Dice Quarterly 1

Issue. 01

ALEA (Al-ee-ah)

A quarterly perspective on pharma March 2021

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Carefully curated by

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A quarterly perspective on pharma

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CONTRIBUTORS SANDRA LAIRD Director – Medical Education & Market Access ROB WILSON Creative Director SARAH BROOKS Manager – Data Analytics RICHARD RAYMENT Creative Director – Copy NEIL DICKINSON Guest Contributor VITALIY YAVTUKHOVSKYI Studio Services Manager MATTHEW DICKINSON Managing Director WINNIE MCFADZEAN Senior Medical Writer

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EDITOR’S LETTER................................................................... 04

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Welcome to Alea MIND THE GAP....................................................................... 06 Challenging immunisation apathy and misinformation IN CASE YOU MISSED IT....................................................... 09 Celebrating the new Rare Diseases Framework SIMPLE CAMPAIGN IDEAS................................................... 12 Creative campaign ideas that have kept their fizz MEDITRENDS INSIGHTS....................................................... 16 Multiple Sclerosis during the Covid-19 pandemic THE ALEA INTERVIEW........................................................... 21 Meet Dice’s Creative Director, Rob Wilson THE PATIENT WILL SEE YOU NOW..................................... 24 The evolution of the doctor-patient relationship THE POWER OF IMAGERY.................................................... 34 Memorable photos from the past year SCIENCE FOR SCIENCE SAKE............................................... 40 Why science doesn’t always need a “reason” THE DOUBLE-EDGED SWORD OF COVID-19...................... 43 Putting the pandemic in perspective IT TAKES TWO......................................................................... 47 Maximising the client-agency relationship BEHAVIOURAL CHANGE....................................................... 51 Lessons from down under THE SCIENCE OF DEATH....................................................... 55

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Living on borrowed time THE LAST WORD.................................................................... 58 With Matthew Dickinson

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ISSUE 01 – CONTENTS

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EDITOR’S LETTER

Welcome to Alea – a new quarterly that’s a result of our whole team’s collaboration and insight.

At Dice Medical Communications, we’re passionate believers in the pharma industry and the work every one of our clients is doing to improve the lives of people living with an unmet medical need. We play our small part by helping brands realise the ambitions of the scientists and engineers that created them – and the idea for this publication is to offer some independent and thoughtprovoking opinion to help us all go about our work with renewed enthusiasm.

You may wonder why we are launching Alea in a printed format. Well, you’re reading this, which means it’s cut through the clutter already. We all have enough digital traffic. Our clients are constantly striving to speak to customers in more engaging ways – and in our case it’s no different. This is our effort at reaching clients and partners in a way that’s engaging. It’s also just nice to have something physical to read in a world full of screens.

However, for those who want to engage with the magazine online, there will still be an opportunity to do so. Simply scan each article’s QR code and you’ll be able to share the content with colleagues, or reach out to the authors directly. We want this to encourage discussion.

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Each edition of Alea will offer an array of content from members of the Dice team, as well as occasional contributions from industry big-hitters. However, the last thing we want to do is bombard clients who already spend their days buried in medical reports. For that reason, we’ve made sure to mix it up, combining industry insight and analysis with interviews and imagery that stirs the emotions.

This quarter, we’ve got all bases covered, from challenging anti-vax rhetoric to campaigns that inspired the team. The goal will always be to provide some intellectual stimulation. You may agree or disagree with our thoughts – debate is always welcome. If, in the smallest possible way, we can positively inspire those within our industry, challenge existing thinking and push our sector forwards, then Alea will be a success.

Finally, this is not designed as a news feed of pharma – we all receive those emails on a daily basis. We’d love to have your input, recommendations for articles, or just simply to chat through your challenges and how we can help.

Oh, and why Alea? It’s Latin for a ‘game of chance/dice’, which seems apt on so many levels. Enjoy!

Matthew Dickinson Managing Director matthew@dice-comms.co.uk

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EDITOR’S LETTER

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MIND THE GAP Challenging immunisation apathy and misinformation.

Education is the only way to subdue anti-vax rhetoric, and it must come from the top, writes Sandra Laird.

Vaccination has arguably made a bigger contribution to global health than any other medicine. The eradication of smallpox and polio (in four of six WHO regions) have been significant wins, and many infectious diseases of childhood have been reduced to a shadow of their former selves.

In 2019, 85% of the world’s children received vaccines that would protect them against diphtheria, tetanus and pertussis.

Immunisations currently prevent 2 to 3 million deaths every year.1 Despite this success, more than 1.5 million people worldwide die from vaccine-preventable diseases each year.2

Written by SANDRA LAIRD Director – Medical Education & Market Access

Vaccination has arguably made a bigger contribution to global health than any other medicine.

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Virtually nobody in the UK now knows someone who has died of measles. This inevitably leads to no perceived risk.

OUT OF SIGHT, OUT OF MIND The root case of the ‘immunisation gap’ differs greatly around the world, but I would argue that, in the developed world, the biggest challenges remain apathy and misinformation.

Since a measles vaccine was introduced in the UK in 1968, Public Health England estimates that 20 million measles cases and 4,500 deaths have been averted.3 But who knows and who cares?

There were 1,145 deaths due to measles in England and Wales in 1941. Between 2000 and 2017 there were 14.4 It is, of course, a very small number; but it is 14 deaths that need never have happened, 14 families who lost a child they need not have lost, 14 personal tragedies.

One of the challenges to overcome is the hard fact that virtually nobody in the UK now knows someone who has died of measles. Even fewer have any idea what measles is and how dangerous it can be. No experienced empathy and no

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understanding perhaps inevitably lead to no perceived risk. People don’t fully appreciate that deciding not to vaccinate their child doesn’t just affect them.

AGE-OLD PROBLEM Apathy surrounding vaccination does not just relate to measles vaccination.

Influenza vaccination suffers from the same challenges. Although the UK has one of the highest vaccination rates of the OECD countries, in 2017 only 72.6% of registered patients aged 65 and over were immunised.5 So, why do nearly 30% of individuals at risk from influenza choose not to be vaccinated? Is it because people perceive flu to be an unpleasant, but not serious, illness? Is it because they don’t know that, although this is true for many people, certain people are more likely to develop serious complications of flu, such as bronchitis and pneumonia? Is it because they neither know, nor accept, that people can and do die as a result of flu?

MIND THE GAP

FROM BLASÉ TO BIAS Maybe the Covid-19 pandemic will have changed us. The measles and flu examples are, to my mind, just two examples of the widespread belief that infectious diseases no longer pose a risk to society. We can see this played out during the second and third UK Covid-19 lockdowns. Despite the evidence of high rates of infection, crushing rates of hospitalisation and depressing numbers of deaths, many have flaunted the rules, presumably because they don’t perceive there to be a risk; well, not to them anyway.

So, apathy is a big problem. Lay on top of that the legacy of Andrew Wakefield and the misinformation peddled by the anti-vaxxers, and you have a dangerous mix. Combine the perception that infectious diseases do not pose a risk with the misinformation that vaccines come with a serious risk of adverse effects, and you start to see why we are where we are.

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VACCINE COUNTER-CULTURE

of pharmaceutical companies. Sadly, too many people are suspicious that the industry is responsible for misinformation or think that every piece of communication is designed to hoodwink us.

So, what should we do? There is, without doubt, a pressing public health People don’t perceive there need to educate the UK population on to be a risk; well, not to the risks posed by infectious disease. them anyway.

We need to calculate and communicate RESTORING RESPECT FOR VACCINES the number of lives saved by every The government and Public Health England single vaccine we use. We need to must pick up the mantle and work with industry to transform ensure that everyone knows that they have a role to play, that the landscape. When we emerge from this pandemic, it will have they have a responsibility to society as well as themselves and been with the significant contribution of vaccines. Let’s use the their families. That will help to establish the need for vaccination. pandemic to drive positive change; to educate, influence and My 12-year-old twin boys recently received their first dose of transform the societal view of infectious disease and create HPV vaccine. There was much discussion amongst the school a country-wide network of advocates. Let’s get back to public mums about whether to vaccinate their boys. Some were asking education campaigns focused on educating the public on why boys were being vaccinated at all, some were debating infectious diseases and the pivotal role that vaccination has whether it was “worth it” and one even shared a WhatsApp to play. message saying “I’ve heard they cause infertility in boys”.

Needless to say, I put them right. It shouldn’t be like this. We can’t assume that people know why particular vaccines are on the national immunisation schedule, because quite clearly they don’t.

More needs to be done to address both the absence of Apathy is a big problem. Lay on top of that information and the existence of misinformation. We also need misinformation pedalled by the anti-vaxxers to ensure that every single person knows about the robust process of vaccine development. This is not just the responsibility and you have a dangerous mix.

