Hospital–pharma clinic partnerships: a bridge too far?

Some healthcare professionals may see the idea of ‘joint working’ between NHS Trusts and pharmaceutical companies as anathema – a bridge too far in the direction of private interests perhaps? However, when the needs of patients, the health system and the company are aligned, it can bring significant benefits for everyone.

At the Leeds Teaching Hospitals NHS Trust (LTHT), we have recently entered into a joint working partnership with Boehringer Ingelheim.¹ This arrangement is helping us to develop a patient-centred clinic specifically focused on reducing cardiovascular (CV) risk in individuals with diabetes recently discharged from LTHT following a myocardial infarction (MI). Initiated in September 2021, the clinic is run jointly by the cardiology department at Leeds General Infirmary and the diabetes services at the Trust. It is shared funded by the Trust and by Boehringer Ingelheim.

Meeting patient needs

Previously, individuals with CV disease and type 2 diabetes in our area were treated by two separate specialty teams. However, it is now well-established that there is significant interplay between CV and metabolic disease, as well as renal disorders.^2,3 Thus, we have come to believe that the management of complex post-MI Cardio–Renal–Metabolic or ‘CaReMe’ cases requires a more holistic care model. In this way, we can ensure that patients gain easy access to all required risk and medicine optimisation, and other forms of care, in line with current treatment guidelines, and individually tailored to their personal circumstances.

Our CaReMe service is built around a pharmacist-led clinic scheduled for six to eight weeks after the patient’s MI. Eligible individuals are first triaged by our advanced cardiology pharmacists, then sent a newly modified version of our ‘MYMEDS’, a self-reporting tool for assessing current secondary prevention medicines (SPMs), practical concerns and (modifiable) adherence barriers; this tool was developed from the broader MYMEDS questionnaire that we have used for many years with post-MI patients regardless of diabetes status.⁴ The ‘MYMEDS-Diabetes’ questionnaire includes exploration of diabetes medicines, knowledge about risk factors and diabetes distress, as well as other elements related to providing CaReMe consultation. We use the information gained from the pre-clinic MYMEDS-Diabetes as the baseline for a comprehensive, virtual or in-person, patient-centred review of their CV, diabetes and renal management needs. This includes:

• Analysis of key risk factors/markers, e.g. cholesterol, blood pressure, glycosylated haemoglobin (HbA_1c), urine albumin:creatinine ratio, estimated glomerular filtration rate (eGFR)
• Post-MI secondary prevention, e.g. antithrombotics, antihypertensives, lipid-lowering treatments, etc.
• Diabetes management, including lifestyle advice and medicines prescription
• Other relevant comorbidities.

The clinic is a ‘one-stop shop’ for these highly comorbid individuals. Although run primarily by a consultant pharmacist and, in the future, by advanced cardiology pharmacists, patients have access to consultant cardiologists and diabetologists, when required. Dietary and weight management support is also available, so it is truly multi-disciplinary.

The model aligns with the comprehensive guidance on medicines optimisation from the National Institute for Health and Care Excellence (NICE), which highlights the centrality of a holistic patient-centred approach when delivering medicines optimisation, led by a pharmacist within their specialty.⁵ However, the focus of the clinic goes well beyond medicines optimisation, with the aim of fostering healthy behaviours and building adherence to both better lifestyle modifications and medicines. Action plans are developed in collaboration with patients and shared with their wider care teams.

A clinic model that works

We have extensive experience of delivering pharmacist-led, multi-disciplinary CV clinics at LTHT.^6,7 Indeed, the specialist CaReMe service was developed from our original, ‘all comers’ post-MI service, which has been operating successfully since 2015.⁶ That clinic has led to reduced waiting times from discharge to first outpatient cardiology review, enhanced SPM optimisation, and significant reductions in rates of non-adherence to SPMs of 43–71% at three to six months post-clinic; patient satisfaction with the model is high.⁶ Furthermore, the pharmacist-led approach has freed up cardiology outpatient clinic space and created more capacity.

Then, in February 2017, we initiated a centralised, pharmacist-led proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) and lipids management clinic to help improve the usage of novel medicines and provide tailored support for lipids optimisation. This service has yielded significant improvements in cholesterol levels, has been well received by patients, and is considered cost-effective by service commissioners.⁷

Benefits of joint working

The proof-of-concept phase of our original (2015) post-MI service development programme was partly funded by AstraZeneca within a joint working framework. The success of that phase led to the clinic being fully commissioned by the Leeds Clinical Commissioning Groups, and it has subsequently become the standard service offered to patients with MI in Leeds. Given our previous success with joint working, it felt natural to do so again with the CaReMe service. Although only recently initiated, the clinic has already begun to identify important adherence barriers and concerns. Early outcomes and patient feedback are promising – and we intend to collect and publish complete data in the future.

