HM Treasury has now wandered
onto the health turf with the publication of the interim report from the
Wanless committee, set up to review key trends over the next two decades likely
to impact on the NHS. Securing Our Future: Taking A Long-Term View sets out the
evidence compiled so far in areas like health trends, public expectations,
changing health needs, workforce and productivity issues, technological
advances and differences between countries within the UK. An invaluable
document for long-term planning. See
www.hm-treasury.gov.uk. The report predicts that over
the next 20 years most primary care and first routine NHS contacts will be
provided by nurses and other healthcare professional rather than by GPs. Roles
are expected to change significantly with much work currently done by GPs being
switched to nurses and a large part of nurses' routine work being carried out
by healthcare assistants. GPs are to become more specialised, managing more
chronic conditions and even cancer in primary care as new drugs develop. So
skill mixes are set for major change and this will be bound to impact on the
industry. The report also makes comment that GPs need to double the amount of
time they spend on clinical governance. For those wanting to know more on what
the 'central' view on clinical governance is all about, a powerpoint
presentation The Seven Pillars of Governance is available at
www.doh.gov.uk/meddirbulletin/presentation.htm.
The Chancellor has said that the
NHS won't get any more money until it reforms, but this is daft talk as it's
already getting shed loads. So with Brown's Billions, the government has
decided to go for broke but is it throwing good money after bad? They have
already admitted that parts of the NHS have 'gone backwards' despite the
already massive boost to health spending. What if the new money still makes no
appreciable difference? Is the Treasury softening up public opinion to accept
higher taxes to fund better health services? The Conservatives now seem to have
finally abandoned the taxation-funding principle and Dr Liam Fox, the Tory
health spokesman, wants to adapt the Swedish or Danish model for funding
healthcare with social insurance
The NHS Alliance, NHS
Confederation and the IHM all welcomed the Chancellor's commitment to a
tax-funded, universally available NHS and his announcement of an extra £1
billion funding this year. "We were particularly pleased to learn that Derek
Wanless had looked at alternative funding systems - and rejected them as too
costly and ineffective", said Dr Michael Dixon, NHS Alliance chairman. "Like
Gordon Brown, we hope that an enduring national consensus can be built around
the central principles that a publicly-funded NHS is vital and that it should
receive substantially increased long term investment", said Dr Dixon.
But NHS manager's real major
concern continues to be that the reality of delegation of Shifting the Balance
of Power comes with an extraordinary level of central direction strings. At the
moment politicians are not only -1- setting the strategic direction and
determining the levels of national funding, they are still trying to manage the
detail at the sharp end as well. This not only undermines managers, it has a
demoralising effect throughout the Service. The corridors of the NHS are thus
not ringing with the hosannas of grateful staff and patients because of
scepticism about the government's ability to deliver. See
www.bmj.com/cgi/content/full/323/7325/1318 for a
fuller analysis on Wanless and funding.
As regards STBOP, wrangling over
the shape of the regional offices has been holding up final guidance and the
government has not been getting an easy ride over its NHS Reform Bill.
Approximately 60 candidates were shortlisted for the 28 StHA Chief Executive
posts and these have now been announced, along with the Chairs. The boundaries
have been confirmed and a few names have changed such as Anglia StHA becoming
Norfolk, Suffolk & Cambridgeshire and West Midlands Central becoming
Birmingham and the Black Country.
So beware, as we start this new
year and all of Europe goes mad over Euros, yet another major NHS
reorganisation gets closer. Prof David Hunter and colleagues, in an article,
The redisorganisation' of the NHS (see
www.bmj.com/cgi/content/full/323/7324/1262, reminds
us that on taking office in 1997, Labour said that the NHS had suffered too
much structural reform and yet this government has embarked on the largest, and
least debated reorganisation of the NHS for two decades. "The NHS does not need
a distracting and unproven reorganisation that, for all the rhetoric about
devolution, leaves unchanged, or even strengthened, the capacity for the centre
to micromanage the service into the ground. What is required is a fundamental
rethinking of the relationship between central government and the NHS. The
answer could lie in a move to regional government, with the NHS being
transferred to the control of bodies like the Spanish regions or the Swedish
County Councils." And we could become part of the Euro Zone too!
