Wellard's Healthcare Managers' Forum 2 November 2006, King's Fund, London The fifth Wellard's Healthcare Managers' Forum was very well attended, with over 40 professionals representing 28 pharmaceutical companies. Notes from speakers Creating partnerships with the new NHS going forward: latest thoughts and views from the ABPI David Fisher, commercial affairs director, Association of the British Pharmaceutical Industry David laid out the themes of his presentation: dialogue, partnership, and national and international lessons. He noted that long-term conditions (LTC) were high on the customer agenda but there were barriers to access. He said patients are allies, and noted that they too come up against barriers, making the following points: There are many different kind of LTC, and an absence of treatment can lead to unplanned and huge expenses in many areas of the health economy. The right patient must be given the right treatment at the right time. The right clinical intervention can be the right economic intervention. Fewer complications mean less cost. Pharma is a business but also has a proud track record of innovation and making new treatments available. But there is a discrepancy between pharma production and uptake. Even when there are positive NICE (National Institute for Health and Clinical Excellence) decisions, they do not lead to uptake. The UK has some of the lowest medical expenditure in Europe. It is a frugal user of medicines. It is therefore failing patients and the NHS must address that. There is still a postcode lottery and some NICE guidance from six years ago has still not been implemented, on atypicals, for example. Pharma companies are innovators and enablers. They have an efficiency skill set from which the NHS could benefit. A holistic solution must be centred on the patient. Medicines can have far-reaching effects. Informed patients can get better quicker. All this is congruent with patient-centred care messages. In this pharma, the NHS and the patient are all allied. What should be the response of industry? Ally itself to the information prescription? Pharma must provide the right answers to patients amidst the killer drug/wonder drug media circus. Are practice-based commissioning, NICE and the quality and outcomes framework (QOF) driving the right behaviours? Where are the incentives for patients to get the right treatments today? Has the primary/secondary barrier been taken down? QOF works for blood pressure control, and reduced incidence of acute spells. The 'find and treat'; programme could have a major impact. Patients are lost in the pathway between disease prevalence and optimal treatment. We need to interact at the right level that uses our skill sets in a relevant way. A targeted find and treat strategy for diabetes for example. We can compare areas and act as a body for passing on knowledge. Industry and NHS partnerships must develop, like in Ashton, Leigh and Wigan PCT in diabetes and CHF. That was seen as a tough nut to crack, so was a good place for success. The pharmaceutical oncology initiative was started through the patients' agenda. What would it look like if pharma worked with the NHS? Capacity modelling gave an answer – planning ahead to have enough chemotherapy treatments and enough infrastructure. It's a win/win/win for patients, the NHS and pharma. The ministerial industry/strategy group is the culmination of partnership working. The political will exists to address the problems. There is a nervous middle ground between the beacon centres and the no-way brigade that can be worked with. Toolkits and governance frameworks can aid. The healthcare development manager as a role varies in quality. The NHS say they have been let down and would give a three out of 10 score. More successful win/win/win initiatives must be successful. We can look to the States for good examples – the Asheville project. Insurance costs are down, prescription costs are up, and with successful management costs, total healthcare cost is down. David Prill of Janssen-Cilag asked: Q: With joint working, diabetes always seems to be the answer. What about other areas, such as palliative care? The NHS doesn't seem to want to spend money on them. A: We have to go to places where we can win. We need to take them through a process of 'why should the customer care more'? Patients can be key opinion formers. Claire Housden of Roche asked: Q: Isn't the risk of sharing postcode data that it is all different? NICE guidance may be more useful. A: We have to identify how population A measures against product B We need to establish targets and meet them. The ABPI advocate publication of NICE data. John Irwin of Bristol-Myers Squibb asked: Q: Ashton 'had their eyes opened'. Shouldn't industry work with each other? A: Collaboration and competition are both good and have a place. Confidentiality must reign supreme. The role of the healthcare development manager David Veitch, managing director, Bristol-Myers Squibb David made it clear that this was the perspective of a countrywide company manager. He saw the NHS now as a health