of events. In the process of understanding the environment and the customer base which James Kingsland sees developing, world class commissioning is an aspiration, but it will never exist. Commissioning is the main job of PCTs now – not in the provision of service, micromanagement of general practice and details of contracts.

Part of the narrative of reinvigorating practice-based commissioning is to articulate what PCTs should be focusing on and their vital role in the system in securing secondary care services. The health economics of prescribing also needs to be looked at in a broader programme of practice-based commissioning.

Finally, ICOs (integrated care organisations) are a look into the future, the natural progression which recognises that commissioning and providing goes on as part of everyday practice. There is no conflict of interest between the provision of services and the commissioning of services within a registered list, but there is a conflict when you become a provider to that registered list. The natural progression is to commission less, and to provide more in an organisational structure that breaks down organisational boundaries. ICOs will be live from 1st April 2009 and will be challenging the primary care system to extend patient care, refer less, have fewer patient bed days in hospital and facilitate early discharge.

The vision for the primary and community care strategy is nothing frightening: build on the best established list-based practice and challenge the world-class commissioning PCT to extend its provision, to have greater aspirations for their patients and deliver to patients a wide range of services which are not part of their practice at the moment. If we need to build a building around those services (integrated between community services, social services, general practice services) that might eventually be the polyclinic.

James Kingsland's questions for the industry therefore are:

• Are you listening to your customer?
• Can you refocus your efforts?
• Can you undergo the cultural change?

The old school 'love-o-meter' that Mike Warren talked about has predominated for so long but should now be dead and buried. The GP-rep interface needs to evolve and the move from supplier to partner means a change in culture so that there are longer and more accountable associations, particularly with PBC organisations.

As an example, James Kingsland's consortium is working with one company on COPD. Within his consortium far too many patients are re-admitted to hospital within two weeks of their discharge. Of those, 50% have COPD. So it seems logical to find out why these discharged patients are being re-admitted. A rudimentary business case was put together that required help and expertise, as well as investment. This was not forthcoming from the PCT but industry was able to supply it, including extra nursing. This assisted practices not experienced in providing integrated care for discharged patients to be able to do so. A code of conduct has been drawn up with the company concerned, and there will be an audit of the area where the company's product is focused.

As another example, too many stable angina patients go for revascularisation procedures they do not need. The consortium has again had investment from a company that is helping to develop a business case, and also looking at service redesign for patients with stable angina. There is a joint code of conduct with this company and an invest-to-save programme. A change of culture means that this initiative will raise the profile of the company concerned and create an association between the product involved and the company that makes it – far too often doctors prescribe a drug and have no idea who makes it. Linking the company name with the organisation that commits the resource is the way ahead.

As to the future of one-to-one GP-rep interactions and whether they are still of value, James Kingsland stated that meetings are now likely to be clinical team meetings. Once the service is redesigned it will be very helpful to have advocates for the products and Pharma reps have a vital role in taking that information out. The one-to-one interview is probably not the way forward now that practices are accountable for budgets.

The joint working strategic framework, guidance and toolkit

Paul Woods of the Medicine, Pharmacy and Industry Group at the Department of Health began by outlining that the Ministerial Industry Strategy Group (MISG) grew out of the recommendation that there should be ongoing dialogue between the Department of Health and the pharmaceutical industry. This group has set out a long term leadership strategy (LTLS) for medicines designed to:

• Secure the provision of safe and effective medicines for patients
• Maintain and strengthen the UK pharmaceutical industry within Europe
• Advance healthcare innovation in the UK.

Part of the remit of the MISG is to look at developing a more 'mature' relationship between the industry and the NHS (at both national and local levels) through joint working on areas of mutual interest and benefit. Market research which found that some PCTs were interested in working with the industry, some were not, and that the majority had never even considered it but wanted to know more. Industry had broadly similar views: some companies had had bad experiences of joint working, some were very positive, but most had not considered it.