The annual NICE Conference bash
was held last month. Clinical Excellence 2001, at the ExCel Conference centre
in the wastes of the London Docklands, proved to be the largest of the NHS
conferences last year with over 1700 delegates. But one did almost needed a
degree in conference participation to work one's way around the huge number of
parallel sessions, streams and satellite meetings. There was certainly lots
going and just about anybody who was anybody was there. I guess the really big
news from the conference had to be that announced by Lord Hunt when he
'formally' notified the NHS that from January 1st this year, NICE guidance is
'compulsory' - previously reported here in October. Many expressed concern that
the new rules requiring treatments approved by NICE to be funded within 3
months from the date of publication of each Technology Appraisal Guidance (TAG)
would mean that other services would have to be cut. The NHS Alliance said that
the government's decision to force HAs and PCTs to fund all treatments
recommended by NICE was 'too simplistic' and as a result services like
specialist nurses would have to be limited to fund the cost of NICE approved
treatments. "We support the government's intentions, but not the way they are
doing it," said Dr Mike Dixon, NHS Alliance Chairman. "I hope we will not see
another kind of rationing, based on whether or not the treatment any particular
patient needs has been looked at by NICE." Note the new directions apply to
England only and HAs and PCTs will be expected to meet the costs of treatments
recommended by NICE out of their general annual allocations. GPs continue to
moan that they are now facing financial penalties for following NICE
prescribing guidance and are having their budgets slashed and development money
taken away to compensate for massive prescribing overspends. This story line
will run and run through 2002!
The conference also marked the
'official' launch of the six professionally led National Collaborating Centres,
developing clinical guidelines and audit advice for the NHS. See NICE Press
Release 2001/039 (www.nice.org.uk) for full details of the NCCs and
partners and the various Directors and Chairs. If you are into Guidelines, this
10-page document is the one to get! Some 35 clinical guidelines and 8 clinical
audits are now in progress.
The NICE crew had lots of
sessions at the conference. In a plenary session, NICE, The Process and the
Programmes, Prof David Barnett, Chair of the NICE Appraisals Committee
discussed the 'evidence gap' that existed between licencing and appraisal
(efficacy versus effectiveness) and that NICE was unique in the world as its
final determination 'injects' into health policy making in order to rationise
the use of available resources. He described what they had learnt so far,
particularly over size of remit and the 'difficulties' with controversial -2-
topics. For instance large topics like the multi-drug appraisals in the
atypical antipsychotics assessment with a 1000 page assessment on 8 different
drugs and very large company submissions. This had had a significant impact on
human resources, he said, and perhaps they had 'bitten off more than they could
chew.' As regards evaluation of health economic data, more independent analysis
was needed in the future, he said and further research was needed in HE
methodology. He also recognised that the TAGs had a significant effect on the
local NHS - budget impact, issues of prioritisation and consideration of lost
opportunity costs, workload issues, staffing levels, training and development.
Sir Iain Chalmers asked an interesting question at this session - the evidence
given by Industry in its submissions is voluntary and/or in confidence. How do
we know all is being given? He suggested that this was not as transparent as it
might be because there was no legal requirement to provide this data…
In a session, HTA and Guideline
Development in Scotland, Karen Facey from the HTBS and Juliet Miller from SIGN
presented. As suspected, rumours of the death of HTBS were premature and it
will apparently now form an agency within the National Clinical Governance
Board (working title). See the SHOW website for a consultation document
Integrating Scotland's Clinical Effectiveness Organisations, with the proposed
new structures. I also have slides of these two presentations for anyone
interested. Email alan.jones28@virgin.net for copies.