business, not a service. He made the following points: The payor [SIC] is the King. And the GP role is still important. The healthcare development manager (HDM) role has many titles. It's not new and has been around since fundholding). Interaction in an appropriate way is a great business asset. There are national and local barriers to implementation. Why do we have a culture of frugality on innovation? With an HDM team, the key to success is clear vision/objectives/focus (CVOF) and superior customer insight (SCI). Customer insight is vital, which is why Wellard's is valuable. But intelligence is useful only if applied to a plan. Payors are healthcare organisations. Their twin drivers are patients and book balancing. There is an NHS tug of war between practice-based commissioning (PBC) and PBR (payment by results). We are in the early days of partnership/transparency/trust. Adelphi survey. PCT priorities vs appropriateness of pharma response. Take value proposition and turn into business proposition. The HDM must navigate between the two poles of strategy and selling a product HDMs must always be 'justified' to higher interests Claire Housden of Roche asked: Q: We need to promote an internal understanding of the NHS. Education or translation – which is better? A: Both. David Prill of Janssen-Cilag asked: Q: Where will the role of the business development manager (BDM) be in 3-4 years time? A: Wherever it is, it must be adaptable to changing customers and portfolios. Martin Whitehead of BMS asked: Q: Would you say that we need superior customer insight (SCI)? A: SCI only works with CVOF (clear values, objectives and focus). CVOF comes before SCI. Q: With 'customers' in two camps, sales and the NHS, must the HDM make the link? A: The NHS has struggled to understand the environment itself. Communicate with your sales team. Inform your internal colleagues about developments, but don't push back on the measurables. Andy Hockey of Lundbeck asked: Q: How is the situation compared with Europe? A: In Belgium, barriers are national. More people are taking up UK models. In Italy there are regional and national barriers. Monica Rafiq of Abbott Q: Would you encourage collaboration? A: If there is trust, transparency, yes, on a case-by-case basis. The ABPI outreach is good model. Trish Canavan of Altana asked: Q: Our customers want collaboration. A: Industry must be prepared to say 'NO'. Where is nurse prescribing going in 2007? Matt Griffiths, Royal College of Nursing Matt looked at the various types of non-medical prescriber and prescribing, giving some figures, and pointed to future trends in this NHS development. District nurse prescribers – 29,000 Extended prescribers – 8,500 Supplementary prescribing nurses – 8,000+ Patient group directions – 67,000 are eligible, of whom 50 per cent use patient group directions (PGDs). Nurse prescribers have to take 27 days training/assessment which can be done through distance learning. It may not seem like much but it is off the back of up to 10 years field experience. Since the recent consultation on NMP, they can prescribe for any medical condition/specifically formulated for their speciality, since 1 May. Supplementary prescribing has individually agreed parameters. ie supply of insulin between agreed parameters. No legal limit on conditions of supply, including unlicensed medicines). A study by the University of Southampton found nurse prescribing to be safe. Difficulties have included: 1. Complexities of implementing individual clinical management plans, frustrations at computer generated prescriptions and getting hold of prescription pads 2. Difficulties with training PGDs could be a tetanus injection with wounds (for patients without tetanus injection) Police custody/defence medical/private care with Healthcare Commission regulation all throw up different opportunities for NMP District nurses can prescribe outside primary care Pro's can now give Diamorphine for cardiac patients in acute/A & E NMP should only work within their area of competence. Patients' safety is paramount. CPD (continual professional development) is important. Education must be continual and adequate. Nurses need to be involved in PBC Some benefits of nurse prescribing: patients are positive/time is saved/ money is saved/ convenience/ continuity of care/ information provision. There have been some concerns about diagnosis/pharma knowledge. But NMP is intended to produce 'maxi nurses, not mini doctors'. Nurses can prescribe from the whole formulary now the formulary has been opened up. 90 per cent of prescribers have, as minimum, a nursing degree. 