Reach out to SANDRA LAIRD sandra.laird@dice-comms.co.uk

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1. WHO, https://www.who.int/en/news-room/fact-sheets/detail/immunization-coverage 2. WHO, https://www.who.int/mediacentre/commentaries/vaccine-preventable-diseases/en/ 3. https://vk.ovg.ox.ac.uk/vk/measles#:~:text=Since%20a%20measles%20vaccine%20was,been%20averted%20in%20the%20UK 4. https://www.gov.uk/government/publications/measles-deaths-by-age-group-from-1980-to-2013-ons-data/measles-notifications-and-deaths-in-england-and-wales-1940-to-2013 5.https://www.nuffieldtrust.org.uk/resource/adult-flu-vaccination-coverage#:~:text=In%20England%2C%20flu%20vaccine%20uptake,70.5%25%20in%202016%2D17

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MIND THE GAP

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IN CASE YOU MISSED IT… The government has unveiled a new national framework that marks a positive step forward for the treatment of rare diseases.

Written by MATTHEW DICKINSON Managing Director

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WHAT IS A RARE DISEASE?

At Dice, we work with many clients who specialise in the treatment of rare diseases.

Suffice to say it’s a challenging area to work in, but it’s also incredibly rewarding.

To give it some context, it’s worth going back 20 or 30 years to when most pharma companies were focused on solving largerscale issues such as HIV. While research into HIV treatment continues – with the ultimate goal of finding a cure – the astounding work of scientists and pharma means a lot of wellknown, chronic illnesses are now treatable.

However, that still leaves the 300 million people worldwide who live with a rare disease.

A rare disease is defined as a condition that affects less than 1 in 2,000 people By current estimates, there are over 7,000 rare diseases, but new conditions continue to be identified as research advances.

While rare diseases are individually rare, they are collectively common; approximately 7% of people are affected by a rare disease at some point during their life. In the UK, that equates to about 3.5 million people.

Rare diseases can be both life-limiting and life-threatening, with children disproportionately affected. 75% of rare diseases affect children, and more than 30% of children with a rare disease die before their fifth birthday.

THE CHALLENGE OF TREATING RARE DISEASES A lack of awareness makes rare diseases very difficult for GPs and other clinicians to identify. In some cases, a patient may know more about their disease than a doctor. This typically leads to delayed diagnoses, with GPs referring patients to multiple specialists, and even then there’s no guarantee of a disease being diagnosed.

Thankfully it’s a problem the government has resolved to tackle.

Most notably, it has published the UK Rare Diseases Framework – laying out a clear plan for improving the lives of people living with rare diseases in the UK.

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While there’s still a lot of work to do, this is undoubtedly a positive development in the treatment of rare diseases.

Signed by ministers in England, Wales, Scotland and Northern Ireland, the framework sets four priorities for rare disease care and diagnosis over the next five years: Helping patients get a final diagnosis faster Increasing awareness of rare diseases among healthcare professionals Better coordination of care Improving access to specialist care, treatments and drugs The framework was informed by the National Conversation on Rare Diseases survey, which aimed to identify the major challenges of living and working with rare diseases. It received 6,293 responses, with more than 5,000 from patients, families and patient organisations.

It’s no surprise that technology sits at the heart of the government’s strategy.

As stated in the framework, “Advances in genomics and diagnostic services have allowed us to make significant strides

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towards shortening the diagnostic odyssey for many rare disease patients.

In the future, we expect that new, validated genomics approaches and diagnostic tools will contribute to further improvements in diagnosis and screening, including improved recognition of which patients should undergo advanced genetic testing.”

It also recognises the value of virtual interactions – whether between patients and HCPs or among specialists – when it comes to information sharing and the coordination of care.

A WELCOME STEP FORWARD While there’s still a lot of work to do, this is undoubtedly a positive development in the treatment of rare diseases.

We personally look forward to working with the government and our clients in continuing to raise awareness of conditions that affect millions of people – and in turn, saving lives.

Reach out to MATTHEW DICKINSON matthew@dice-comms.co.uk

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SIMPLE CAMPAIGN IDEAS THAT HAVE KEPT THEIR FIZZ One of the many lessons I’ve learnt over the years is that behind every good campaign there always lies a simple idea. The simpler the idea, the more powerful the campaign.

I’ve singled out three campaigns from the soft drinks market that have been successful in not only producing a memorable ad, but have also gained market share in an extremely competitive market – the true benchmark of a great campaign.

Written by ROB WILSON Creative Director

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ARTICLECAMPAIGN TITLE SIMPLE IDEAS

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A good campaign is one that won’t need constantly reviving after the first execution; it has strength, depth and energy. The idea is the heartbeat, lifeblood and soul of any campaign.

ROB WILSON

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PEPSI COLA: TASTE TEST The Pepsi Challenge undoubtedly made an impact on the cola landscape. In 1975, Coke was already a well-established brand with a sleek marketing machine, and had enjoyed years of unrivalled brand loyalty that generated countless happy customers.

Pepsi was the new kid in town and was looking to get a foothold in the market. A bright exec at Pepsi came up with a bold and brave campaign to do just that. That idea was the Pepsi Challenge.

Pepsi went inside malls around the country and invited people to do a blind taste test between Coke and Pepsi. The results were remarkable; people picked Pepsi over Coke by a significant margin.

Pepsi was only too happy to show the results in a TV campaign, incorporating footage of people picking Pepsi, much to their own surprise.

To view the ad, simply search ‘Pepsi Challenge At Tulane University Commercial (1977)’ on YouTube.

TANGO: YOU’VE BEEN TANGO’D Trevor Robinson OBE was behind this masterpiece. Without the huge marketing budgets of Coke, and with no social media at the time, he realised that Tango had to generate its own momentum. Word of mouth was essentially its media spend.

The campaign features a fat orange genie who runs up and gives the Tango drinker a huge slap on the face. The idea bucked the trend of slick, big

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budget productions around at that time.

This simple idea had kids talking in playgrounds up and down the country, and they lapped it up.

Eventually the slap got a bit out of hand, as doctors complained that kids were ‘Tangoing’ each other at the cost of perforated ear drums. Naturally, it got banned and the fat orange genie had to revert to a kiss. Even with this slight tweak, the success of the campaign never wavered; the controversy possibly even helped it.

You can view this campaign by searching ‘Tango Adverts ‘91-’97’ on YouTube DR PEPPER: ‘WHAT’S THE WORST THAT COULD HAPPEN?’ Who doesn’t like humour, especially when it’s concerning cringeworthy moments for teenagers; such fertile territory for any creative.

Introduced in the 1980s, the ‘What’s the Worst That Could Happen?’ ad campaign was a great success for the soft drink, Dr Pepper. These words were used in a catchy song that helped make the ad memorable and effective.

Dr Pepper knew its brand; it also knew its worldwide audience. The campaign worked particularly well here in the UK, playing on the fact that many UK consumers didn’t know what the drink tasted like and were in many instances suspicious of trying it.

This award-winning creative has been repeated time and time again in different

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guises and is an example of a simple idea having the potential to create some memorable ads such as Mother’s ‘Emergency’.

Take a look by searching ‘Dr Pepper Emergency’ on YouTube.

WHY THESE CAMPAIGNS WORKED I love everything about the delivery of these campaigns for many reasons, but dig a little deeper and you’ll find they all had strong foundations:

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They all had a simple idea central to the campaign.

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They were bold, brave and innovative.

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They were perfectly targeted at their audiences.

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WORD OF THE QUARTER

Don’t be surprised to see these campaigns resurface again in some form; good ideas don’t go flat.

I acknowledge soft drinks aren’t exactly healthy, but what valuable marketing lessons, if any, can pharma brands draw from these campaigns? The answer is plenty; the principles of marketing are still the same.

If you’re the underdog with smaller pockets, be brave, think big, and above all, have a good idea that will transform your brand and live long in the memory.

And in any case, what’s the worst that could happen?

ZOONOTIC (adjective; applied to disease or infection)

Courtesy of WINNIE MCFADZEAN Senior Medical Writer

An infectious disease that has jumped from a non-human animal to humans. Zoonotic pathogens may be bacterial, viral, parasitic or unconventional, and can spread through direct contact, or through food, water or the environment.

Reach out to ROB WILSON rob@dice-comms.co.uk

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“Zoonotic” was a word with little currency outside of microbiology until last year. It aptly describes coronavirus disease and speaks to the origins of the Covid-19 pandemic – a viral disease that originated in animals.

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Covid-19 has made the term notorious. In reality, zoonotic diseases are ubiquitous. Notable examples threatening human health and posing public health problems include:

HIV, malaria, Ebola, dengue fever, salmonellosis, anthrax, Lyme disease, rabies, bird flu.

