In the hands of drug giants

Is the 'Disease Management Package' the answer to total health care? Rita Carter investigates

Two years ago, the Department of Health warned National Health Service providers to beware of pharmaceutical companies bearing the ultimate gifts - "Disease Management Packages" (DMPs), which promise to provide whole categories of patients with everything from diagnosis to post-operative nursing. Now the department is about to give the go-ahead, albeit a cautious one, for trusts and health authorities to join the drug giants in developing such schemes. Supporters see it as paving the way to cheaper, more efficient health care. Critics fear it could result in patients being treated as profit-making units in some monstrous McHealthburger dispensing machine.

Limited sponsorship is already common within the NHS but DMPs go much further than anything seen so far. An ambitious package may entail a 20- year commitment from a private sponsor to give total care to every NHS patient in a given area with a particular disease. A drug company may pay for building and equipping a clinic, developing treatment protocols (including selection of patients) and clinical and support staff.

The NHS provider, in return, may give the sponsor the sole right to supply drugs, and allow preferential use of its products. If the disease or condition is widespread, chronic and involves straightforward drug-centred treatment, these provisions alone may be enough to make a DMP profitable. If it also provides the sponsor with a database of NHS patients - a useful marketing and research tool - there is a bonus. And if the disease can properly be treated mainly by using the company's own drugs, the DMP could be a major money-spinner.

Most major pharmaceutical companies are currently sizing up the prospects for DMPs in therapeutic areas where their products are already widely used. Their plans are likely to gather impetus when, in a few weeks' time, the DoH publishes a draft framework for DMPs in what a department spokesman described as a spirit of "benevolent neutrality". The framework will suggest that any DMP must:

safeguard the individual clinicians' freedom to prescribe

safeguard patient confidentiality

not compromise the integrity of NHS staff

provide benefit for patients as well as the providers

give good value for money

be in keeping with the general principles of the NHS.

If all these provisions could be guaranteed, it is difficult to imagine that even the fiercest critic of privatisation could object to DMPs, given that in most cases the immediate effect of setting one up would be to release a small fortune for use elsewhere in the NHS. But will theoretical boundaries hold firm in practice?

The experience of nurses working in stoma care - the therapeutic area where existing sponsorship is most widely established - suggest they may not. Patricia Black, a senior stoma care specialist with Hillingdon Health Authority, believes the corporate funding which currently pays for about one-third of stoma care nursing has compromised the service badly.

"Private sponsorship started in stoma care because we were seen - correctly - as a soft target." she says. "The stoma equipment manufacturers came to the NHS offering packages worth pounds 20,000 and pounds 30,000 - wonderful. But in the long run many of these deals haven't saved money at all because they have led to far higher equipment bills.

"Green young company-sponsored nurses are persuaded to order extras like deodorants, and the sponsor makes sure they prescribe the company's own products rather than rivals'. Sponsors have even encouraged the patients themselves to order more equipment by giving them inducements to send in extra prescriptions. Catalogue stamps for things like lawn mowers was one.

"In one area, GPs complained their prescription costs for stoma equipment increased by 200 per cent in a single year when sponsored nurses came in."

Stoma care nurse Janet Griffin, who left the NHS last week after working in a sponsored post for three years, says she was aware of commercial pressures from day one.

"The company came and told me I would have to show my patients their products before any others. I flatly refused because at that time my sponsor's products were not right for most of my patients. A year or so later the range was changed and I was happy after that to prescribe them. If that hadn't happened I think my sponsor may well have withdrawn.

"It wouldn't have mattered much to me because I was never totally dependent on the work. But many sponsored nurses are - you can't expect them to refuse to co-operate with the people who are paying their wages."

In theory none of this should have happened. All nurse sponsorship is meant to be run according to guidelines, produced by the Royal College of Nursing, which are similar in spirit to those now proposed by the DoH for DMPs. "In practice," says Patricia Black, "the guidelines are walked through time after time. The ostomy companies treat them with disdain - and so do many of the trusts."

The RCN itself is "guardedly welcoming" of DMPs - but it is acutely aware of the potential problems they may bring. "Our main concern is that such schemes should not dole out treatment as though patients are on a factory production line," says RCN community health advisor Sue Thomas. "We need to know what will happen to the patients whose treatment doesn't tie in with the protocols operated by the DMP. What if they develop complications or other diseases? Will the DMP look after someone with Parkinson's disease who gets hypotension as a complication of their illness? Or will these patients find themselves falling between two stools - not having their full needs met by the DMP but not eligible, either, for treatment outside it? And what if a DMP does not prove profitable - how can the NHS be sure the sponsor won't suddenly pull out and leave the patients high and dry?"

The drugs companies protest that such concerns are unfounded. "We believe we have a duty of care over and above simply supplying drugs," says Dr Anna Sorman, health-care relations director at the multinational Rhone- Poulenc Rorer. "We want to help make sure our drugs are used safely and appropriately and cost-effectively, not on a 'one size fits all' basis.

"Nor would we ever seek to influence a physician's prescribing decisions inappropriately. We believe clinical judgement is paramount in patient care."

Mike Wallace , managing director of Schering Health Care, thinks that health authorities and trusts, anyway, would refuse to sign contracts which gave sponsors control over which drugs were used. "You mustn't assume that one party is out to exploit the other," he says.

"Some people seem to think that the big bad drugs companies are out to screw the NHS. In fact we see the possibility of developing partnerships based on mutual trust which work for the patients as much as for the companies."

But can patient welfare and drug company profits ever be reconciled? After all, what patients ultimately want is a cure. Yet a drug company operating a DMP has a vested interest in keeping people sick so they can go on treating them.

"I think that is a very cynical view," says Mike Wallace. "I also believe that it is the reverse of what will actually happen. A good disease management package will provide a database which should greatly improve the chances of both giving improved treatment and finding a cure. Apart from anything else, if the company that is providing the disease management package doesn't come up with a cure, it's for sure that someone else will.

"Any company must think of its profits. But profits will never be the first consideration in a DMP - good treatment will come first."