It should be noted that ‘joint working’ is not a catch-all term for any form of pharmaceutical involvement in National Health Service (NHS) funding. It is instead a specific type of collaboration defined by the Department of Health and Social Care as: “Situations where, for the benefit of patients, NHS and industry organisations pool skills, experience and/or resources for the joint development and implementation of patient-centred projects and share a commitment to successful delivery”.⁸ The main beneficiary must always be patients.

For us at LTHT, joint working is facilitating redesign of the care pathway. However, there are many other ways in which this type of model can be deployed – for example in increasing the treatment capacity of the system, identifying uncontrolled patients, economic analysis, or generating patient experience data.⁹ Joint working arrangements must always be non-promotional, and ideally should be underpinned by a written agreement outlining clear milestones, the ’exit strategy’, and methods for measuring outcomes, so that successful programmes can be replicated and scaled across the country when appropriate.⁹

Apart from our own experiences, other recent, successful joint working collaborations have included:

• A project in the West of England aimed at stroke prevention in individuals with atrial fibrillation through improved medicines management in primary care, which has successfully reduced the number of strokes and yielded significant cost savings
• The ‘All Wales Haematological Malignancy Data Solution’, capturing real-world evidence for improving patient outcomes in myeloma
• A programme in London attempting to improve the detection and treatment of heart failure and educate patients on home management of their condition.⁹

Conclusion

Joint working between the NHS and pharma can bring significant benefits, most importantly for patients – for example, fewer hospital appointments, better information and/or a better experience of the healthcare system. There can also be important advantages for the NHS (e.g. higher-quality care configured around patient needs, improved health outcomes, and better use of resources) and for the pharma company (e.g. increased appropriate use of medicines aligned with guidelines, and improved internal understanding of the challenges facing the health system).⁹

Thus, used appropriately, joint working can be a win–win–win. Our experience of hospital–pharma partnerships to develop novel clinics is leading to improved care. Rather than a bridge too far, these collaborations have instead been a bridge to better healthcare provision.

Conflicts of interest

The author is the lead for both the Boehringer Ingelheim and AstraZeneca joint working projects.

Funding

The project is funded by both the Leeds Teaching Hospitals NHS Trust and Boehringer Ingelheim as part of a joint working arrangement.

Acknowledgements

Thanks to Professor Steve Wheatcroft and Professor Ramzi Ajjan of Leeds Teaching Hospitals and LICAMM, University of Leeds, for their support in this project.

References

1. Leeds Teaching Hospitals Trust. Dedicated Leeds clinic for patients with type 2 diabetes who have been admitted to hospital with a heart attack. Available at: https://hubpublishing.co.uk/dedicated-leeds-clinic-for-patients-with-type-2-diabetes-who-have-been-admitted-to-hospital-with-a-heart-attack [accessed 27 June 2022].

2. Mata-Cases M, Franch-Nadal J, Real J, Cedenilla M, Mauricio D. Prevalence and coprevalence of chronic comorbid conditions in patients with type 2 diabetes in Catalonia: a population-based cross-sectional study. BMJ Open 2019;9:e031281. https://doi.org/10.1136/bmjopen-2019-031281

3. Kenny HC, Abel ED. Heart failure in type 2 diabetes mellitus. Circ Res 2019;124:121–41. https://doi.org/10.1161/CIRCRESAHA.118.311371

4. Khatib R, Patel N, Hall AS. The my experience of taking medicines (MYMEDS) questionnaire for assessing medicines adherence barriers in post-myocardial infarction patients: development and utility. BMC Cardiovasc Disord 2020;20:46. https://doi.org/10.1186/s12872-020-01362-y

5. National Institute for Health and Care Excellence. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. NG5. London: NICE, 2015. Available from: https://www.nice.org.uk/guidance/ng5

6. Khatib R, Patel N, Laverty U et al. Re-engineering the post-myocardial infarction medicines optimisation pathway: a retrospective analysis of a joint consultant pharmacist and cardiologist clinic model. Open Heart 2018;5:e000921. https://doi.org/10.1136/openhrt-2018-000921

7. Khatib R, Khan M, Barrowcliff A et al. Innovative, centralised, multidisciplinary medicines optimisation clinic for PCSK9 inhibitors. Open Heart 2022;9:e001931. https://doi.org/10.1136/openhrt-2021-001931

8. Department of Health and Social Care. Moving beyond sponsorship: joint working between the NHS and pharmaceutical industry. London: DoH, 2010. Available from: https://www.networks.nhs.uk/nhs-networks/joint-working-nhs-pharmaceutical/documents/joint%20working%20toolkit%20dh.abpi.pdf

9. Association of the British Pharmaceutical Industry. Joint working. A toolkit for industry and the NHS. London: ABPI, September 2019. Available from: https://www.abpi.org.uk/publications/joint-working