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Editor's blog Monday 8 November 2010: Wellards conference quotes - White Paper reforms, NICE work and known unknowns

Last Wednesday saw the third Wellards annual conference. I went along.

It's an interesting event: Wellards provide information on the NHS, targeted at the pharmaceutical industry - and COI declaration: I do bits and pieces of consultancy and editorial work for them.

At last year's conference, DH primary care czar Dr David Colin-Thome made his infamous remark that "the corpse (of GP practice-based commissioning) is not for resuscitation".

That was, you may recall, during the time when the DH was still desperately trying to pretend that the policy of PBC was not a Norwegian Blue. Colin-Thome's candour amounted to quite a decent bit of news.

There wasn't quite anything of that magnitude dropped this year, but a lot of Rather Interesting Things were articulated.

Conference co-chair Professor Kieran Walshe of Manchester Business School
"The White Paper represents a return to the days of ideology – decentralised, market-based, driven by competition”

Nigel Edwards, acting chief executive, NHS Confederation
"The White Paper is more radical than it appears; it disrupts power and accountability radically, especially regionally, and it completely shifts power and accountability”.

"Having all NHS providers becoming foundation trusts is the state saying, ‘we no longer want to be involved in the detail of healthcare provision’.”

"Andrew Lansley seems to significantly under-estimate how difficult outcome measurement is – much work is needed to collect and present this data in a way that is clinically ‘edible’.”

The White Paper is very detail-light ... on accountabillity, When a rationing decision is taken to deny a certain treatment, to whom can the denied patient complain? The logic of lobbying one’s MP will disappear".

"We lack clarity on what will happen when one of the new GP commissioning consortia fails. It is unclear that developing risk reserves in the system is efficient or effective; yet when similar financial decentralisation happened in education, schools set up lots of reserves".

"It's not clear whether the accountable officer job in the new consortia is going to be one that's really worth losing".

"Many politicians underestimate the management challenge of major change".

Dr Peter Brambleby, joint director of public health for NHS Croydon and Croydon Council
"The NHS has a strong tendency towards 'deficit attention disorder'. Rational rationing has been incomplete, unequally delivered and not reduced inequalities. The current correction is long-overdue, and will be good for the NHS if it forces efficiency - not just technically but allocatively, which means doing the right thins to maximise public resource”.

"The Prime Ministership of Margaret Thatcher did the most to force the NHS to focus on evidence-based healthcare: not just on ‘does this work?’ but ‘which intervention gives us the biggest return on investment?’ Now we must confront the reality of scarcity, the question for the NHS is, how to thrive?"

"“the change coming is a matter neither of epidemiology nor of health economics; but rather one of psychology – moving away from thinking about funding cuts or lost anticipated increase, towards thinking ‘what health improvement do we want to buy with the money available?’."

Dr Richard Barker, director general, Association of the British Pharmaceutical Industry
"This period represents a watershed in the healthcare environment: a collision of supply and demand driving up costs as far as the eye can see. The mentioned £15-20 billion gap between now and 2015 is not just the result of financial crisis; it’s the beginning of rest of our lives, in the gap between the healthcare we’d like the system to deliver and what we believe we can afford”.

“Outcome-based value will be the key lever of transforming healthcare productivity. This means not wasting 30-40% of pharmaceutical products on patients whose genetics mean they will not respond to the drugs. The industry is not exempt, and we might be first up on this. So we need to think differently about our products and measurable outcomes in clinical and economy and be able to make a return-on-investment case in front of customers”.

"Value-based pricing (VBP) is the quid pro quo for Health Secretary Andrew Lansley’s repeated statement that 'I don’t want to manage the medicines bill' ... Potentially, VBP could see a move away from UK price being that of reference for Europe. The move also re-casts NICE as an adviser; not a decision-maker. In my view, VBP is thoroughly logical but it’s not a magic bullet. It will release the NHS from arbitary decisions on medicines bill release the industry from an arbitrary profit cap".

"The government rather rushed into the cancer drugs fund"

"The industry’s willing to see prices reflecting value, but probably only on new medicines. There’s an unrealistic view of government that many prices will fall: I don’t think we know”.

"NICE must:
- broaden its value parameters
- agree in advance the clinical trial requirements to demonstrate good value
- accept new drugs present inexact science at launch by defining value range
- speed up its appraisal-appeal-reappeal process
- leave reimbursement negotiation to the DH
- focus its resources on clinical best practice vs. health technology appraisal (HTA)"

"The new proposals present fresh access problems:
- for government and NICE – how can they say no?
- for the industry - how to implement the cancer drugs fund in a rational, forward-looking way, without the risk of a race to the bottom for a share of the £200 miilion
- for NHS commissioners – what notice will they get of any need to pay to new drugs in time of economic constraint unless approval offers a clear 'yes' and price?"

Sir Andrew Dillon, chief executive, National Institute for Health and Clinical Excellence
"Predictions of NICE ‘blight’ as a barrier, dampener or deterrent to life sciences industry have proven incorrect: the UK leads France, Germany and Sweden in direct foreign investment in new pharma projects. This proves that NICE is part of promoting the UK as a place for the industry  to do business in a rational way"

"Whether the White Paper reforms will work will depend on the wisdom and enthusiasm of GPs"

"The control exercised by the DH has ebbed and flowed through the decades, and it’s not obvious which is better as between tighter or looser control. The NHS, like any organisation, needs to be managed: to understand its goals and expectations. However federal the structure may be, it remains a national health service. Those in power, who are responsible to us for the NHS, need to give us faith that what they want it to do can be achieved".

"“don’t write off central control”.

"We have to be cautious about the notion that quality saves money: improving and extending the system is going to cost us money”.

Sophia Christie, director of alignment and coordination, Department of Health
"We struggle as an NHS to work collaboratively with the pharma industry and other partners. The NHS has (with a lot of practice) become slick at internal change management, but 90% of organisations don’t do cross-boundary change management, and instead try to solve system problems by internal redesign. But patients experiences whole systems".

"How will we really get into challenging variation in activity and outcomes when opening up and diversifying the commissioning role? There’s a real danger that by shifting it to GPs, we let people off the hook who should actually be  held to account for their own historical poor practice”.

(Asked about the official statements that no money is going to be available to incentivise commissioning)"I'm not sure about that ... we’re in the process of understanding the financial incentives in the new system; they’re not yet clear. Many GPs I work with are looking to see what’s going to be the business model for their getting involved in commissioning.

“We’ll need to have incentives for GPs to use different approaches in future if we want real change. There are always about 20% of GP practices who will step out and do the right thing, regardless of their financial interests. The other 80% are small businessmen, asking ‘what’s the business model, how do I  incentivise my time?’ There have to be incentives to make it worth practices’ while to engage”.

Mark Jennings, director of healthcare improvement, Kings Fund
"The NHS will get 0.087% real-terms increase per annum to 2014-15, which is about nothing, it’s met the manifesto commitment of real-terms growth, but only just”.

"This is being seen as a financial cut, when it is actually an opportunity to improve NHS quality".

"We think reorganising the NHS is a sideshow".