Partnerships and trust are key to progress

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Partnerships and trust are key to progress

  By Rob Darracott

In the middle of his significant presidential year at the ABPI, Erik Nordkamp changed jobs. Last December, after four years as Pfizer’s UK managing director, he become the UK general manager and cluster lead Europe/Australia/New Zealand for the company’s disease management division, Upjohn.

The change is one he clearly relishes. “For the whole of my career I’ve been focusing on bringing innovative medicines to market,” he says as we sit down in Pfizer’s UK headquarters in Surrey. “The role I am moving into now operates in a part of the healthcare system I have not focused on before, but where I think the biggest need is, which is ‘how do you optimise the use of medicines, and the management of chronic disease in the community?’. It’s a fascinating challenge, and one all healthcare systems need to tackle. So, I’m personally very excited to move into that space and see what can be done.” 

While his new brief ranges across half the globe – the Upjohn Division is headquartered in Shanghai – Erik is happy to remain based in the UK, and not only because this Dutch national has a British family. With improving the use of medicines on his new agenda, it is not surprising to find pharmacy in his sights when he says: “I think the UK is a great place to be looking at the evolution of this space for a couple of reasons. One is that the UK is a diverse market. Others, like Germany and France, have rules that make it much more difficult for large chains to develop, for example, but we have all the ingredients in the UK to really try to do something. We have chains, we have supermarkets, we have independent pharmacists who are disruptors, we have digital start-ups. At the same time, we have a very ambitious long-term plan for the NHS. The big opportunity is how community pharmacy can play a role in integrated care.”

But while the ingredients might be right, he says the incentives clearly need some work. “I personally think more can be done to give community pharmacists a role in service provision. If you look at other countries, like Australia, you have to pay a fee to go to the GP or there’s a co-pay. If you provide a service in a pharmacy, very quickly you have an incentive to go to the pharmacy.” He accepts that it’s more difficult to change behaviours in the UK, where the NHS remains essentially free at the point of use for most patient contacts, but he cites the ambition of the NHS Long Term Plan. “Look at long term conditions and chronic disease, where 50 per cent of the GP appointments are, and 70 per cent of the costs of healthcare and social care. There is a huge opportunity to do better, and in my view, service provision through community pharmacy is one of the ways you could do that.” He says the NHS seems to be banking everything on primary care networks (PCNs). “I think one of the opportunities would be to open it up a little more and have the debate.”

I press him a little further on how he thinks the sector’s current challenges might play out. “There are people who want to disrupt the system,” he says. “[They are saying] ‘where are the opportunities if the revenues that we can make out of dispensing are going down, and the margins are being squeezed?’” The former managing director of the company that brought us Pfizer Healthy Partnerships says collaborations are part of the answer.

The right partnerships are the way forward

“You need to form the right partnerships, and we need to convince the Government they need to facilitate that,” he says. “The NHS budget is a zero sum game. OK, it’s growing a little for the next five years, but in the end if you move significant sums of money from pot A to pot B, then there is less money in pot A and more in pot B. Everybody is fighting for their bit.” He thinks there is a growing acceptance of a way forward, which may well include a requirement that pharmacists need to be trained to a certain standard to be involved. 

“I think patients would welcome more options. If you go to other countries, including some of those where I have worked, like Greece, community pharmacy is still the centre of the community. People really trust their pharmacists, and they are more likely to have a discussion with them. The more you involve pharmacists, the more you will relieve the burden for GPs. The better you do that, the less likely you will see people going into hospital.” 

You need to form the right partnerships, and we need to convince the Government they need to facilitate that

It’s early days for Upjohn in the UK. “In the therapeutic areas where we are active, we are thinking about partnerships in the adherence space,” Erik says. “Adherence partnerships can require very different types of players: technology companies with wearable devices, pharmacy players on both education and monitoring, primary care networks, and integrated care systems [ICSs].” Some initial partnerships have attracted publicity. “We have a partnership in Swansea with the University and with the NHS to think about some innovative ways in which we can pilot a change of treatment pathway.”

But with maybe a thousand PCNs likely across England, I suggest that’s quite a challenge. He agrees. “Scalability is always the challenge. The only discussions we have at the moment is to pilot certain concepts, but always with a view ‘if you were to scale them, what would this look like?’. PCNs are very decentralised, but they will probably be representing primary care in an ICS, so it is by partnering with them in a particular ICS that you are going to make the whole thing work. That’s where we are aiming.”  

As in so many conversations about system change that are happening now, ‘trust’ is a key ingredient. “If you are going to create something like this, I think the key is to say, ‘what is the shared vision we all have here?’. If you can do that in a PCN on an equal footing, you create the trust to say, ‘how are we going to do this together?’. The bit that is missing for me is how community pharmacy plays a role in an ICS, because all that is described in the 10 year plan is how the PCNs are going to perform, and how they are going to represent primary care in the ICS. There is no description as to how community pharmacy is allowed to play a role in that.” 

Trust building was vital to the success Erik and his colleagues at the Association of the British Pharmaceutical Industry (ABPI) have had in the negotiation that led to the creation of the new voluntary arrangements for medicines pricing, agreed last December and covering the next five years. On the face of it, a five year agreement which caps the growth of total sales to the NHS to 2 per cent per annum over five years is a great deal for the NHS, but Erik says that the industry achieved a number of its longer terms goals too; the deal was not just about pricing.

“The first challenge was that the relationship we had between the industry and the NHS needed to change from one that was transactional to one that was more one of dialogue and trust,” he explains. “The reason: we really need each other. The industry needs the NHS, for the simple reason that if our medicines don’t get used by patients who need them, it’s more difficult for us. The NHS I believe also needs us, and I believe not only the pharmaceutical industry but other producers of transformative technologies, to keep improving in the way it delivers healthcare and the way it improves productivity.”