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MULTIPLE SCLEROSIS DURING THE COVID-19 PANDEMIC Written by SARAH BROOKS Manager – Data Analytics

It’s undeniable that the Covid-19 pandemic has had a significant impact on the treatment of a lot of, if not all long-term and chronic conditions.

Here, we explore the impact that Covid-19 has had on Multiple Sclerosis (MS) activity in the inpatient setting, using Hospital Episode Statistics (HES) data collated in Meditrends, our online real-world data business intelligence platform.

Meditrends provides detailed analysis and interpretation of aggregated and anonymised HES data, helping HCPs and pharmaceutical professionals define, refine and inform healthcare decisions and improve health outcomes.

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HOSPITAL EPISODE STATISTICS (HES) DATA

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Hospital Episode Statistics (HES) is a database containing details of all admissions, A&E attendances and outpatient appointments at NHS hospitals in England. It allows hospitals to be paid for the care they deliver (Payment by Results).

Each HES record contains a wide range of information about an individual patient admitted to an NHS hospital. For example: Clinical information about diagnoses and operations Information about the patient, such as age group, gender and ethnic category Administrative information, such as date of admission and treatment speciality Geographical information on where the patient was treated and the area in which they lived

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PRIMARY INPATIENT ADMISSIONS – PATIENTS WITH A PRIMARY DIAGNOSIS OF MS A primary admission indicates the reason for the admission – the primary diagnosis.

Unfortunately, HES data coding does not allow us to distinguish between the different types of MS – clinically isolated syndrome (CIS), relapsing-remitting MS (RRMS), secondary progressive MS (SPMS) and primary progressive MS (PPMS). However, it does still offer some valuable insights.

As can be seen on the graph below (taken from Meditrends), in January 2020 there were 5,510 primary admissions for MS, which reduced to just 3,200 at the

height of the pandemic and first lockdown in April 2020. There was a slight increase in the number of primary admissions as restrictions following the first lockdown were relaxed; July saw 5,045 primary admissions, but since then the number of patients being admitted with a primary diagnosis for MS reduced again to 4,285 in August and 4,670 in October 2020.

It is worth noting that October’s data will

include incomplete admissions – where a patient was still in hospital at the end of October when the data was submitted.

As shown on the graph on the left and the two graphs below, the number of non-elective admissions for MS is consistently low, pre-pandemic and during the pandemic, so it is mainly day case and elective admissions that have been impacted.

ELECTIVE ADMISSIONS

DAY CASE ADMISSIONS

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INPATIENT ADMISSIONS FOR PATIENTS WITH MS IN ANY DIAGNOSIS POSITION ‘Any diagnosis position’ means that MS was captured as either the primary diagnosis or as one of 20 ‘other’ diagnoses that are recorded for each patient admitted to hospital.

Inpatient admissions for patients with MS in any diagnosis position have been similarly impacted by the Covid-19 pandemic.

We can see from the graph opposite that in January 2020, pre-pandemic, there were 10,435 admissions for patients with MS in any diagnosis position, which reduced dramatically to just 5,390 in April 2020. July saw numbers increase to 8,630 admissions, but in October this had reduced to 7,470 admissions.

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Admission frequency looks at the number of admissions per patient. Whilst we can see from the graph opposite that single admissions are most common, there are a large number of patients being admitted more than once. This is most certainly due to multiple day-case admissions for treatments such as infusions.

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PREVALENCE Prevalence relates to the number of patients (who are still alive) who have had a primary diagnosis of MS in the past five years. To calculate prevalence we use the last five years of data, and prevalence figures stated are cumulative. Note that prevalence is calculated based on inpatient admissions, so if an MS patient has not been admitted, they will not be included in this count.

We can see from the HES data in the opposite graph that prevalence of patients with a primary diagnosis of MS has increased from 13,705 patients in October 2016 to 23,775 patients (cumulative) in October 2020.

MORTALITY Meditrends also shows us that the leading cause of death in admitted patients with a diagnosis of MS in any diagnosis position is ICD10 code G35X, which is the code for MS. ICD10 code U071, which is the emergency code used for Covid-19, is listed as the third highest cause of deaths in the last five years, with 255 deaths attributed to this code.

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Meditrends provides an invaluable resource for any NHS or pharmaceutical professional wishing to understand more about the demographics of their disease area.

IN SUMMARY The ability to see inpatient hospital activity across all diagnoses and procedure codes shows particular therapy areas clearly in the context of the whole NHS – whilst reporting on secondary and primary diagnoses, as well as elective vs planned admissions, gives a true picture of the burden of disease.

Meditrends provides an invaluable resource for any NHS or pharmaceutical professional wishing to understand more about the demographics of their disease area – giving users unparalleled access to anonymised and aggregated HES data.

Without knowing when and how patients present at hospital with a particular condition, efforts at planning for all aspects of your strategic and operational process, for example, often involve guesswork. However, Meditrends can give you invaluable insights that you know are based on reality.

GET IN TOUCH with

SARAH BROOKS To find out more about the impact Covid-19 has had on patients with a diagnosis of multiple sclerosis – or to obtain similar insights relating to your disease or therapy area – please contact Sarah Brooks.

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sarah.brooks@dice-comms.co.uk

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CAN YOU PINPOINT THE MOMENT YOU GOT YOUR CREATIVE ‘SPARK’?

THE ALEA INTERVIEW – with –

YOUR FIRST JOB WAS AS A GRAPHIC DESIGNER FOR SELFRIDGES. HOW DID THAT COME ABOUT AND WHAT WAS THE EXPERIENCE LIKE?

ROB WILSON

Dice’s Creative Director talks Selfridges, skiing and the power of simplicity.

There’s rarely a challenge you can’t solve with creativity.

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I’ve always had a passion for ideas and how things look on a page or screen.

At the age of 10, I’d be in my bedroom drawing logos and improving them. I lost count of how many times I drew the Liverpool crest, trying to perfect it. It gave me a real sense of pride.

I also loved the iconic TV ads of the 80s, such as Guinness, Hamlet Cigars, Carling Black Label and Levi’s. I watched TV for the ad breaks, not the programmes!

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It was a hard job to get because there was a recession when I graduated in the early-1990s. I didn’t even know what a recession was when I was at uni. I just remember struggling to get my foot on the ladder, going up to London for numerous interviews and writing 60 to 70 application letters. I only had an inkling I was getting closer to the Selfridges job when I was whittled down to the last few, and then the last two.

I had three great years working at the flagship store on Oxford Street. The studio was on the roof with amazing views of London, and your work was showcased around the store, so you could see your portfolio wherever you walked.

It also meant I got to work on the Christmas window displays, which were

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I want to create a safe, creative space for everyone to experiment and push the boundaries.

very creative in the early days. We’d work all day and night in the windows the day before launch, and there’d always be a celebrity to open them. However, we usually missed that part as we were so knackered after working through the night. We just wanted to go down the pub!

WHAT IS YOUR CREATIVE VISION FOR DICE? Dice has come from very humble beginnings, and my role as Creative Director is very different now to when I started with just a few people. I don’t want to be the sole creative at Dice. I want to create a safe, creative space for everyone to experiment and push the boundaries. Above all, I want Dice to be renowned for its creative qualities, so people say “I want the Dice treatment”.

WHAT ARE YOUR VALUES AND HOW DO THEY INFORM YOUR CREATIVE DIRECTION?

Rob was fortunate to work on the Christmas window displays for Selfridges.

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I think simplicity is everything. Provided you hit the brief, get the simple things right and keep refining, a good idea has the potential to get even better. From there, successful execution is almost like

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a dance. Every element – from the words and typography to photography and illustration – comes together to create a performance.

Finally, I love what I do. That’s incredibly important to me, as I’m sure it is for other creatives. You can always tell when someone has had fun with a project.

HOW DOES THE CREATIVE CHALLENGE OF HEALTHCARE COMPARE TO OTHER INDUSTRIES? I’ve been fortunate to work in many sectors, but healthcare has been by far the most rewarding. Hearing people’s stories about their health and what it means to do the basic things – go shopping, go to work and things that you and I take for granted. Making a difference to those people is far more rewarding than promoting the latest car and clothes range.

Of course there are plenty of challenges within healthcare, but there’s a good reason for that. Once you understand the regulations, it becomes easier to work within them. In fact, it almost forces you to be more creative. There’s rarely a challenge you can’t solve with creativity.

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I really feel agencies thrive on communicating, brainstorming and getting the best out of people. Losing that suddenly in the first lockdown was the biggest shock.

HOW HAVE YOU SEEN THE PHARMA INDUSTRY CHANGE IN THE TIME YOU’VE BEEN WORKING IN IT? When I first started, iPads were just coming through and weren’t really being used as a sales tool. Over the years, they have become a huge sales tool for reps. Our digital output has increased dramatically over that time, and now with the Covid situation, it has pushed it to a whole new level. We have had to adapt to that as an agency; however, we have always found ways to solve problems digitally, while never forgetting the importance of traditional channels.