It was also felt that the term 'partnership working' might be too narrow and instead opted for 'joint working' as being more viable. The recommendations that the MISG came up with were in three brackets:

• First, guidance was needed specific to joint working between the NHS and the pharmaceutical industry, and this was issued by DH in February. In March, the ABPI and DH issued the best practice online toolkit on joint working for NHS and industry managers. This toolkit was promoted and disseminated at key conferences and other forums
• Second, to look at training for industry managers initiating and implementing joint working projects
• Third, to provide industry and NHS stakeholder training and support

There have to be benefits for all involved, otherwise people will not engage in the projects. It is also vital that joint working agreements and management arrangements are conducted in an open and transparent manner. Some examples of the benefits that can accrue from joint working for patients result in care closer to home, fewer hospital admissions, more equitable and consistent care/access to care, better information on conditions and treatment options, a clearer pathway of care and improved experience of the system.

For the NHS, examples of the benefits include higher quality of care, more consistent, and faster care. Services are configured around patients' needs with better health outcomes, and with better use of resources. More people are treated appropriately with lower costs in terms of hospital admissions, more support for achievement of performance targets, more creative approaches to problems, better cross-sectoral working and better skilled personnel. Examples of the benefits for the industry include more people being treated appropriately and a better use of medicines, better customer understanding and an improved reputation for the industry.

The toolkit is available on the internet as an interactive pdf. It was built by and is maintained by the ABPI and the Department of Health, with the NHS also having considerable input. The toolkit provides templates that help decide whether joint working is right for you, how to engage potential stakeholders and how to draw up joint working documentation.

Below is a sample page from the toolkit, showing the steps in a joint working project.

Continuing the presentation, Martin Anderson (Director of NHS Policy and Partnerships at the ABPI) discussed the ABPI/NHS outreach programme that has been running in parallel with the above. This aim is to reach out to NHS customers that have not previously talked to/engaged with Pharma, describe mutually beneficial ways of working to improve service/quality to patients, introduce companies to new NHS customers, facilitate joint working projects, and learning and sharing what works and how.

The outreach programme is not about the ABPI constraining individual company activity (all are free to pursue their own agendas in parallel to Outreach), or about NHS customers seeing 'working through ABPI' as 'working with Pharma'. Particularly it is not about the ABPI 'pooling' Pharma resources to offer to NHS customers. What it is about is breaking down the barriers and engaging customers. It has a local focus – that's where the actual business gets done, where patients get treated and prescriptions get written.

Industry colleagues identified particularly challenging customers and these were approached. A total of 32 out of 33 of these agreed to work with Pharma in principle. Since its inception two years ago, 39 companies have been involved in ABPI 'regional' meetings and more than 20 are actively involved in projects, with 11 active projects currently under way. The programme is helping companies think through the learning need of their front-line staff and asking NHS customers to promote the benefits of working with Pharma.

The pharmaceutical Industry has been excited about the toolkit, but some have worried about any potential or perceived conflict with the ABPI Code. The ABPI are therefore developing guidance notes for companies on joint working taking the Code into account. This guidance should be available in February 2009.

For the pharmaceutical industry, working with the NHS to improve the quality and quantity of care provided through provision of high quality education programmes and helping to increase access and capacity of services will ultimately result in more patients receiving appropriately prescribed and cost-effective modern medicines. That is the 'win' for the industry.

As an example, the Happy Hearts programme for CVD risk identification and management is based in Nottingham. This programme is targeted in areas of deprivation where the CVD death rate is worst and people with a greater than 20% risk of developing CVD have been identified. It is a two-year project, uses specially trained healthcare assistants and specialist software to identify patients and invite them to attend for a full health check. It then supports patients to make healthier lifestyle choices, referring them for medical/pharmaceutical intervention as required, and providing ongoing follow up and support.

