Strange bedfellows?

The political climate is ripe for joint working between the NHS and the drugs industry, and there are many innovative schemes. But problems remain on the ground, reports Alison Moore

Once upon a time, joint working between the NHS and the pharmaceutical industry amounted to little more than the drugs company paying for the curly sandwiches and luke-warm wine served at an 'educational meeting'.

Those times have long gone; to be replaced with a cornucopia of innovative schemes, as drug companies try different initiatives to see what works.

Joint working is, of course, very much within the spirit of the public-private partnerships the government has sought to promote. Whereas before, the sub-text of any guidance from the Department of Health was very much 'do not get involved', this has changed with the setting up of the pharmaceutical industry competitiveness taskforce. This has explicitly encouraged co-operation, especially around the national service frameworks.

1This has led to a representative from the Association of the British Pharmaceutical Industry sitting on the diabetes framework implementation group.

Forthcoming frameworks in which industry involvement is likely include children, renal services and long-term conditions.

There has also been co-operation on the mental health framework between the National Institute for Mental Health and the ABPI mental health partnership - including a booklet of examples of good joint working on the ground, Meeting of Minds.

2ABPI set up a working group to look at what its input into the framework for older people could be: it later ran a conference for the NHS's 'older people's champions' and developed a toolkit for them.

'A strong message is going down from [health secretary] Alan Milburn and the DoH that this partnership is to be encouraged, ' says Richard Marsh, director of external affairs at Bristol Myers Squibb, a pharmaceutical and related healthcare products company.

The DoH has said that the pharmaceutical industry has the skills - and sometimes the resource capacity - to assist in the professional development of many primary care health workers. 'Collaborating with the industry in delivery of a framework would be of significant advantage to both the department and the industry, ' it says.

3But though the political climate nationally may be right for co-operation, there are still difficulties on the ground. Drugs companies have had to switch from influencing individual GPs in their prescribing decisions to working closely with primary care organisations on both prescribing policies and implementation.

This involves understanding what each party wants out of any joint working: Mike Sobanja, a director of Healthgain Solutions Ltd, a company which works at the interface between the NHS and the pharmaceutical industry, says: 'I am astonished by people in the NHS who reckon they can just go along to the pharmaceutical industry and say: 'You have lots of cash - give us some'.'

He prefers working on joint projects as a description of what should be attempted - rather than a partnership which suggests some sort of shared goal.

The goals of both sides may be very different - but working on a joint project can help both sides achieve them.

Mark Blowers, national healthcare development manager for pharmaceutical company Solvay, says: 'It is very much that we will work with primary care organisations if they understand what we want to get out of it and we understand what they want to get out of it.

Otherwise, we walk away.

'It is a mistake to make out that we are not a commercial organisation. We look at every penny we spend very carefully.'

The company has been working to get its products included in primary care trust 'directions' on prescribing and will then work with the PCT to ensure that prescribing decisions do reflect this central line. For example, it has a hypertension management programme, backed up by study days, which can assist PCTs: the company benefits as one of its products is a popular 'add on' therapy for treating hypertension.

'With 300 PCTs, you need to know what goes on in each one, ' says Tom Marshall, from Isis Research which specialises in the pharmaceutical and healthcare sectors. 'PCTs need extra resources - and drug companies need to be able to promote their drugs before they come off patent.'

With the growth of PCT-wide formularies and prescribing policies, the pharmaceutical adviser has increasingly become the person for drugs companies to contact and seek to influence, rather than individual GPs. The growth of strictly controlled prescribing by nurses and pharmacists should also put the PCT centre stage.

But not every 'investment' in partnership working is meant to pay back immediately in terms of increasing sales - or even the crucial inclusion of a drug on a PCT formulary. With some ventures, the benefits for the drugs company will take some time to come through.

How long that payback can take depends on the company and the product. Louise Jarvis, primary care organisation marketing liaison manager for AstraZeneca, says the pharmaceutical company always has an outcome which it is looking for - even if it is simply good access to key PCT people at the end of six months joint working. But the company does take a longer view and accepts that the full benefits may not be felt for longer.

Drugs companies talk of relationship building and understanding their customers as some of the immediate benefits.

'It benefits us being seen in a constructive light, as a positive partner, ' says Mr Marsh.

One way to do this is to get inside the NHS: Research-based pharmaceutical company GlaxoSmithKline has had 'job swaps' with the NHS, allowing both sides an insight into how different organisations work.