HOW DO YOU THINK COVID-19 HAS INFLUENCED PHARMA AND HEALTHCARE MARKETING? HAS IT SHAPED YOUR OWN THINKING AT ALL?

communications with the team has been vital, even if it means more time on Zoom or Skype.

There’s no doubt that digital is king during Covid, but it’s up to us to think of other digital solutions and new experiences. Have we reached a saturation point with these digital executions like video, email and online sales tools? Is there anything else we can do?

HOW HAVE YOU KEPT YOURSELF GROUNDED OVER THE PAST YEAR? I’ve probably had less time on my hands than a lot of people, to be honest.

However, I have enjoyed many runs and long walks with my German Shepherd and played a bit of golf when it’s been possible. I’ve also discovered that a good Fortnite session solves everything.

I really feel agencies thrive on communicating, brainstorming and getting the best out of people. Losing that suddenly in the first lockdown was the biggest shock. Keeping up

WHAT HAVE YOU MISSED THE MOST?

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Skiing. Mountains are the best place ever in my opinion. If there’s one place I could be tomorrow, it’s a mountain. Getting back

to the office will also be amazing, when it’s safe to do so. I can’t wait to be back working face-to-face with people again.

WHAT DO YOU WANT TO ACHIEVE IN THE NEXT FIVE TO TEN YEARS? There’s so much more to achieve with Dice, and I’m looking forward to helping the agency grow, bring on new talent and explore new opportunities for clients. I also want to see more of the world and grow as a human being; learn more, be respectful and have more experiences.

The last year has taught me not to take anything for granted. I’m lucky to live in a reasonably-sized house; my heart goes out to people who can’t get out and have a less fortunate life than me.

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THE PATIENT WILL SEE YOU NOW: THE EVOLUTION OF THE DOCTOR-PATIENT RELATIONSHIP Few relationships are as revered or as important as the one between a doctor and a patient.

Written by RICHARD RAYMENT Creative Director – Copy

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THE ARTICLE PATIENT TITLEWILL SEE YOU NOW

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The importance of an intimate relationship between patient and physician can never be overstated because in most cases an accurate diagnosis, as well as an effective treatment, relies directly on the quality of this relationship.

PROFESSOR TERESA HELLÍN, MASTER IN BIOETHICS AT RAMÓN Y CAJAL HOSPITAL

BENEFICENT PATERNALISM: THE EARLY YEARS OF THE RELATIONSHIP

In the words of Professor Teresa Hellín, Master in Bioethics at Ramón y Cajal Hospital, Alcalá University in Madrid: ‘‘The importance of an intimate relationship between patient and physician can never be overstated because in most cases an accurate diagnosis, as well as an effective treatment, relies directly on the quality of this relationship’’.1 Throughout the ages, the doctor-patient relationship has undergone significant transition. And the way that society has viewed the roles of doctors and patients has changed through history.2 This evolution has been influenced by many factors. In recent times, this change has been driven in the UK by, amongst other things, the advent of the internet and the digital age, the media, high-profile scandals, the rise of cosmetic surgery, litigation and very recently, Covid-19.2-12

Since the days of ancient Egypt, man has attempted to master fears of helplessness, sickness and death through magic, mysticism and even theology.

Healers were as much magicians and priests as they were doctors, and magic was an integral part of care. The notion that the doctor-patient relationship evolved from the priest supplicant relationship was proposed by Edelstein et al in 1937.11 For most of the past 3,000 years, the basic style of doctoring can be described as ‘beneficent paternalism’. The medical profession has adopted a well-meaning parental role in most patient encounters.

Doctors have acted on behalf of, and for the good of, their patients. They have also wielded power over them. This role, which until recently has been taken for granted

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by society, produces behaviour that is disease-oriented with a strong tendency towards authoritarianism.2 In this paternalistic model of the doctor-patient relationship, the doctor uses their skills to choose the necessary interventions and treatments to restore the patient’s health or ameliorate their pain. Informing patients about the uncertainties and limitations of medical interventions is thought to undermine the faith so essential to therapeutic success.

Any information given to the patient is selected to encourage them to consent to the doctor’s decisions.2 This paternalistic attitude is thought to be promoted by the dependency and submissiveness shown by many patients.

It may lead to doctors overlooking the patient’s wishes and concerns, as they pursue their own professional agenda.13

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NEW MILLENNIUM, NEW RELATIONSHIP Paternalism is an imbalanced interaction between doctor and patient and has been challenged during the last few decades.14 Over this period, an extensive body of literature has emerged that advocates a more patient-centred approach to medical care.11 It promotes a shift in the doctor-patient relationship from the ‘guidance-cooperation’ model to ‘mutual participation’, whereby power and responsibility are shared with the patient.15 Angela Coulter’s 2002 book ‘The Autonomous Patient’ ventured that paternalism has had its day. She talked about redefining the patient’s role to emphasise autonomy, emancipation and self-reliance rather than passivity and dependence.16 “No longer is he or she simply a victim of illness. In the 21st century patients must be treated as co-producers of their own health and care-managers when they are ill. They must be encouraged to see themselves as decision-makers, evaluators and stakeholders with a key role in shaping health policy.”16 This new alliance between the doctor and patient, based on cooperation rather than confrontation, requires the doctor to understand the patient as a unique human being, according to Enid Balint’s prescient 1969 article. Balint argued that the patient, not the illness, should be the primary focus of medicine such that the

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“No longer is he or she simply a victim of illness. In the 21st century patients must be treated as co-producers of their own health and care-managers when they are ill.

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primary objective of the doctor is to listen to the patient in order to identify what the ‘real’ problem actually is, instead of simply eliciting signs and symptoms.17 In the 1990s, both Stewart et al.18 and Grol et al.19 also asserted that the patientcentred approach requires a willingness to become involved in the full range of difficulties patients bring to their doctors, not just their biomedical problems.

Professor Teresa Hellín goes as far as to suggest that patient-centricity is a fundamental requirement for being a physician: ‘‘…one of the essential qualities of the clinicians is interest in humanity, for the secret of the care of patients is in caring for the patient’’.1

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PERSISTENCE OF MEDICAL PATERNALISM Although the balance of power may have shifted more in favour of the patient, can the balance ever truly shift?

There is evidence that, despite the current challenges to medical authority, a power imbalance still remains. Some patient organisations feel there is

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still intransigence among healthcare professionals, and a continuing need for a change in attitude. This has been described in terms of resistance to change, reluctance to share power, and protection of professional boundaries.3 To quote the senior officer of one user group, “I see this on the various agencies and boards that I belong to.

Health professionals have changed very little, even after Bristol. Doctors and nurses, their agenda is to hold on to their power base.”3 One independent midwife talked about the way doctors, nurses and midwives were encouraged to think that they “knew best”.

“We may now teach ‘communication’ in new ways, but do we still instil in health professionals a sense that they know better than the patient?”3 In addition, some senior members of Royal Colleges articulated a more intransigent approach to change.

“Professionals have to make a judgement about what people can handle and what they can’t handle,” said one senior officer.

Another commented: “We always groan inwardly when we get very intelligent parents, because they’re terribly time-consuming.”3 In 2001, Rudolph Klein emphasised that attitudinal change is not easy to bring about, but that it is pivotal if the objectives of a more patient-centred service are to be met.20 A King’s Fund study into these changing relationships, published just after the turn of the

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The continuing grip on services exerted by central government casts doubt on the extent to which power and control can really be shifted to patients.

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millennium, contended that: “The continuing grip on services exerted by central government casts doubt on the extent to which power and control can really be shifted to patients.”3 So, while the climate surrounding medical practice may appear to be shifting the balance towards the patient, it is arguable that the medical profession remains firmly in control of key decisions concerning treatment, and that patients continue to expect this to be the case.5

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RECOGNIZED MODELS FOR THE DOCTOR-PATIENT RELATIONSHIP15 In 1956, Szasz and Hollender described the three core doctor-patient relationships. These three models are still cited today.

Active-Passive Model

Mutual Participation Model

The active-passive model is the oldest of the three models and is based on the physician acting upon the patient, who is treated as an inanimate object. This model may be appropriate during an emergency when the patient may be unconscious or when a delay in treatment may cause irreparable harm. In such situations, consent (and complicated conversations) is waived.

This model is based on an equal partnership between the doctor and the patient. The patient is viewed as an expert in his or her life experiences and goals, making patient involvement essential for designing treatment. The physician’s role is to elicit a patient’s goals and to help achieve them. This model requires that both parties have equal power, are mutually interdependent and engage in activities that are equally satisfying to both parties.

