Fixing the crisis of trust between the NHS and Big Pharma

There is a crisis of trust in the NHS but it isn’t the one you might be thinking of.

Despite a wave of crises, debacles and reorganisations, Ipsos Mori’s trust survey shows doctors topping the polls for the ‘most trusted’ again at a huge 89 per cent (7 per cent higher than 30 years ago). This compares, perhaps unsurprisingly, to just 18 per cent of people who generally trust politicians. Globally, multiple studies have shown that the level of trust in healthcare professionals has remained high and stable over many years.

While trust in healthcare professionals does not equate to trust in “the NHS” − indeed, studies have shown that the public trust healthcare “systems” and doctors in management roles far less than they trust their own doctor − it is clinicians in their care-giving roles that make up the day-to-day experience of patients and their families.

We cannot take this trust for granted but there is an unspoken crisis in trust that needs our immediate attention. It has been around for significantly longer and potentially has a greater impact on the experience of patients and their health outcomes.

The NHS doesn't trust “Big Pharma” and they don’t trust the NHS. Specifically, Big Pharma doesn't trust the NHS's competence and the NHS doesn't trust their character.

It wouldn't make for a great marriage and it doesn't make for a great business partnership. Consequently, patients suffer by not having access to the innovations that would flow from a genuine partnership focused on delivering quality, innovation, productivity and prevention.

Going to extremes

How to build trust is the subject of Don Peppers and Martha Rogers’ book Extreme Trust. Central to their theory is that the very nature of trust is changing. The level of information available in this increasingly interconnected age means that being trustworthy is no longer sufficient. Peppers and Rogers have coined a new term: “trustability”. This extreme form of trust translates as “proactive trustworthiness”.

Trustworthiness is defined as merely “doing the right thing and doing things right”. Trustability goes one step further and requires the seeking of proactive understanding of the other party’s needs and meeting them. Trustability facilitates collaboration rather than cooperation.

I could explore all the reasons why trust is currently missing but many others have done it far better than I could, including Ben Goldacre in Bad Pharma. The crux is this:

• The NHS believes Big Pharma is dominated by a short term profit focus and that this clouds all other considerations.
• Pharmaceutical companies believe the NHS does not fully appreciate the value of its products (created through massive investment), caused by a cultural unwillingness and structural inability to focus on anything other than price.
• When the NHS does appreciate that value, it fails to secure it through poor execution;

Taking just a short leap of faith and assuming that current levels of trust are low and that high levels of trust would be beneficial, what do we do about it? Peppers and Rogers set out a three-stage process:

• do the right things;
• do things right; and
• do them proactively.

Do the right things

Doing the right things is about finding a way to align objectives. It is about intent. We clearly intend to have a positive impact on the health of the populations we serve. What needs to be adjusted is the intent we have when working with potential partner organisations, including Big Pharma.

Stephen Covey sets out in his book The Seven Habits of Highly Effective People a way to re-examine our intent. He explains that what we see affects what we do, which in turn affects what we get. In other words, how we choose to view the world affects how we behave, which naturally affects the behaviour of others towards us.

If we keep seeing Big Pharma as a poorly intentioned monolith, we will continue to avoid open partnerships. Avoiding open partnerships will mean companies won’t enter partnerships and will continue to make their profits by selling us “things” rather than results.

This will involve a challenging thought exercise. Pretend for just a moment that:

• QIPP gives us a useful framework in which to align objectives.
• It’s OK for Big Pharma to make a reasonable level of profit.
• The industry will only make those profits if their products and services make the lives of patients better and longer.
• Collaboration will make the delivery of QIPP targets more likely and quicker.
• Big Pharma involves individuals who have similar life experiences and values to our own.

The right thing in this “see” context is to design innovative programmes, pathways and pilots that harness the investment power and capability of Big Pharma.

Do things right

Intent is a great starting point but it is nothing without competence. Trust will be built by demonstrating that partnership with the NHS will achieve excellent results. This needs to be not just for one involved party, it must be a win-win for all involved.

In this context, competence is:

• Accurate identification of opportunities where working in partnership delivers additional value for all parties.
• Co-development of plans with an open and explicit identification of where the win-win is
• Clarification of expectations around how commercial arrangements will work;
• excellent project management and execution, drawing on the latest tools and techniques; and
• clear and timely measurement of the impact.

Proactivity is at the heart of trustability. It is one thing to have good intentions and deliver on them competently when required. It is another to proactively seek out benefits for your partner and work in partnership to secure them.

What does this mean in this context? You need to gain a deep, evidence-based understanding of your own organisation and where objectives can only be delivered by collaboration.

Understand the market. More importantly, understand where potential partners are developing new services. Build an understanding of who might be willing to reciprocate your brave move of extending trust.

Do not wait for the sales rep to show up at the door. The battle is no longer to be fought by procurement at the hospital entrance. Go and knock on their door for a change.

Unchained trust

This article is not really about the character or competence of either party but about meeting the huge challenges ahead. The role that genuine collaborations will play in this and the opportunities high-trust relationships can bring cannot be underestimated.

I am not suggesting anything as drastic as a “trust development authority” (who would think of such an organisation?!). Building trust starts with the intentions and behaviours of individuals. We will only change the world one conversation at a time.

Find a safe environment in which you can start to extend trust. Be clear with the other party that you are prepared to take a risk and ask them to reciprocate. Keep your initial bets small and the losses manageable.

Pharmaceuticals is a global business. Investment and attention can shift between continents and away from the UK in the blink of an eye. Likewise, our favourable tax system is attracting US based companies to the UK. Big Pharma is undergoing a huge structural change in the UK to attempt to meet what it believes are the needs of a changing NHS. If we fail to offer the olive branch now, the NHS may regret it.

Extreme Trust contains a wonderful quote from Miss Piggy from The Muppets: “All you need to know about bankers (only 21% of the public trust them to tell the truth!) is that they attach little chains to their ball-point pens”. It is about time we took the chains off our pens and created a ripple effect of trust that will extend beyond our own interactions and organisations.

This is a blog-size, adapted and updated version of a piece originally published in the Health Service Journal (HSJ).