Andrew Garvey, senior external affairs manager, says the company is strong on project management and stakeholder skills. In return, it gets 'an understanding of what is going on in the NHS - it is of enormous value to us'.

Ms Jarvis agrees about the benefits of secondments: 'You are getting inside your customer - seeing it from their point of view.'

Companies are also able to provide non-clinical skills which the NHS does not have in sufficient quantity: healthcare research and development company Novartis, for example, has developed a communication toolkit with associated workshops for PCTs, which helps them plan and develop a communication programme.

But probably the most common for joint working is reviewing drugs existing patients are on, or auditing care and prescribing for certain common conditions where drugs companies often offer technology and nursing expertise in the expectation that their product will be seen as more cost effective or beneficial for more patients.

Drugs companies working in CHD, for example, can expect partnership working on statins with PCTs to bring benefits, simply because so many patients will benefit from taking them.

Not all of these drugs will be made by the company putting the money in, but with such a rapidly expanding area, enough will be to make the investment worthwhile.

Research-based pharmaceutical company Pfizer has run cardiovascular workshops to help PCTs work towards the milestones and targets of the CHD framework. The content of each workshop is determined by the local situation and to what extent CHD registers have been set up, for example. Novartis also offers an interactive computer program to deal with implementation, and an independent program to look at cost effectiveness for statins.

But it can be harder to set up partnerships when a treatment area is not high up the NHS agenda - through frameworks or national guidance. Sometimes, however, extra resources are especially welcome for 'Cinderella' services and successful partnerships can be set up.

Companies are also keen to work with PCTs to raise awareness of alternative treatments to those traditionally given. Pharmaceutical and healthcare company JanssenCilag has been working with Rotherham PCT on revising guidelines for pain management: it makes Durogesic which is an alternative to morphine preparations for moderate to severe pain. The guidelines are now being used across primary and secondary care in the area, and have been taken up by the Yorkshire cancer network.

Janssen-Cilag has sponsored a training module, which uses the guidance and helps to facilitate the module, with the Macmillan nursing team. 'In this project, there are only winners, ' says David Prill, head of NHS affairs at Janssen-Cilag.

So what is stopping some of these successful schemes being replicated across the NHS? The drugs companies can be reluctant to publicise them in case the format is copied by other firms, also eager to get an extra edge in a competitive market.

Another factor may be the different cultures of organisations within the NHS. Some health communities are known to be 'pharma-phobic', says Mr Sobanja - sometimes due to a past arrangement not working out.

Even in 'pharma-friendly' PCTs, some managers and doctors may feel unhappy about working with just one company.

Hillingdon PCT was one of the first to enter into agreements with the industry but did it by inviting all interested companies to a conference (see box, right).

Jane Austin, policy manager of the NHS Confederation, says much joint working remains small scale and may be dependent on individual relationships.

'Obviously if at a local level it can be made to work, That is a good thing - It is getting more leverage out of NHS resources.

But the question is whether it is scaleable up to the level that would be needed to make a difference in the NHS, ' she says.

The current proliferation of schemes may be temporary as companies and PCTs experiment with a range of alternatives, not all of which may stand the test of time. Mr Garvey says: 'It is hard to see where things will go ultimately - we are in an experimental pilot phase.'

An issue for many managers on the ground is sustainability.

Short-term sponsorship of specialist nurses, for example, risks leaving the NHS with a long-term funding commitment.

And it can lead to money being devoted to areas which may not be top priority once the co-funding disappears.

Passing on skills and knowledge to permanent staff is also important. Silas Nichols, head of the NHS Alliance group at healthcare products and services manufacturer 3M Healthcare, says the company tries to transfer skills over to people through training - and also runs helplines to sort out any problems.

But sometimes projects can come to an abrupt end. One NHS manager recalls working with a secondee from a drugs company, who was project managing a successful revamp of services.

She was able to bring useful skills to the health community - and demonstrated the effectiveness of having a manager devoted to a single project - but there were issues around patient confidentiality and the company's desire to use the project for its own publicity.

When the drugs company went through a major reorganisation, the project manager post was left unfilled - which had knock-on effects for the whole project.

'You have to be quite cold about this - we were using them, they were using us, ' the NHS manager says.