While each of these models may be appropriate in specific situations, over the last few decades there has been increasing support for the mutual participation model whenever it is medically feasible.11

Guidance-Cooperation Model In the guidance-cooperation model, a doctor is placed in a position of power due to having medical knowledge that the patient lacks. The doctor is expected to decide what is in the patient’s best interest and to make recommendations accordingly. The patient is expected to comply with these recommendations.

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It is believed that the use of technology in consultations can dehumanize the relationship because physicians pay more attention to the computer than to the patient.

THE IMPACT OF MASS MEDIA AND THE DIGITAL AGE Increased access to information for patients is a key facet of patientcentred care, and the internet has transformed access to this information for the majority. New technologies are opening up innovative ways of communicating, delivering services and creating opportunities for new and different relationships between health professionals and patients.3 The use of computers in the medical consultation has drastically changed the physician’s communication and personal treatment of the patient. Using computers in the practice of general medicine began in the United Kingdom in 1972. But by 1997, the use of computers in medical consultation was calculated at 92%. Now, virtually every medical consultation involves a computerized system.4 Using computers facilitates patient registration, screenings, repetition of prescriptions and notations related to each case, as well as decisions on support aids,

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preventive measures and the use of treatment protocols.4 While the advantages of using computers in medical practice remain clear, it is also clear that it can affect the physicianpatient relationship in a detrimental way.

It is believed that the use of technology in consultations can dehumanize the relationship because physicians pay more attention to the computer than to the patient. Computers can change the conversation pattern with the patient to one in which data are constantly being entered into the machine, depersonalizing patient care.4 Mass information technologies have also led to a greater number of patients exercising self-diagnosis, and to physicians continually being questioned. Naturally, this has played its part in eroding the trust between patients and physicians.4

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THE MEDIA AND THE GROWING MISTRUST OF DOCTORS Increased public access to health information has been paralleled by a decline in public trust of the medical profession. Patients are more willing to question their doctor’s judgement, as the position of authority that doctors have occupied is undermined.

“There is a widespread view that respect and deference are all but dead and that professionals must now practice in an environment where their authority is not automatically ceded”, stated Mike Bury in his 2004 paper about patientprofessional interactions.5 In May Ann Elston’s 1991 book, ‘The politics of professional power: medicine in a changing health service’, she highlights the role the media has played in challenging the autonomy of the medical profession. “Few would dispute that overt questioning of medical autonomy and expertise has increased markedly in the past decade in Britain... ‘Doctor-bashing’ and calls for reform have become major sports in the mass media.”7 Several relatively recent high-profile cases and subsequent inquiries in the UK have influenced public opinion, undermined doctors’ professional authority and accelerated the loss of trust amongst patients.5,6 Cases that have seriously eroded public trust in the medical profession and its ability to selfregulate include Alder Hey Hospital, Bristol Royal Infirmary and Harold Shipman.8

In addition, media-led health scares eliciting contradictory medical advice have raised further concerns amongst patients about whether they can trust their doctors.5 A good example in the UK is the controversy surrounding the childhood vaccination for measles, mumps and rubella (MMR). Papers by Wakefield et al. in 199821 and Wakefield and Montgomery in 200022 suggested that the MMR vaccine could be linked to an increased risk of developing bowel disease and autism.

Despite strong scientific evidence to the contrary,23 many parents remained unconvinced of the vaccine’s safety, and immunisation uptake fell.24-27 These antiMMR authors were eventually discredited, and their papers retracted,28-30 but the damage had been done.

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Concerns regarding MMR vaccination highlight the way in which mistrust of doctors and access to health information through the media and internet can work in tandem.2 Vaccinations are a wonder of modern science and have, to quote my colleague Sandra Laird, “arguably made a bigger contribution to global health than any other medicine”. Yet this narrative often gets overshadowed by the power of bigger, almost irrepressible, forces.

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The Shipman case made people more uncomfortable about the control doctors can have over the end of someone’s life.

People who had previously placed blind faith in the medical community became newly aware of the sheer power of the doctor, who held the hand of patients as they walked the tightrope between life and death.34

THE SHIPMAN EFFECT

As a consequence of the growing mistrust of doctors, particularly in the often profit-driven field of aesthetics, legal claims in the UK have risen 15-fold since April 1995.

In 2000, GP Harold Shipman was convicted of 15 counts of murder.31,32 A subsequent inquiry found that Dr Shipman had unlawfully killed at least 215 of his patients between 1975 and 1998.32 Shipman’s relationship with his patients may be characterized as paternalism on his part and deference on theirs. Shipman has shown all too clearly how this type of relationship is open to abuse.33

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One worrying consequence of this case is the ‘Shipman effect’. Patients with end-stage COPD experience dyspnoea, which is often distressing for patients, their families and their professional carers. Although opiates are recognised to be effective in relieving dyspnoea, a study identified the Shipman case, and associated fears of litigation, as the key barrier to prescribing. Whilst this was seen as a particular problem within the primary care setting, it led GPs to admit patients to hospital rather than prescribe opiates.9 As a consequence of the growing mistrust of doctors, particularly in the often profit-driven field of aesthetics, legal claims in the UK have risen 15-fold since April 1995.10 This has eroded the doctor-patient bond, with more patients seeking second opinions, and led to the development of adversarial relationships.11

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Most of the time they’re people who are doing it because they want to. Doctors don’t really have any other agenda than treating people and getting people better. There’s nothing suspicious about their motives.

THE COVID-19 PANDEMIC Undoubtedly, the relationship between doctor and patient has been disrupted by Covid-19. Patients have been physically and emotionally separated from doctors due to use of personal protective equipment (PPE), telemedicine and patients’ fear of accessing healthcare.

During the Covid-19 pandemic, many patients may have received less care due to constraints, or even no care at all, as many have kept away from GP surgeries and hospitals.12 Empathic, clear communication is seen by patients as an indicator of competence and skill. Poor communication is often the differentiating factor between those

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doctors who are sued and those who are not. Telemedicine relies heavily on communication, which is impaired by loss of verbal cues, non-verbal cues and impatience. And, given the limitations of medical examination in this setting, some physicians who are unduly influenced by the pervading context may incorrectly attribute patients’ symptoms to the disease (as happened during SARS and MERS).12 So, there is a fear that a tsunami of claims may be approaching, particularly owing to delayed and missed nonCovid-19 diagnoses. The MPS (Medical Protection Society) has called for emergency laws to protect UK healthcare workers from criminal and regulatory investigation – a call supported by two thirds of the public, according to a YouGov survey of over 2,000 adults in Britain.12 Currently, much respect and empathy is being shown by the public and press towards healthcare workers. Could this translate to greater tolerance of medical error? In one sense, the crisis has escalated the break-up of the doctorpatient relationship; in another, it seems there may be a new love affair between the profession and society.12 SHOULD WE BE INNATELY MISTRUSTFUL AND JUDGEMENTAL OF DOCTORS? Although the overriding impression from recent studies and data is that ascendant doctors frequently abuse their power and still need to be knocked off their pedestal, their role in this most

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precious of relationships, and in the care of the people, clearly remains paramount.

And perhaps this is one of the reasons we often judge them so harshly.

Surely, most would agree that the overwhelming majority of doctors have no agenda other than to provide the best possible care for their patients, and that this is still the main reason they become medical practitioners.

In the words of Harry Hill, the comedian and former GP, “People who go into medicine have lots of options, they don’t have to do it. They can go and be lawyers or vets or dentists. Most of the time they’re people who are doing it because they want to. Doctors don’t really have any other agenda than treating people and getting people better. There’s nothing suspicious about their motives.”35

Reach out to RICHARD RAYMENT richard.rayment@dice-comms.co.uk

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References 1. Hellı˜n T. Haemophilia 2002; 8(3): 450–4. DOI: 10.1046/j.1365-2516.2002.00636.x.

2. T he Doctor-Patient Relationship: An Exploration of Trainee Doctor’s views by Sarah Elizabeth Burke. School of Education, The University of Birmingham, March 2008 (PhD thesis).

3. G illespie R, Florin D, Gillam S. Changing Relationships: Findings from the Patient Involvement Project. Published by Kings Fund 2002.

ISBN 1 85717 468 2.

4. Osorio JH, PhD Colomb Med. 2011; 42: 400–5 5. Bury M. J of Health Services Research and Policy 2004; 9(S1): 48–54. DOI: 10.1258/135581904322724130 6. Calnan MW, Sanford E. Quality and Safety in Health Care 2004; 13(2): 92–97. DOI: 10.1136/qshc.2003.009001 7. E lston MA (1991) “The politics of professional power: medicine in a changing health service.” In Gabe J, Calnan N and Bury M (eds.) (1991) The sociology of the health service. London: Routledge. pp.58–88.