Industry brought funding to the programme (eight companies are working on the project and collectively they have brought £100,000), but also brought business acumen and, most importantly, a different mindset that defined objectives and measures of success. The NHS also brought (equal) funding and the strategic fit with health improvement work.

In Martin Anderson's view joint working is not an easy journey but over the last couple of years these projects have proved that it is "possible to achieve the impossible". It is not the panacea to apply universally, but it can be achieved, to the benefits of all concerned, and most importantly, patients.

Panel discussion

In answer to a question about how easy it is for individual companies to achieve positive results, Mike Warren stressed that it definitely possible. He had real concerns about the outreach multi -company approach at the start because it sanitises the effect. The Pfizer experience has in fact been the opposite and the benefit can be seen very clearly. Martin Anderson believes it definitely can work for individual companies. For example, if a NICE guidance names a particular drug then the company can gain by working with a PCT to implement those guidelines effectively. He added that more case studies would be helpful but companies are sometimes unwilling to share these due to company confidentiality. Chris Town noted that changing mindset within the industry takes time.

Chris Town added that from a chief executive's viewpoint, at the outset joint working was scary but learning from experience has meant that many of the early difficulties have been overcome. Of course the approach suits some disease areas better than others. It is also optional and up to companies to decide individually how to take it forward. Martin Anderson stressed that at the outset some customers were 'not fit for purpose' and a lot of time has been wasted learning this. He would be much more selective now about who to work with. Equally, not all Pharma company personnel fully understand how to properly undertake joint working with the NHS.

Asked about guidance on contracts in the toolkit, Paul Woods stated that it does include a template for a joint working agreement but a more detailed guidance on contracts could be included if stakeholders felt it necessary. Martin Anderson added that it was perhaps naively thought at the time that the agreement template would suffice, but pharmaceutical company legal departments required more detailed contracts. Happy Hearts has thus developed a long multipage contract and it is hoped to genericise this and include it in the toolkit.

In response to a question it was confirmed that there is also no reason why CME accreditation cannot be included in joint initiatives, and indeed this is already the case for some Outreach projects.

Sean Morgan Jones of Pharma Times pointed out that awareness of the toolkit is quite low. He thought a more intuitive URL might help. In his view it is a fantastic resource and Paul Woods and his team are to be congratulated on it.

Case Study 1: MERIT Diabetes Education Course

Jean Woodward (Head of Education Programmes at Novo Nordisk) talked about MERIT (Meeting Educational Requirements Improving Treatment), a diabetes education course aimed at primary care.

Achieving win-win actually starts with the agenda, in Jean's view. Novo Nordisk's objectives were to help upskill primary care in insulin management. Chronic disease management (including diabetes) is currently being moved from secondary to primary care. Unfortunately primary care are expected to take this on but without the upskilling and education being provided to go with it. MERIT was designed to fill this gap. It is a win for the NHS and also for Novo Nordisk, 80% of whose business comes from diabetes. Another objective was to improve care for patients on insulin – by appropriate dose titration or changes in insulin regimen. The third objective was to identify customers in primary care and build relationships with them enabling rep access.

The numerous existing courses in diabetes are very broad and not necessarily aimed at primary care. This made the primary-care based MERIT programme different. Three modules have been developed:

• module 1 – initiation of insulin in type 2 diabetes
• module 2 – management of insulin in type 2 diabetes
• module 3 – the patient-provider partnership: optimising communication via a communication skills workshop to identify the barriers to good management.

The programme is flexible and the modules can be taken as required in any order. MERIT was also linked to the Skills for Health Competency Framework, meaning MERIT is closely linked to the NHS agenda for diabetes.

MERIT was designed to promote co-working between primary and secondary care, so Novo Nordisk work with secondary care in a particular area to provide them with the tools to disseminate education to primary care. This is in the form of a set of flexible presentations and workshops that can be tailored to individual localities' needs.