Trusted relationships take time to build

“For that we need earlier and deeper collaboration and coordination, to bring new innovative medicines into the health system, and once they are in the system, to make sure they are optimally used, especially for chronic disease and long term conditions, because clearly that’s where most of the health burden is. For that you need a trusted relationship, and that takes time to build.”

Given the repeated assertions of pharmacy leaders and negotiators that their priority has been rebuilding relationships, and with Erik’s experience of working in different countries, I’m interested in what he says next. “The relationship here was an exchange of positions, of messages to each other,” he says. “That’s quite formal, instead of having a dialogue around issues, in informal and formal settings, and to really explore mutual gain positions. From my experience, where that happens in the right way, both benefit.”

There’s a sting in the tail. “That’s how you create trust, but obviously that trust can very quickly disappear again if either party betrays it. In the world we live in today, where so much depends on really good collaboration, and good networks between the various stakeholders that need to work together to achieve mutual goals, that’s really a key component of success.” 

So, to the detail of what that dialogue achieved. “The industry views the new VPAS scheme as a success for a couple of reasons. One, it’s very broad ranging – we changed the name (from the Pharmaceutical Price Regulation Scheme, PPRS), because it includes arrangements on access and uptake. Second, the NHS (England in particular) was at the table. They are part of the agreement, so they are also committed to making it a success. If we are going to make a commitment to capping growth to a certain extent, what we want back is that all parties commit to all elements of the scheme. The health system benefits because they have predictability, and UK plc benefits because it’s good for the life sciences sector as well.” Erik says the discussion was conducted with mutual respect. Neither side felt the need to escalate to a higher level at any point. 

Community pharmacy needs to do more to insert itself into the discussions in the Department of Health and the higher layers of the NHS

I suggest you could draw a direct parallel to the current negotiations between the Department of Health, the NHS and the Pharmaceutical Services Negotiating Committee, with the DHSC interested in the money, and the NHS interested in the service, and more particularly the outcomes for patients. 

“You are right to draw the parallel,” Erik says. “The big need the health system has, is to make sure that integrated care, and particularly in the primary care setting, works well. For that, they need to make use of all the stakeholders in the system. The role pharmacy plays could be much bigger; it needs to be more integrated into that primary care network. I know there is a negotiation going on that needs to take that into account.”

Long term benefits can be more significant than headlines

While the price capping in the VPAS caught the headlines, it’s the other parts of the package Erik suggests are more significant in creating long- term benefit. “Compared to three years ago, we now have many more forums where we’re in discussion together. It has already done a lot to a create a different type of relationship, a trusted relationship, a good foundation for the future.” He says the Access Collaborative – “a runway for innovative medicines into the NHS, with an evaluation cycle for how we can improve over time” – has been expanded. The Life Science Council, the Life Science Strategy Implementation Board, the Patient Access Medicines Partnership are all now part of a new dialogue. And all facets of VPAS are subject to regular monitoring in a formal sit down between the parties. 

So, having survived a hectic year – we don’t even talk about Brexit, which must have consumed many hours of Erik’s year as ABPI president (he stood down in April) – what advice does he have for community pharmacy? 

“Community pharmacy needs to do more to insert itself into the discussions in the Department of Health and the higher layers of the NHS,” he says. “The dialogue in terms of the policy agenda at a senior level needs to happen more regularly. As somebody who has been working on innovation policy for some time, I would say that’s missing. Maybe it’s there and I just haven’t seen it enough – that’s possible – but I think more needs to happen. At the moment, when I look at where the funding is going, it is not necessarily including pharmacy.” He adds that there is always a lag between policy shaping and implementation. “What the pharmacy contract is going to be about is being shaped two or three years earlier, so if you are not in those discussions…”

That gap has consequences. “I think we are missing a trick. There’s a lot of capacity that can be utilised. I’m not saying that people won’t do things online, but people like talking to people; there will always be a role for that.” Erik says it’s better to embrace change as the way to get more of what pharmacy wants, while getting the enabling factors sorted out along the way. “I know change is difficult, but there are many disruptors, so embrace what technology has to offer, what different players have to offer, and be open to new partnerships.”

He says the company is ready. “Upjohn is a new division within Pfizer, but it’s set up as a start up to say: ‘How are you going to play a leading role in the management of non-communicable diseases and long term conditions? How can we treat patients better, improve adherence?’,” he says. “In the past every company like us would say ‘how do we improve adherence to benefit my medicine?’. We want to step away from that. Let’s see where innovative ways of doing that in new partnerships takes us. 

“It’s about making sure you manage diseases in a different way. It doesn’t stop with diagnosing a disease; how do you make sure people manage over a period of 20 years when adherence to their medication is important? How do you manage polypharmacy, for example? How do you take advantage of new technology, like wearables? When you look at diabetes, that is now 10 per cent of the cost of the NHS.”

Erik says that while the goal is improving the way diseases are managed, there’s no point being prescriptive at this stage about how you get there. “That’s very open-ended. I’m not saying it needs to go in direction A or B.” First step: building new trusted relationships with the key players. “It doesn’t mean we don’t have any relationships right now, because clearly we do, but we need to have more, and we need to have different ones.” 

He’s keen to test things out. “We need to start doing; it’s better to start testing some of these concepts, taking a therapeutic area, developing something that has all the stakeholders on board, industry stakeholders, technology ones, integrated care systems, pharmacy players – a coalition of the willing if you like – to see what those solutions could look like. There are a lot of people in the NHS now willing to collaborate to try things out. I think the time is right to make it happen. Show it can be done, and do it. 

“Anyone who wants to talk to us – get on the phone or drop me a mail.” 

 

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