8. Kaye J, Martin P. BMJ 2000; 321(7269): 1146–1149.

9. Gott M et al. Progress in Palliative Care 2010; 18(2): 79–84. DOI: 10.1179/096992610x12624290276700 10. C ampbell D. The Guardian newspaper, Sunday, 8th January 2012. Accessed on 17.01.2021. Available at: https://www.theguardian.com/ society/2012/jan/08/patients-sue-plastic-surgeons-faulty 11. Kaba R, Sooriakumaran P. Int J of Surgery 2007; 5: 57–65 12. Bradshaw P. Medicolegal Lead, Risk Prevention at the Medical Protection Society. BMJ, June 2020.

13. M yerscough PR and Ford M (Eds) (1996) Talking with patients: keys to good communication. Third Edition. Oxford: Oxford University Press.

14. Parsons T. The social system. New York: Free Press; 1951.

15. Szasz T, Hollender M. Arch Int Med 1956; 97: 585–92.

16. Coulter A (2002). The autonomous patient: ending paternalism in medical care. London: HMSO. 17. Balint E. J R Coll Gen Pract 1969; 17: 269–76.

18. Stewart M et al. Patient-centred medicine: transforming the clinical method. London: Sage; 1995.

19. Grol R et al. Fam Pract 1990; 7(2): 100–4.

20. Klein R. Health Service Journal 2001; 111(5770): 28–30.

21. Wakefield AJ et al. The Lancet 1998; 351(9103): 637–641.

22. Wakefield AJ, Montgomery SM. Adverse Drug Reactions Toxicology Review 2000; 19(4): 265–283.

23. Elliman DAC, Bedford HE. Archives of Disease in Childhood 2001; 85(4): 271–274.

24. Thomas D et al. Communicable Disease and Public Health 1998; 1(1): 44–47.

25. Wilson CB, Marcuse EK. Nature Reviews Immunology 2001; 1(2): 160–165.

26. D rop in MMR jabs blamed on media scare. BBC News, 26 June 1998, available [online] at: www.bbc.co.uk/news; accessed 17 August 2005.

27. P arents’ fear over MMR remain. BBC News, 13 February 2001, available [online] at: www.bbc.co.uk/news; accessed 17 August 2005.

28. Deer B. BMJ 2011; 342. DOI: https://doi.org/10.1136/bmj.c5347 29. Godlee F. BMJ 2011; 342. DOI: https://doi.org/10.1136/bmj.c7452 30. Sathyanarayana Rao TS, Andrade C. Indian J Psychiatry. 2011; 53(2): 95–96.

31. Dyer C. BMJ 2000; 320(7231): 331.

32. Smith J (2002) The Shipman Inquiry: first report. London: HMSO. 33. Baker R. J R Soc Med 2004; 97(4): 161–165.

34. A licia Queiro. Shipman effect: How a serial killer changed medical practice forever. BBC News, BBC Scotland. Accessed 14.01.2021.

Available at: https://www.bbc.co.uk/news/uk-scotland-30192721#:~: 35. Harry Hill. The Big Issue. 10 Feb 2017.

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POWER – The –

of imagery

There’s a cliché somewhere about a picture and a thousand words. Don’t worry, we’re not going to use it here. However, we firmly believe that great content doesn’t have to be written; sometimes it just has to be seen.

With that in mind, the Dice team has collated a selection of photos from the past 12 months that either tell their own story or have quite simply left us speechless. Or both.

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SCIENCE

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SCIENCE SAKE Written by NEIL DICKINSON

Like great works of art, there was no ‘reason’ for certain scientific endeavours, but this ‘just for the sake of it’ philosophy is now delivering tangible benefits.

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Guest Contributor

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Everyone is no doubt familiar with the phrase ‘Art for Art’s Sake’, coined in the early 1800s in France and taken to mean that the creation of art needs no purpose or objective, other than simply existing.

I think we can all recognise that even the greatest artistic creations, from the Mona Lisa to Beethoven’s Fifth, didn’t need to be created, but humanity can be pleased that they were.

A cube of carbon atoms with the formula C8 H8

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The question is, could the same be said about science? I would maintain that not only could it be said, but that we are doing humanity a disservice by not saying it often and forcefully enough.

This is especially true in the modern context of science denial and bogus conspiracy theories, which gain traction partly due to a suspicion of the pursuit of science and its motives. It can be seen often in throwaway comments such as “what was the point of going to the moon?”, when in fact, even a cursory internet search reveals that so many of the things we take for granted these days, from cordless tools to fabrics and protective gear, were given a huge helping hand by the driving forces behind the NASA missions.

My own personal anecdote about pursuing science ‘just for the sake of it’ encapsulates perfectly the benefits that such a philosophy can bring to the world.

In the mid-70s, during the final year of my chemistry degree, I was captivated by a lecture in which the professor demonstrated how he had contributed to the development of a new molecule called cubane. Without going into detailed chemistry, it was the synthesis of a molecule which could never occur in nature – literally a cube of carbon atoms with the formula C8H8.

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So there you have it: the inspiration for first synthesising cubane was no more than a whim.

“I wonder if it could be done.”

Everyone assumed it would be impossible to create such a molecule because the angles of the bonds between the carbon atoms would be too acute and make it inherently unstable, even if it could be achieved. But to everyone’s surprise, when it was finally synthesised, it proved to be remarkably stable and, perhaps more importantly, benign and non-toxic.

At the end of the lecture, I clearly remember the professor saying that it had all been a bit of fun and they couldn’t really see any use for it. I sincerely hope that he lived long enough to at least see the early fruits of his labours, because cubane, in true ‘science for science sake’ fashion, is proving to be something of a revelation, with applications from the military (sad but inevitable) through to materials science and pharmaceuticals.

First, the bad news. We are all familiar with TNT – a high explosive which is essentially a benzene ring (toluene to be exact) with three nitro groups replacing

three of the hydrogen atoms. That confers on the molecule a huge explosive potential. Crudely, explosives can be thought of as ‘unstable’ molecules being desperate to transform into more stable ones. So TNT turns into three very stable gases: carbon monoxide, carbon dioxide and nitrogen. Bang! It’s that simple.

Going back to cubane, someone had the bright idea of replacing all those eight hydrogen atoms at each corner with eight nitro groups. Octanonitrocubane (ONC for short) can convert into eight molecules of CO2 and four molecules of N2 with an explosive force that makes TNT seem like a popping balloon. Seriously deadly in the wrong hands.

More optimistically, cubane holds vast potential in materials science. Because it is a rigid, 3D structure, it can be layered or chained together to make amazing new translucent materials that could have applications in so many other science and technology disciplines.

But to my mind, cubane’s

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greatest potential lies in the field of pharmaceuticals and medicine. Again, it’s all down to its unique geometry and non-toxicity. The eight corners allow it to carry pharmaceutically active yet different molecules into the body, molecules that couldn’t otherwise co-exist. It’s still early days, but cubanebased pharmaceuticals are already showing promise in HIV and cancer.

So there you have it: the inspiration for first synthesising cubane was no more than a whim: “I wonder if it could be done.” Genuine science for science sake.

Now, over half a century later, the world of science and technology is waking up to the wonders of this little cube of carbon atoms. To me that’s every bit as satisfying as listening to Beethoven’s Fifth.

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DOUBLE-EDGED SWORD OF COVID-19 DOUBLE-EDGED SWORD OF COVID-19 Written by SANDRA LAIRD Director – Medical Education & Market Access

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If necessity is the mother of invention, then Covid-19 will have been the biggest driver of innovation in the last century.

If we look around our communities, we can see those businesses that have risen to the challenge… and those that have not. The pubs that immediately offered a takeaway service, those that transformed into outdoor cinemas or offered drive-through services, and those that simply shut up shop.

New businesses have sprung up in the toughest of times. Were cocktails delivered to your home even ‘a thing’ in January last year? Would musicians even have imagined a Zoom gig? I’m sure the answer is no; but yet here we are!

Covid-19 has brought great hardships, but it’s also accelerated change that’s been years coming.

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DIALLING UP THE DIGITAL In healthcare, the Covid-19 pandemic has driven the adoption of digital health in a way that seemed impossible months before. Suddenly every GP in the country instigated a triage process and embraced online consultations. Is this a temporary change? No, almost certainly not. Could it go further? Yes, without a doubt. Could community pharmacists play an even more active role in prescribing for simple ailments? Yes, absolutely.

You could argue that the pressure for change in primary care has been there for years, and you would be right. We’ve known for years that we don’t have enough GPs and that demand for services continues to grow, but yet change was slow and progress hard-won. Suddenly, every GP practice evolved at warp speed.

A positive legacy of the pandemic, without a doubt!