Insulin used improperly can kill – so classroom courses alone are not enough. Support is needed post-course and MERIT also provides this. Novo Nordisk employs a team of nurses who set up the meetings, help facilitate the meetings themselves and provide mentorship afterwards. This makes MERIT sustainable ? nurses leave a skill base behind. The benefits are also measurable, both for healthcare professionals (in terms of their competency after the course) and for patients (in terms of the HbA1C levels).

Many PCOs are using MERIT as a named course within their education pathways and many PCTs have MERIT linked to payment for enhanced services (paying their practices to start insulin and to undertake MERIT module 1). Other PCTs have linked it to clinical governance.
By the end of 2008 Novo Nordisk will have run around 200 courses across the country, training around 2400 delegates. Course feedback is always good to excellent, both for the course itself and also for the mentorship afterwards. It can be demonstrated that blood glucose (HbA1c) levels are reduced – every 1% reduction in HbA1c can mean a 21% reduction in diabetes related death, a 37% reduction in microvascular disease and 43% reduction peripheral vascular disease. For patients this means potentially less blindness, fewer amputations and fewer strokes. That has a positive impact on the NHS in terms of long-term costs.

One of the Novo Nordisk objectives was identifying customers and contacting them. Novo Nordisk is not a large company so they have to ensure they use their resource wisely by focusing on the right people. MERIT allows them to do that. Many who come on the MERIT course have had no previous contact with the company so it allows the company to expand their customer base and be reassured that they are focusing activity on the right people. Novo Nordisk won a Pharma Times Joint Working Initiative award a few weeks ago.

A magic answer to achieving a win:win does not exist, in Jean Woodward's view. The answer is in fact a common sense checklist. Any initiative has to be unbiased. It is important to know the environment and think things through. Any project has to be cost-effective and it has to be reproducible. It must also be sustainable. The Pharma industry is good at putting money into projects and getting them up and running but that is useless if all those skills disappear when the company leaves. One of the successes of MERIT is that it leaves learning and a sustainable package. Forget 'one size fits' all. Any offering must be flexible enough to meet individual needs. Above all, put yourself in the shoes of the PCT, and think how they will regard your initiative. Be aware of their needs.

Case study 2: Pharmaceutical Oncology Initiative

Andrew Curl (Chief Executive of Pharma Partners Ltd) identifies partnership working opportunities for the industry and then project manages them on behalf of individual companies. One such project is the national Pharmaceutical Oncology Initiative. This comprises a group of 18 ABPI member pharmaceutical companies, who have joined together to work with the NHS in improving access to cancer medicines across the UK. Within this is the POI Partnership (POIP) in which those 18 companies engage.

The vision of the POI is to ensure that all people with cancer have access to the right medicines at the right time, giving them the best chance to fight cancer regardless of where they live. The POI believes that everyone in the UK with cancer should have a chance of survival comparable to the best in Europe.

Sadly, and many of us know from personal experience, cancer is an all too common disease in the UK. Nearly a quarter of a million people will be diagnosed with cancer in the UK this year and around half of those will die from it. Although cancer care has improved over recent years there remain a number of challenges, particularly access to new medicines and lack of universal standards. In the UK, uptake of new medicines is only about 60% of what it is in other European countries, with nearly 10% of healthcare budget in Germany being spent on cancer medicines, but less than 6% in the UK.

The principal partner to the POI is the Department of Health, but is actually a three-way partnership between the 18 companies, the National Cancer Action team, headed by Mike Richards (the National Cancer Director) and his staff, and the various NHS improvement teams around the country. The partnership has been an outstanding success. Over 100 POI meetings have been held with very little dissent with regard to either purpose or implementation – quite an achievement.

Working with the National Cancer Action Team and NHS Improvement Teams the POI has developed two major projects to assist the NHS in commissioning and delivering better cancer maximising value for money and improving outcomes for patients.