Details on the long awaited Citizen's Council were also finally announced at
the conference. It is planned that the Council will have up to 30 members who
will be representative of the England and Wales population - now that's a
challenge! Industry and lobbying groups will not be allowed and they are keen
to avoid the usual suspects that get involved in CHCs etc - just Jo and
Josephine Public. It is planned that the Council will meet in public every 6
months - interesting! The ABPI in fact launched their latest Media Briefing on
NICE at the conference (MedBrief018;
www.abpi.org.uk).
Through 2001 folk have been
talking about a fundamental review of NICE, particularly the ABPI, but nothing
materialised. Now the House of Commons Health Select Committee is to scrutinise
the Institute in an official inquiry beginning this month, to assess its
independence and how successful it has been in meeting its key goals and
objectives as envisaged in A First Class Service. The HSC will also consider
how clear and credible NICE's guidance has been; whether NICE guidance is
accepted locally and acted upon and whether NICE has enabled patients to have
faster access to effective medicines. Certainly with all this stuff going on,
it is bound to be an interesting year ahead for NICE!
Last autumn, we reported on some
interesting comments in the BMJ following a Pharmaceutical Marketing
publication on Medical Education (BMJ 2001;322:1312). Well the BMJ has picked
up this area again. conference. Sellings drugs - with a little help from a
journalist (www.bmj.com/cgi/content/full/323/7323/1258/a) asks
exactly how are journalists recruited to work on behalf of corporate clients?
Referring back to the PM guide which said, "…the best marketing, is
editorial…readers believed claims made in editorial sections far more than
claims made in an advert," the article says, "those in the business of
promoting drugs - or more genteely described as 'pharmaceutical marketing' by
its practitioners - know that one of the biggest factors in determining the
financial fate of a drug is the quality of media coverage in specialist medical
journals." So this is about the fact that readers do not know that writers are
by paid by a drug manufacturer. "Fancy a trip to Paris? You will fly business
class, stay at a luxury hotel and dine well. The pharmaceutical industry is
well known for using such incentives to build relationships with key opinion
leaders in the medical profession. Less well known, perhaps, is that
journalists are also the recipients of such largesse."
Primary Care is of course going
to undergo tremendous change this year when it effectively takes over the
funding reins. Please see my article in this month's Pharmaceutical Times for a
more detailed 'exposition. The DoH's GP Bulletin for December (www.doh.gov.uk/gpbulletin/index.htm) has some
interesting stuff - GP Specialists, envisaged in the NHS Plan, are now to be
called 'GPs with Special Interests', stuff on GP Appraisal, Primary Care Cancer
Leads and PMS. Regarding the latter read the latest at www.doh.gov.uk/pricare.
Chief Executive posts for the West Sussex Health & Social Care NHS Trust
and West Kent NHS & Social Care Trust were advertised, the first of the
Mental Health Care Trusts. See
www.wsussexhealth.org.uk/HA84 for the consultation
documents.
Guidance on primary care
prescribing & budget setting 2002/03 has been issued. See
www.doh.gov.uk/pricare/pcts.htm. The National
Prescribing Centre (NPC) has produced a Competency Framework for Nurse
Prescribers. It provides a useful summary of the history of nurse prescribing
and next steps. See Maintaining Competency in Prescribing: An Outline Framework
to Help Nurse Prescribers at
www.npc.co.uk. This has to be a sensitive area for
the Industry and this is clearly recognised in the Framework. Some 'behavioural
indicators' are "critically appraises the validity of information (e.g.
promotional literature)"; "works within the NHS organisational code of conduct
when dealing with the pharmaceutical industry" and "recognises and deals with
pressures that result in inappropriate prescribing" (p.17). Ray Rowden in
November's Pharmaceutical Marketing (pps 27-28) reports on a survey amongst
current nurse prescribers of attitudes to the Industry which showed that many
are already wary.
The Mental Health Promotion
Project continues to develop and with its objective of supporting the
implementation of NSF Standard 1, regional and local mental health promotion
networks have now been mapped. See
www.doh.gov.uk/mentalhealthpromotion/index.htm. The
NSF Workforce Action Team (WAT) for Adult Mental Health has produced an interim
report setting out the results of the exercise to map the education and
training that is being commissioned and provided in mental health. See
www.doh.gov.uk/mentalhealth/watmapexfinalreportdec2001.pdf.