For the pharmaceutical industry, it’s been a time of opportunity and challenge too. Early in the pandemic we ran into supply issues. The almost wholesale move to manufacturing generic medicines in India over the past 20 years suddenly didn’t make sense, and sourcing even the simplest of medicines became impossible.

The reliance on China for API suddenly seemed like madness.

But solutions were found, regulators were flexible, emergency processes put in place and we moved on.

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FROM VALUABLE LESSONS TO LESSONS IN VALUE Perhaps we should stop and look back at this point, though. Maybe we need to think about whether a drive for cheaper and cheaper medicines is sustainable. If there hadn’t been a drive to the bottom on generic pricing then maybe companies wouldn’t need to have sourced products at increasingly lower prices. Maybe it’s time for the industry and the ABPI to lobby more effectively and negotiate guaranteed minimum prices for all essential medicines in return for a de-risked supply chain. Now, that would be progress.

Research has been the bigger winner surely? We have shown that it is possible to develop safe and effective medicines quickly. Funding has been available, proven mRNA vaccine platform technology developed over two decades was deployed rapidly to a new threat, and regulators adopted rolling reviews for the Covid-19 vaccines and fully engaged in evaluating promising drug candidates though the PIMs and EAMS programmes. All of these demonstrate what can be achieved when there is a pressing societal need.

We ought not to revert to a ‘one size fits all’ approach to drug development and licensing. We could, and I would argue should, develop a new segmented approach to drug development based on the degree of unmet clinical need.

Stakeholders in the rare disease arena

have been championing such changes for years. Maybe it’s time to listen.

Together, pharmaceutical companies, health systems and regulators should agree on priorities for drug development based on need. These priority therapy areas could potentially benefit from expedited review, co-funding of development and preferential pricing.

This would disincentivise the development of yet another ‘me too’ and truly incentivise innovation.

Our approach to evaluating costeffectiveness and affordability would of course need to change in line with a new ‘unmet needs based’ development

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programme, but that may be a good thing. Whilst QALYs of course have their place, they have their limitations. There has long been a debate about their appropriateness in oncology and other severely life-limiting conditions.

“Together, pharmaceutical companies, health systems and regulators should agree on priorities for drug development based on need.

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CONNECTING AND RELATING – INTERACTIONS COUNT Covid-19 has taught us that the impact of disease on society is multifactorial and far-reaching. It impacts day-to-day living, our mental health and our ability to perform our jobs, socialise, access leisure and healthcare. In fact, it impacts every single part of our lives and our society at large. We need to be more holistic in how we assess and communicate the value of medicines, and maybe now, for the first time, our clinicians and local/ regional/national payers are open to considering this.

The approach to pharmaceutical sales and marketing, like all other areas of society, has seen a seismic shift in the last 12 months. Who would have thought that everything from advisory boards and congresses to 1:1 selling and service redesign could be conceived, developed and delivered online?

Companies continue to evolve their approach via Veeva CRM, Zoom, MS Teams and a plethora of other platforms.

But, as in all walks of life, people remain people and people buy people. That’s why, for me, 1:1 selling will always be important. The question is, does it always need to be in person, or can it be done remotely? In five years, the model will, I think, be more mixed. Maybe we will need less people, perhaps there will be more contact ‘after hours’, but relationships and rapport will be no less important.

Our approach to marketing has and will

We ought not to revert to a ‘one size fits all’ approach to drug development. We should develop a new segmented approach based on the degree of unmet clinical need.

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continue to change. We are making every interaction count, we are making sure that we sweat our assets. So, when we develop footage for a satellite symposium, we are making sure that we create additional assets from it. These might be podcasts, webcasts or talking heads videos that we embed in email fragments, or a million other things. We are making sure that our marketing activities are not a series of individual, standalone tactics, but an integrated programme of communication.

Should it always have been like that? Yes, of course. Was it? For all sorts of reasons, no it wasn’t.

So yes, Covid-19 has been a personal, social, national and international challenge. By necessity, however, it has focused us to evolve. To work smarter not harder. If we hold on to this legacy, the pandemic will have brought benefits that may well help offset some of the hardships.

Reach out to SANDRA LAIRD sandra.laird@dice-comms.co.uk

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IT TAKES TWO Maximising the client-agency relationship

No-one knows your business and therapies better than you, and nobody understands your audience the way you do either. So why do you trust an agency to deliver targeted messages and strategies, rather than doing it yourself?

Written by VITALIY YAVTUKHOVSKYI Studio Services Manager

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Partnering with an agency to devise and deliver marketing strategies ensures key information is shared with your stakeholders in the right way, through the correct channels. A good agency will look at you as your customers do – considering patient management, the patient journey and the delivery of treatment.

You can read about an approach to marketing on any agency’s website, you can talk to their team, clients and possibly even the patients that have been specifically impacted. However, there’s just as much onus on you to get the most out of the relationship.

If you adopt the mindset that your agency works with you, rather than for you, you’re halfway there. It should be a partnership with one common objective: improving, or saving, the lives of patients.

Because after all, that’s why you exist, why your therapy was developed and why you need to shout about it.

So, how well do you know your agency, and are you really using that relationship to your advantage? Here are a few things to consider.

TRUST Marketing agencies are professionals in their field, but if you don’t trust their professional opinion, there’s little point to the relationship. Trusting your agency’s recommendations to push the boundaries and elevate you above the competition can not only produce truly amazing, valuable and impactful work, but it can be exciting and invigorating for all involved.

Trust your agency to recommend the best path in terms of marketing, expect them to ask questions and question the answers. If you’re engaging the services of an agency and they haven’t taken the time to truly understand you and your brands, it may be time to reconsider the relationship. In other words, find

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an agency that aligns with, or exceeds, your expectations.

in what you do and the impact it has.

Your agency should meet with you at regular intervals, not only to update you on progress and/or receive new briefs for marketing requirements, but also to remain informed and propose additional added-value marketing opportunities that you should be considering.

It’s fair to expect your agency to take the lead, to force deadline compliance and hold you accountable just as much as you do them. If they’re not doing this, and you’re leading the way, you might need to consider the value of your investment in their services.

say when something isn’t ‘working’; it’s a two-way street, so be prepared to take on board the agency’s feedback too. However, the relationship shouldn’t revolve around them asking you what’s next. Any agency worth its salt should be proactively seeking opportunities to enhance their delivery, and telling you about it.

Be constructive and feed back regularly on how you think the agency is performing, how your experience is, and how it could be better. A good agency wants to know how they’re doing and how they can improve things.

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Begin the relationship with your agency with discovery meetings to enable them to really and truly understand you, your brand and your values, as well as the needs of those who need your drugs and/ or treatments. They should ask to be or be invited to meet all key team members, attend with questions relating to goals, and generally be engaged and interested

There is a great irony in any marketing and communications agency not... communicating. But it happens.

Be sure that your agency drives communication as much as possible; confirm to them that you anticipate that they will keep you informed of progress with regular updates and confirmation of agreed actions.

But it goes beyond literally making sure they talk to you – being open and honest with one another is just as important. This stems mostly from the relationship you have with them and vice versa; you should expect your agency to be demanding and ask questions, then ask even more.

To be truthful if something isn’t clear, if information is missing, or if they have questions that need to be answered in order for them to deliver their expertise.

You should both feel comfortable to

A difficult relationship will obstruct any progress with a marketing agency; be sure that the chemistry is right and that you are happy and comfortable with one another, that you feel you can question them and they you.

If a member of the agency’s team doesn’t work for you, make sure you’re addressing this. Consider, however, that if they’re asking questions, being demanding or firm with you, it may be to your benefit. There shouldn’t be discomfort at every meeting, but you should feel challenged and forced to consider everything when engaging with your agency.

Likewise, ensure your team is engaged and on board with the decision to appoint an agency, and your expectations of how that relationship will work.

They may feel uncomfortable being

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PLAN & SPEND It’s not customary for any marketing agency to ‘fly by the seat of their pants’, or advise you to do so! Alan Lakin suggested that planning is where you bring the future into the present so that you can do something about it now, and he’s not wrong.

Having a comprehensive, strategic plan can influence business performance, engagement and enthusiasm, all of which directly benefit you and your team, while reducing the opportunity for error. If your team is under pressure, there’s a higher likelihood of rushed decisions, errors of judgement and incomplete or inaccurate information being shared.

Budget shouldn’t ultimately affect the effectiveness of a campaign. Well-planned and timed execution of marketing can be extremely impactful, and an agency should be able to work with you within any budget or time constraints. That’s what you’re paying them for, after all.

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challenged regularly, but if it’s positioned correctly ahead of the appointment, it should encourage their interaction and engagement with the agency.

APPROVALS AND PERMISSIONS Clearly define roles, responsibilities and authorities.

Much of the information you deal with on a day-to-day basis will be sensitive.

