National Institute for Clinical Excellence.

NICE news dominated last month's agenda as several 'controversial' decisions were announced. Top of these was the atypical antipsychotics decision. Although not directly relevant to all companies, the issues arising are.

"NICE recommends that atypical antipsychotics should be considered alongside traditional medicines, as one of the first choice options to treat people with newly diagnosed schizophrenia and for those people who are experiencing unacceptable side effects on their current medication."

NICE estimates that this will add some £70m in additional drug costs per annum to the NHS. See www.nice.org.uk. NICE's green light met with mixed reactions. The decision delighted mental health campaigners, but worried senior clinicians and academics who argued that the drugs' worth has not yet been proved. The move ends a long running campaign by mental health groups, who have accused the NHS of rationing these drugs to 20% of the patients who could potentially receive them.

Last year the BMJ published a paper by Dr John Geddes and Prof. Paul Harrison from Oxford University's Department of Psychiatry. They concluded that there was 'no clear evidence' that the new drugs were any better than traditional drugs. Dr Geddes said of the decision, "The jury is still out on the quality of these treatments. There have not been any systematic independent trials - most have been done for licensing purposes". Another academic has said "There isn't the evidence around on which to base any firm conclusions. The guidance has come too soon. There has been pressure by the drug companies for this treatment, many of whom have targeted patient groups to push it forward."

However the Health Service Journal (20/6/02) published a range of letters generally in support of the NICE ruling "The evidence is not thin. I accept that it is not gold-standard RCT evidence, but there is evidence that RCT methodology does not suit research into mental health, where outcomes are less clear…. Mental health is one area of research where the users voice must prevail. Give a room full of health economic decision-makers the choice between a dose of haloperidol and a dose of olanzapine and you'll be killed in the rush for the latter." This from Dr Gary Sweeney, Mental Health and Clinical Governance Lead at Tendring PCT. Cliff Prior, Chief Executive of the National Schizophrenia Fellowship, found the comments by academics 'extraordinary'. "The ruling by NICE is ground-breaking, putting the user at the heart of healthcare decision-making. It should be welcomed, implemented and funded," said Cliff. Expect this to run for a while longer yet.

NICE featured in the media too last month. The Evening Standard (7/6/02) reported that Glivec (in leukaemia) is now being restricted by the NHS (at a cost of £18,000 per patient) whilst slimming surgery (at a cost of £5300 per patient) is to be made available on the NHS. 'Outrage' and 'revolutionary drug' and 'profoundly illogical and grotesque' were words and phrases used. Also mentioned were NICE's (other) controversial decisions, such as - beta interferon in MS being refused whilst the go-ahead was given for the antismoking drug Zyban. The Sunday Times (23/6/02) also entered the fray with an article entitled, 'Cost-effective decisions that are killing the NHS'. This about NICE's decision on the colorectal cancer drugs. "It is difficult to understand the importance of each day of life for someone who is dying of cancer. Every hour is precious".

NHS/Industry Parnerships.

An important note for Industry readers appeared on the DoH website last month. This positive article, discussed how the pharmaceutical industry can be involved in the development and implementation of NSF's. It is suggested that involvement should be at four different levels - the development stage including the External Reference Groups and Topic Working Groups, the Emerging Findings Stage and Implementation and Delivery Stages. Some selective quotes: "The Secretary of State is keen to involve the pharmaceutical industry in the development of National Service Frameworks……. Industry might wish to offer facilitation and to support regional workshops to test NHS capacity and we would welcome this on a 'without prejudice' basis. It may also be possible to work with Industry in dissemination to user groups…. The effective delivery of NSF standards and key interventions is dependent on fundamental change and changes in clinical and professional practice. The industry has both the expertise (and in some areas, resource capacity) to bring to bear in the professional development of GPs, primary health and social care teams, clinicians and others. Collaborating with the industry in delivery of an NSF would be of significant advantage to both DoH and the Industry, where a pharmaceutical intervention has been identified in the NSF….. The arrangements described here do not effect the way in which PCTs work at a local level with individual pharmaceutical companies". See www.doh.gov.uk/nsf/pharmaceutical.htm. Much of the 'co-operation' so far has been mostly at a national level through the ABPI rather than at an individual company level but the implications of all of this do need working though at an individual company level - particularly the last comment above. So some very good news here. These messages should be picked up and rolled out by Industry NHS teams.

Primary Care.