Take your partners: implementing a CHD protocol

Drawing up protocols for treating diseases is a relatively easy task, compared with getting them implemented on the ground.

So when Guildford and Waverley primary care trust decided to implement protocols for CHD, it turned to pharmaceutical companies for help. AstraZeneca was one of two companies initially involved in a partnership with the PCT's predecessor primary care groups - three more partners joined in the spring - and has provided some funding, manpower and marketing expertise. The company was interviewed before being accepted as a partner, and there are rules of engagement covering the relationship, what benefits each side expects and an exit strategy.

CHD guidelines were drawn up without the involvement of the drugs companies. 'It created some distance and credibility, ' says Beverley Gall, regional business development executive for AstraZeneca. 'We have given the project a name - the Guildford and Waverley healthy heart project - it has its own logo and any communication goes out under that logo. It is a matter of brand identity.'

Ms Gall is involved in marketing the protocols to practices, usually with a PCT pharmaceutical adviser at a practice meeting, and the company has borne some of the costs of producing the document. 'We have the flexibility - if we need different coloured paper for part of the folder of material, we can run up to Rymans and buy it, ' she says.

The benefits for the company are increased sales, if the protocols are put into practice, and potentially a bigger share of the market. 'Because we are very involved, we have a lot of face-to-face contact - our profile is higher than other companies', ' she says.

From the PCT side, the benefits are information about what is happening elsewhere in the country and some resources - especially IT and marketing skills. PCT associate director of nursing and operates Jane Thwaites says the partnership - which is already looking at diabetes - could be extended into other areas.

CFC free: mutual benefits

Over the next few years, many patients will move to CFC-free inhalers for long-term treatment of asthma.

Helping patients make this change and adjust their dosage is a massive task and would take many hours of practice nurse time. However, there are potential cost savings for primary care trusts.

Bristol North PCT has offered all practices in its area assistance from a team of nurses, employed by an independent company but funded by healthcare product and services manufacturer 3M Healthcare and working to protocols agreed with the PCT.

'It seemed as if it would save us money and be beneficial in drawing in patients who had not been seen for some time, ' says the PCT's head of medicines management Alaster Rutherford.

Around half the practices in the area have taken up the offer and savings are around£15,000 - but may be more in a full year.

He points to a number of factors which helped smooth implementation. Practices could choose whether to take part; and the nurses employed were former practice nurses who understood primary care and formed good relationships with the practices.

From 3M's point of view, the benefits were obvious: as the only CFC-free manufacturer of preventative treatment licensed in the UK, it will get increased prescribing.

Done deal: how a PCT worked with pharmaceutical companies Hillingdon primary care trust was one of the first to enter into PCT-wide agreements with pharmaceutical companies - but met opposition from some of its own GPs.

One concern was that the PCT should not be seen as tied to one company. This was overcome by having a meeting with all interested companies at which the PCT set out what it hoped to achieve and the sort of assistance it was looking for. The companies were then invited to discuss how they might want to become involved.

The PCT also drew up a code of conduct to govern relations with the industry with quarterly reports to the board and all projects recorded in the annual report.

4'We made sure that all the things we needed to be careful about - such as data going out of practices - were dealt with, ' explains Vasundra Tailor, a pharmaceutical adviser at the PCT. 'If there was a baseline audit on diabetes, for example, that data came to us. After it was evaluated, anonymised data could go to the company that sponsored it.'

Companies were also allowed to see and comment on draft guidance for prescribing drugs. But the PCT said it would only change matters of fact, such as drug dosage, rather than which drugs were included.

Inevitably, some companies chose not to get involved with the PCT, feeling they had little to gain, but many others have. This has allowed the PCT to do work it could not otherwise afford, such as a recent project on hormone replacement therapy, as well as improving management and prescribing in key framework areas. Drugs companies provided£65,000 to fund key projects such as coronary heart disease registers and diabetes audits. The PCT has also had a secondee from a drugs company helping to run a project on the use of non-steroid anti-inflammatories.

'In the end, the majority of GPs were okay with it because it was all above board and had the approval of our medical director, ' says Ms Tailor.

'The companies have got an awareness of how the PCT works. They also get a raising of the profile of certain therapy areas. They seem to be falling over themselves to work with us.'

REFERENCES

1www. doh. gov. uk/pictf

2www.NIMHE. org. uk

3www. doh. gov. uk/nsf

4www. hillingdon. nhs. uk/