C-PORT is a web-based simulator which enables cancer hospitals to effectively plan capacity and improve access to cancer medicines for patients. It helps chemotherapy suites and pharmacy units plan how they deliver services, and what might be re-designed effectively to cope with the ever-increasing demand and the changing face of chemotherapy. This is now being implemented widely throughout Cancer Networks.

Work began two years ago, and C-PORT was rolled out in 2007 in two networks. All cancer networks will be using it by the end of this year. Industry provided people to work alongside NHS facilitators within the networks and patients are already seeing benefits in terms of shorter waiting times to begin treatment, quicker visits to hospital to have chemotherapy delivered, and better environments for drug administration. Buy-in from the NHS has been enormous, with benefits to the Department of Health, to industry and individual companies ? with better services there is a better chance of modern medicines being used, and more patients can be treated with existing resources so existing money can be spent on medicines rather on new infrastructure.

The second tool, the Cancer Commissioning Toolkit (CCT) was launched by Mike Richards 10 days ago after 18 months' gestation. This is also a web-based tool which supports commissioners and cancer service providers, helping them to understand and apply data to assist the planning and delivery of world class cancer services for the communities they serve. The toolkit contains an electronic library of metrics for aspects such as treatment, awareness, funding etc, to allow individual localities to assess where they sit on various scales. The toolkit also contains chapters covering each of these parameters on a national and local basis, enabling commissioners to chart where they are and from that to draw out customised data and develop an action plan. An example is given below.

The benefits of the POI to industry are that by working together, pharmaceutical companies are able to bring a unique insight to the opportunities and challenges in improving cancer services. The POI products are designed to harness this insight for the benefit of NHS services and ultimately patients, and to link everyone together, ultimately enabling people with cancer to receive the best possible treatment regardless of where they live.

There are considerable benefits to the 18 companies involved because their products have been included on the C-PORT regimens. Their teams have been trained and accredited in the use of these tools and worked alongside specialists in implementing them. Benefits to patients are that the activities of the POI and the tools they produce will help ensure that cancer services have planned sufficient capacity to enable the safe and effective delivery of new therapies and result in reduced post-code prescribing and treatment variation.

Case Study 3: Joint working – where are the opportunities? The results from a recent survey

Ram Patel (Director of Brainsell Ltd) sees the NHS as an enormous cherry cake, where the cherries represent the joint working opportunities. Are these cherries really scarce or it is just difficult to find them because, as Delia Smith says, they always seem to sink to the bottom of the cake?

The PAMMtrak survey (Pharmaceutical Advisors and Medicines Management Tracker) is a research-based information service used for segmenting and targeting PCOs, developed with PCO medicines management healthcare professionals and with input from pharmaceutical companies. There are two online surveys a year and results are available in spring and autumn.

The autumn 2008 survey had 100 respondents from across the UK, the majority of whom were pharmaceutical prescribing advisors. Asked which clinical areas had an immediate service development need, 44% of PCOs expressed a need in diabetes, 36% in COPD, 32% in smoking cessation, 32% in obesity, 28% in sexual health and 26% in CHD. Only 10% of respondents said they had no immediate service development needs. So roughly 75% of respondents have some service development needs – which represents a lot of cherries! In autumn 2007 that figure was only 40%, so things are changing rapidly.

Looking at what their needs were in terms of diabetes, principal among these was identifying missing patients from QOF lists. i.e. those that do not attend their GP for reviews/check ups. PCOs were also looking into enhancing and expanding services which can be delivered in the community, and patient education to reduce excessive use of BGTStrips. A patient information leaflet regarding blood glucose testing strips provides an ideal opportunity for joint working.

In terms of smoking cessation, results were felt to be levelling out and PCOs want to re-involve community services to provide new impetus by identifying smokers and improving quit rates. In CHD there was seen to be a need for vascular risk assessment service development, including a primary prevention pathway, and identifying missing patients from QOF lists. i.e. those that do not attend their GP for reviews/check ups. In the area of asthma, it was all about patient and professional education, increased use of inhaled steroids, medication reviews to ensure compliance with treatments, and equitable access to expert healthcare professionals.

