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BigPharma and the NHS

Up to Additional Mental Health Information
December 05. 2011
Theresa Eynon

David Cameron’s latest Big Idea is that the NHS should let the pharmaceutical companies in to mine its vast database of patient information. Those on the left of the current government are asking if it is naive, stupid or merely greedy?

Those on the right see a different picture. The NHS rivals Scandinavia in the extent and quality of its outcome-related data. Information is a commodity. Selling it to BigPharma is another strategy for getting this country out of its economic mess. Drugs which are proved to be effective in the NHS would command a higher price on the world stage. UK-PLC could make a tidy profit selling that information

Those of us who care more about effectiveness (does it work in practice) than efficacy (does it work in a clinical trial) see the NHS wasting its data resources and failing patients by doing so. Service user and carer groups want us to ‘Stop doing things that don’t work’. It says so in Leicestershire’s Mental Health Charter. We can’t exactly accede to that request without some reliable data at the individual case level.

One of the problems the NHS has with effectiveness data is defensiveness. Nobody likes to be told they’re not doing a good job. So when service users and carers complain there is a tendency to try to justify our approach, prove we are coming up to standards and, seen from a service user perspective, fob them off.

I have recently had to witness the unedifying spectacle of a public health consultant in conversation with Action Deafness. The latter are, rightly, concerned that British Sign Language speakers find it difficult to have psychological therapies in their own language. Action Deafness have a cohort of BSL speaking counsellors. They’d like a tie-in with the NHS IAPT service. What a good idea.

Watching my colleague tie himself in knots – some of which included suggesting that it was up to individual GPs to source a therapy in BSL, hence my involvement – was most depressing. The bottom line, I am afraid, was the need to ensure that Action Deafness did not go away with the message that services for their community are not good enough.

Oh dear. How can we ever improve unless ‘every defect is a treasure?’ If we are going to make things better in the NHS we first have to be able to admit they could be better.

So, back to Cameron, BigPharma and the NHS. What do BigPharma want? To sell more drugs. How can they do that? By proving their drugs work in real clinical practice.

And that is where, for caring clinicians, there could be a tie-in.  If they are careful.

And more care really will be needed. While the NHS has been trying to reformulate its approach to clinical commissioning, some of the big questions for mental health have been put on the back burner by the CCGs. They are so busy working out how they are going to manage the big General Foundation Trusts that the issue of Payment by Results (PbR) in mental health has totally passed many of them by.

Meanwhile, those with a vested interest in controlling care pathways have been very busy. Our local mental health FT has, since the PCT dismantled the GP-led Mental Health Clinical Forum, been happily drawing up its own care pathways and payscales with no primary care input whatsoever.

Janssen-Cilag are being helpful to GPs. They have teamed up with the NHS Confederation and created a Yammer site for them. They have put out a very nice summary of the NHS Operating Framework.

But not all relationships are so rosy. The manufacturers of atomoxetine Eli Lilly were so pro-active in improving the care pathway for Adult ADHD that some clinicians have accused them of creating a disease entity in order to make a profit from it (Moncrieff J., Timimi S.2011).

I am glad to say, not all BigPharma-clinician relationships are so fraught. Here in Leicestershire, Lundbeck put on an excellent educational evening. Yes, they want escitalopram on the PCTs list of best choices for depression. But in order to persuade us, they brought along two excellent and independent minded speakers. Celia Feetam’s explanation of the basic pharmacology of enantiomers and the efficacy and effectiveness of a range of antidepressants, was the best lecture I have been to in a long time. David Nutt’s understanding of the neurobiological underpinnings of anxiety and depression reminded me just how much I love neuroscience.

What is more, by the end of the evening, we were all happily agreeing that a good IAPT service with a 50% recovery rate was the best first-line treatment for anxiety and depression. Which is why Lundbeck, bless their cotton-socks, are supporting the CBT training we give to GPs. They know that, if we get the care pathways right, good drugs will make more money because good drugs can be shown to work in clinical practice.

I can see, at the level of the individual patient and their clinician, that, carefully done, improved relationships with BigPharma could work. But with one big caveat. ‘When you sup with devil, you need a long spoon’.

 If CCGs think they can play this game without well-informed clinical representation, then they are the ones being naive, stupid or just plain greedy.

 

References

Moncrieff J., Timimi S. (2011) Critical analysis of the concept of adult attention-deficit hyperactivity disorder. The Psychiatrist 35, 334-338  doi: 10.1192/pb.bp110.033423

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