Public health professionals are raising concerns at the lack of detail regarding the level and resourcing of the public health function in PCTs. This is not stopping Barnsley PCT who are appointing a senior public health nurse to lead and co-ordinate 'national programmes around cancer, CHD, mental health and the older people NSFs'. The Midlands Directorate of Health & Social Care (DHSC) are appointing 5 Public Health Managers based in Nottingham as part of Midlands & East of England Public Health Group who amongst other things will be 'required to foster an increasing emphasis amongst commissioners and providers of the effectiveness of clinical interventions'. For more on public health and PCTs see the report from the All Party Parliamentary Group on Primary Care and Public Health. This welcomes for instance the multidisciplinary approach now being taken in PCT land. Some examples here are Tower Hamlets PCT where the Director of Public Health (DPH) is a health economist, Preston PCT where the DPH is a social scientist and Plymouth PCT where the DPH is a health visitor. But the appointment of non-medics as DPHs is causing concern in some quarters. The report also talks about extending 'public health family' to health visitors, district nurses and school nurses and even specialist nurses in coronary care and diabetes. Some PCTs are still advertising for their Chief Executives, 3 months after the new organisations were created! The latest was South Liverpool PCT. Many other critical Director posts (e.g. Directors of Finance) are also still being advertised.

Last month the HSJ again had an article on GP prescribing (13/6/02; pps 26-27). This is about (re)weighting the ASTRO-PU formula for allocating prescribing budgets to take more account of chronic disease, this from East Kent Coastal PCT. This emphasises the need for disease registers and firmly places prescribing in the clinical governance agenda. Industry could help relevant practices here in areas like asthma, CHD, etc?….. The latest prescription statistics data has been published by the DoH. Prescriptions Dispensed in the Community; Statistics for 1991 to 2001: England shows that the prescribing bill in 2001 reached £6.12bn and that 74% of all prescriptions are now written generically. See www.doh.gov.uk/public/sb0214.htm for the details.

PCTs have been invited to apply to be a third wave site for the National Medicines Management Services (MMS) Collaborative Programme beginning in October 2002. This programme is to help meet commitments in the NHS Plan and Pharmacy in the Future for every PCT to have such schemes by 2004. As with the first wave of 26 sites and the second wave of 40 sites, a third wave of up to 40 sites will be supported by funding from the Department and by the project team based at the National Prescribing Centre (NPC). Sites chosen for the third wave will recruit local facilitators to work closely with GPs, pharmacists and primary healthcare teams to re-shape local services so they meet the needs of patients and ensure value for money. Further guidance on the MMS programme and the application form are on the NPC website at http://www.npc.co.uk/mms.


Scotland

Folk north of the border were a bit surprised when First Minister Jack McConnell announced last month that the Scottish Executive is to publish a white paper on health this winter! Nothing had been expected before the Scottish elections next May and anyway there is already ongoing a major review on management and decision making in NHS Scotland, supposedly running for another 12 months. Managers are worried that this might presage more initiatives rather than focussing on delivering what they already have to deliver…. At the Institute of Healthcare Management's (IHM) Scottish summer conference key areas for debate included how to achieve closer integration between the primary and acute sectors and whether HB boundaries needed to change to lead to greater coterminosity with local authorities. Trevor Jones, Chief Executive of NHS Scotland, said the current system of Unified Boards, introduced last October, was not being implemented consistently across Scotland. "We want the Boards to be strategic, not operational, yet some are being asked what colour a Trust should paint its toilet doors." It's exactly the same issue in England with StHAs. Scotland's Chief Medical Officer has promised that NHS Scotland will not be judged by 'crude death league tables.' Dr Mac Armstrong said that the new Quality Standards Board for Scotland (QSBS) would build a 'new understanding' of what clinical outcomes meant. Revised guidance was issued in June on the Health Technology Board for Scotland's (HTBS) HTA process (see www.htbs.co.uk). As folk will probably know the HTBS will form part of QSBS from October this year (see www.show.scot.nhs.uk/crag).

New customers

On April 1 this year, there were 1200 new recruits to the NHS - these were the lay chairs and non-executive directors of PCTs. What do they do and are they are important? Are these industry customers? Non-execs get involved in many PCT subcommittees and working groups and could indeed be relevant. Perhaps they need factoring into PCT account management strategies? StHAs across London have recently advertised for Directors of Nursing. With Nurse prescribing so 'hot' at the moment these customers are bound to get involved with this initiative.

About the author

Therapy specific - corporate newsletters, written by Alan Jones of AJC Healthcare, are used by Sales Teams throughout the UK Pharmaceutical Industry, as a source of crucial NHS intelligence.

To discuss how your team could benefit from regular up-to-date analysis of the NHS changes and issues that directly impact on your business, please contact Alan Jones of ajc healthcare (alan.jones28@virgin.net)

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