Unsurprisingly prescribing and medicines management support have had the highest level of effectiveness among respondents, as well as practice visits and prescribing incentive schemes/targets. Medication reviews have seen little success, but this may be a cherry in disguise in that PCOs are crying out for help in this area.

In terms of additional support needed, over one-third mentioned educational meetings and 25% mentioned medicines use reviews. Specifically regarding educational meetings, PCOs stated that they wanted sponsorship of unbiased local secondary care practitioners to speak to primary care GPs and community pharmacists, as well as sponsorship of secondary care-primary care joint meetings. They also wanted funding for venues, and organisation of events.

With regard to what joint working initiatives they have found useful in the past six months, what stands out is how little experience there has actually been. But many PCOs expressed the wish for more joint working. The joint working initiatives regarded the most useful were training events and sponsored meetings. Training events were felt to be useful because they enabled PCOs to offer training which they would otherwise not be able to provide, due to lack funding and lack of expertise. Training events are also useful for networking, and allow dedicated time for particular issues, resulting in improved communication.

As for sponsored meetings, getting funding for attendance at meetings is always difficult in the NHS, so sponsored meetings are a way for best practice to be communicated and liaison with colleagues working in other areas is facilitated. It was also felt that guideline publications are useful.

Panel discussion

Asked where joint working starts and MEGS (Medical Educational Goods and Services) offerings end, Jean Woodward noted that when Novo Nordisk set out to develop MERIT it was seen as an educational initiative. It has developed to joint working because the company has worked with a variety of partners at different levels, both practice level and at PCT level. Diabetes care is so diverse and variable, so MERIT varies across areas and can be tailored to meet individual local needs.

It was pointed out that true joint working cannot be measured on a MEGS initiative. Joint working needs to be a bundle of initiatives, education being one of them, before it can be truly measured financially.

Andrew Curl was asked if there was anything he would do differently in the cancer projects. He stated that if they were to do C-PORT again they would work out the implementation programme earlier on in the process so that it could be rolled out more quickly. He was also asked where the idea for C-PORT originated, who drove it, and whether could it be repeated in other disease areas. Andrew Curl noted that the drivers were a couple of pharmaceutical companies who were keen to bring about change and recognised that the chances of success were increased if it was done on a wider basis, i.e. by a larger consortium of companies. He is also working on establishing similar consortia in different therapy areas.

It was also felt that joint working needs to be part of a mix and adds a further string to the bow that is well accepted by the NHS. Times have changed and PCTs are now more willing to work with industry. Chris Town agreed that there is a shift in the decision-making process – decisions are taken at a higher level and those higher up in the organisations do not have time to see companies individually. The pharmaceutical industry needs to get the right amount of the right product to the right person at the right time. It was stressed that joint working is an opportunity for the Pharma industry as a whole to change its relationship with the health service. That is the take-home message.

Chairman's closing summary

Chris Town closed the meeting by picking out a few highlights. Mike Warren's view is that joint working is not going to be easy, that there will be mistakes and it will take time. James Kingsland's key message was knowing who the customer is and whether you are listening to them. It is now about understanding the language of the people you are talking too. Medical reps taken off the road are not good at speaking to managers – their agendas are different, and expectations are different. The toolkit on joint working has cut out many of the difficulties but there is a high degree of cynicism and it is not going to be an easy journey.

In the recent Darzi review, one of the key points was that innovation must be adopted. Medicines are a key part of that and we need new ways of making the most of those opportunities. Commissioning has to be about radical new approaches. The real solution to balancing the books is clinical pathway redesign and service redesign. Vast amounts of money can be saved in this way. The opportunities for partnership working to maximise the use of the products the industry produces are huge. This is the way forward.

Held on: 26/11/2008