A 'Capable Practitioner' document has also now been published on the NSF
website at
www.doh.gov.uk/nsf/mentalhealth.htm.
A 12 page report, The NHS Cancer
Plan: Making Progress, is available at
www.doh.gov.uk/cancer/makingprogress.htm summarising,
from the government's perspective at least, where we are with in the
implementation of the NHS Cancer Plan. 279 PCT cancer lead clinicians have now
been nominated as part of the DoH/Macmillan Cancer Relief initiative. Also the
joint report from the Commission for Health Improvement and the Audit
Commission is now out. This looks at the implementation of the recommendations
of the 1995 Calman-Hine report on the commissioning of cancer services. The
report focuses on the period 1995 - 2000, before the publication of the NHS
Cancer Plan. The report is available at www.chi.nhs.uk.
The BTS have done a good job in
publicising their report The Burden of Lung Disease (www.brit-thoracic.org.uk). It suggests many more
specialist respiratory nurses, consultants and surgeons are required and that
lung disease is at least as important as cancer and heart disease and a NSF
would be nice. Other groups like the RCN have rejected this approach. A DoH
spokesperson reminded the BTS that much of the morbidity and mortality is due
to lung cancer and not COPD and asthma and that was why the burden of
respiratory disease was so high and that this was already being tackled!….
The first part of the National
Service Framework (NSF) for Diabetes has been published The second part, the
'delivery strategy' will arrive in the summer. The twelve recommendations
include patient-held records and personal care plans and the NSF clearly
recognises the key role of primary care. Said Dr Michael Dixon, Chair of the
NHS Alliance, "There is clear evidence that the quality of care in diabetes has
often been variable, and that patients have fallen into an invisible gap
between primary and secondary care - between GPs and specialists. The emphasis
throughout is on locally agreed protocols to meet national standards. We
welcome the explicit recognition of the cumulative effect of NSFs on primary
care and anticipate that the strategy for delivery will take full account of
the extra demand on primary care and the resources needed. We must not risk
unbalancing those areas not covered by NSFs,"
Bandolier's November issue
can't resist having a go at the industry, "Bandolier sometimes despairs of
healthcare industries. Evidence should be their meat and drink, yet they shrink
from helping us by giving us the evidence the way we want it, in unbiased,
independent, systematic reviews. Though there are exceptions, too often they
are afraid of what's on the other side of the hill. So after incredibly
expensive research, carried out over a whole afternoon, Bandolier has come up
with the answer. Anyone from industry bearing an unbiased, independent,
systematic review of a company's product will be rewarded with a Bandolier mug.
That should do it!"…. I wonder!…….
An article in the McKinsey
Quarterly Journal is being heavily sold to the NHS at the moment and is worth a
look at for those with an interest in hospitals. Hospitals get serious about
operations is at
www.modernnhs.nhs.uk/newsdesk/operations.pdf and has
stuff about service improvement and redesign techniques - very much the sort of
work of the Modernisation Agency. A letter from David Fillingham, MA Chief
Executive, commends the article to NHS Chief Executives and asks that they draw
the article to the attention of their boards. See
www.modernnhs.nhs.uk/newsdesk/df-mckinsey.doc. The
Audit Commission has come out with a very bleak picture of hospital pharmacy
services. A Spoonful of Sugar claims that thousands of patients are being
killed by medication errors/adverse reaction to drugs. It also recommends as
too few Trust Boards have understood the importance of the link between
effective clinical governance and medicines management and that the role of the
Chief Pharmacist should be elevated to the equivalent of Clinical Director.
Therapy specific, corporate
newsletters, written by Alan
Jones of AJC Healthcare, are employed throughout the UK Pharmaceutical
Industry, as a source of crucial NHS intelligence, within many Sales Teams.
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) |