93.5 per cent have done in excess of 10 years' practice. There is a lot of support from doctors, who mentor nurses. CHD, COPD, diabetes, trauma, dermatitis, mental health, substitute misuse are all big NMP areas. Nurses make up 1 per cent of the overall prescribing budget. Pharma can speak to nurse prescribers: find out their needs, get involved with education/CPD and get it validated. They can support NMP events. Clare Housden of Roche asked: Q: Is there a move to have list of prescribers for pharma? A: Pharma must build up its own list. Ian Little of Sanofi-Aventis asked: Q: What should we do about CPD? What's the first port of call? A: Pharma should set up of focus groups. Nurses want education on policy. John Prendergast of Alchemy asked: Q: One per cent of total prescribing! Isn't that why pharma isn't taking notice? A: The update since May has opened up the formulary. Diabetic nurses can now prescribe insulin, and COPD nurses, inhalers. NICE into 2007 Andrew Dillon, chief executive, National Institute for Health and Clinical Excellence Andrew subtitled his talk 'learning to love health technology evaluation (HTE)'. He gave an overview of the body's work since its establishment ion 1999, and made the following points on HTE, concerning why it was done, its value, its limitations, its conditions for success, some trends, and some prospects: HTE is under pressure from all sides. We must find a way to unlock the potential of the NHS and pharma working together. Some payer objections have been effective care, efficient funding, and stimulation of innovation. Additionally: is therapy worth it with a limited amount of NHS cash? For resources must be spread fairly and equitably. NHS must make rational purchasing decisions like any big business – but also make optimal use of new technologies. Selective application based on careful targeting of incremental therapeutic benefit. There is a scale where on one hand we may be wasteful and on the other we may frustrate innovation. The same approach is taken by NICE whatever the outcome. There is a perception that NICE production is 'fiddled', but nobody interferes with the independent evidence advisory committee. They would walk away from such pressure. There have been very few examples of poor pharma relations, and then they were to do with getting to the bottom of the evidence base. The single technology assessment programme is a new venture intended to make appraisal more efficient. NICE responds to arguments, not to bullying by some agency or other. The NICE website gives a guide to the decision rules. 'Assumptions' about the evidence can change the cost of treatment per quality-adjusted life year (QALY). People can make appeals against NICE rulings. NICE uses a curve that measures uptake against cost effectiveness. An exception was made in the case of a leukaemia drug which did not fit into the curve's assessment of cost-effectiveness, but was decided to be effective enough on the seriously ill to justify NICE backing. One benefit of this system is that it recognises the reality of fixed resources. It is explicit about value for money. It promotes effective practice. It promotes medical consistency. Doctors like it because it gives them a firm back–up. It provides a benchmark for trust delivery. Its limitations are noticeable when a lack of clinical evidence is not the same as a lack of effectiveness. The benefit for payers is that improves effectiveness of resource allocation. It is also a global payer resource used all over the world. One benefit for pharma is that it offers a constructive dialogue. It also increases transparency, and identifies and promotes use of effective and innovative technologies. For pharma, the jury is out on NICE. But NICE at least has the power to unlock technology. It has made 107 appraisals and 31 are now routinely used. Upward trends are likely as health costs increase. Companies are giving cost-effectiveness a thought. Pharma knows best how to evaluate products. When working with NICE there is space for constructive engagement. Dialogue is always good. The challenges for 2007 include reviewing the appraisal methods, and handling an increase in guidance. NICE will continue to expand. Peter Merry of Wellard's asked: Q: Why is selection so closely guarded by the DH? A: NICE manages selection through consideration panels, with information fed in from horizon scanning. Atta Hanfi of Schwarz asked: Q: Does the QALY curve take into account medical inflation? A: No, a good point. But the range is tougher now than it was. Incidentally the QALY curve is not a DH policy. NICE uses it because it was the model used pre-NICE. Clare Housden of Roche asked: Q: Should the PCT take legal advice on the direction of funding for NICE recommendations? A: PCTs must make resources available — that is the legal position. PCTs can say that other duties override the direction of the secretary of state. But we must ask — what are they doing with their money? NICE guidance is good business guidance. If they don't follow guidance, PCTs risk failing the annual healthcheck. Mark Blowers of Innovative Healthcare asked: Q: Why hasn't NICE always been part of the QOF? A: The QOF is for the UK, and NICE guidance only for England. It would have been seen as too tough for GPs in the early days of the QOF and the government was worried about underperformance. In fact they needn't have worried. Mark also asked: Q: National service frameworks (NSFs) predate NICE. Are the two complementary? A: Should be the case. NSFs should be updated and informed through NICE.