With this in mind, it’s imperative that you confirm confidentiality and approval processes with your agency. A good agency will have considered this ahead of your first meeting, and it should be part of their everyday management and timelines.

Your agency should also have firm processes in place for planning, delivery and execution of marketing activities.

They should take time to explain the creative process, so that everyone remains ‘on the same page’. This should avoid any frustration if the first iteration of work they deliver doesn’t quite hit the nail on the head.

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In summary, any agency you engage with should be interested, informed, knowledgeable and skilled, but more than that, they should come to feel like part of your business rather than an outsourced supplier. Above all else, your agency should bring something to the table that you aren’t able to deliver yourselves; namely a perspective and observation of your brand as the customer sees and experiences it.

This is how we like to work at Dice – acting as a partner in our clients’ mission to transform lives; not just because it’s our job, but because we are genuinely invested in their work.

Reach out to VITALIY YAVTUKHOVSKYI vitaliy@dice-comms.co.uk

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Above all else, your agency should bring something to the table that you aren’t able to deliver yourselves; namely a perspective and observation of your brand as the customer sees and experiences it.

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BEHAVIOURAL CHANGE – LESSONS FROM DOWN UNDER As communicators, the last 12 months have been fascinating to watch purely in terms of behaviour change.

Written by MATTHEW DICKINSON Managing Director

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Humans are notoriously habitual creatures, using heuristics to make decisions constantly, mainly sub-consciously. This is now widely understood and there’s enough literature out there to spend a career in the field – everyone’s read Kahneman’s ‘Thinking fast and slow’, I’m sure...

But impacting behaviour – more specifically, changing behaviour – is an uphill battle, and yet this is fundamentally our exact job as marketing communications experts: to elicit change in someone’s decision-making behaviour.

When we think of patients, this is manifested in terms of adherence to treatments or finding ways to build a therapy into daily routine. For HCPs, getting them to challenge pre-existing habits in the way they’ve approached treatment of a certain condition might be more pertinent and impactful.

In the current climate, it’s government communications that I take a view on here. As of January 2021, £100m had been spent on marketing communications to the public, and yet I would argue people just got more and more confused as time went on.

Meaningful behaviour change was hard to make happen over and above wearing a mask and staying two metres apart from others. For £100m I would argue that’s an appalling return on investment, but more importantly it’s money that

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could have been better spent – and not on other elements of managing the pandemic. By this, I mean it could have been better spent in terms of the strategy and delivery of government comms.

‘Staying alert’ was a particularly strange example – I’m still not sure anyone ever successfully explained what that meant or understood it.

The fact is that, unfortunately, behaviour change is unlikely to happen overnight. It requires persistent consistency! But communications, when delivered correctly, can still achieve the desired goals.

Hence I wanted to demonstrate an approach to a behavioural problem, and award-winning work (not mine), which overcomes the entrenched actions of people – establishing a framework we can all think of when looking at behaviour change problems.

BEHAVIOURAL CHANGE IN PRACTICE When I lived in Melbourne, Australia, I worked on the Victorian government’s bushfires campaign. Now, in the UK you would think that many people when told to leave their homes due to oncoming bushfires would do just that – but that was not the case. It was a huge hurdle to overcome a sense of ‘defending one’s property’.

While we’re unlikely to encounter bushfires in the wet and mild UK (at least for now), I wanted to share how we approached the problem using a framework we’re all familiar with – road

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safety, namely drink driving and speeding, both of which are classic behavioural change problems and exist in every country on the planet.

1. How do you stop people from drinking and driving?

2. How do you get people to follow speed limits in built-up areas?

We followed a strategy of three messaging vehicles (pardon the pun):

1. Consequences of action 2. Education on why we’re asking you to change 3. Fear of being caught On their own, they may be effective in the short term, but it was only when all three were used in tandem, consistently, that behaviour changed over time.

A blend of rational and emotional messaging was also crucial.

Of course, this was supplemented by action in the field by the police force and government support, which after all is vital. Communications on their own aren’t going to do the job, although I would argue strong creative work will have a greater than expected impact if done correctly.

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The support of PR and TV shows help – as well as PR pressure. The age of some of these adverts simply prove the length of time you need to remain consistent.

In Victoria, where my experience comes from, the results speak for themselves. The behaviour change has been extraordinary, and will continue to positively impact results. And just think – we all wear seatbelts now. That’s not by accident.

DISCLAIMER Please note that the videos referenced below are all available on the Transport Accident Commission Victoria (TAC) YouTube channel and contain some graphic scenes.

Drink Driving

Speeding

Consequence of action

Education

Fear of being caught

Consequence of action

Education

Fear of being caught

Fatality and SHOCK factor.

How drinking affects your driving ability.

Police are breathalysing motorists constantly.

Fatality and SHOCK factor.

The reason speeds are set at 30mph (60kph).

Speed cameras.

Tell an emotional story of the consequences of doing the wrong thing e.g. crashing a car when drunk and killing a loved one.

Talk about the reasons drinking affects driving, focus, attention span, reaction time, etc.

Demonstrate the police presence and the punishment for being caught drinking and driving.

Tell an emotional story of the consequences of doing the wrong thing e.g. crashing a car when speeding and killing loved one(s).

Demonstrate the difference in stopping distances of a car travelling at 65kph and 60kph and what it means. Or in the UK market, hitting a pedestrian at 30mph (walk away) vs.

35mph (hospital).

Punishment for speed cameras and the fact that police are also doing so on mobile devices.

Search for...

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‘If you drink, then drive, you’re a bloody idiot’

‘What impacts your Blood Alcohol Concentration (BAC)?’

‘TAC Xmas Drink Drive enforcement campaign 2011’

‘The Lucky Ones Get Caught 60” MA’

‘What happens when you wipe off 5?’

‘TAC Xmas enforcement campaign 2011’

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Or what does affect your drinking level in order to drive?

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‘Driving 10km/h less will save lives’

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So what lessons can we learn? When thinking about a behaviour change problem, can you think of a way to approach the problem which positively overcomes the multiple habits and heuristics that are ingrained in all of us?

For patients starting out on a new therapy who need to remember to take medication:

Education

Habit forming

Working with your HCP

How the therapy works and why it will help.

When to take and why.

Sharing adherence data.

Give knowledge of the therapy.

Combine with an everyday task to make it easier to become a habit.

Helps maximise your treatment.

Combined with great behavioural insights, this strategic framework can make a huge difference to a campaign and its execution. At Dice, we call the framework Pharmacohesion – but no matter what you call it, you can be sure of impressive results.

Reach out to MATTHEW DICKINSON matthew@dice-comms.co.uk

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THE SCIENCE OF DEATH – LIVING ON BORROWED TIME Most people have probably considered how their life may end, but few will have considered why.

Written by NEIL DICKINSON Guest Contributor

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Let me make it clear at this point that I am writing from a purely biological and scientific perspective. You may all have your own spiritual take on this, but debates on the meaning of life belong elsewhere.

Unlike matters of faith, which are often personal and individual, the science I’m about to describe is common to all of us, no matter what your belief systems are.

As I mentioned with my mother, the healing process never really stops, no matter how old we are. Of course it takes longer than if we were still in our 20s, but it still happens, which suggests that our bodily systems still function at a reasonable level. So why can’t that keep on going forever?

Similarly, we recycle ourselves in such a way that, in effect, we have a new body – even a new skeleton – every ten years or so. That doesn’t apply to our brains which physically remain unaltered throughout our life from the late teens onwards. So why are these new bodies not as good as the old ones?

This is an area of active research, and there are many hypotheses that generate a heated debate in the scientific community, but for me personally, there are three that are most compelling.

Firstly, recycling is not an accurate process. We see in recycled paper remnants of a previous life: the flotsam and jetsam of yesterday’s newspaper stories.

A good way to look at it is to compare it to a software upgrade on our computers. You get a new operating system, but there are always some little bits of rogue code left

Everyone, at some point in their life, thinks about their own death.

Morbid curiosity often leads us to think about how we might die, but that’s just an exercise in navel gazing with no possible answer until the day arrives.

Much more interesting is the question, ‘Why do we die?’

Now it may seem an irrelevant question.

Of course we all die – it’s the one absolute certainty in life. But why? What are the biological reasons for death?

The question occurred to me on a recent visit to my elderly mother. Late into her ninth decade, it struck me that her hair is still luxuriant and clearly grows, as do her nails. Her recent wrist break has healed nicely and her mind, thankfully, is still as sharp as ever. Her heart has already beaten about three billion times and shows no sign of stopping. Clearly the biological processes of life – those of growth, healing, renewal and basic metabolism – seem to be unhindered.

And yet the prospect of death obviously looms ever larger in her life.

So why will she die?

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A good way to look at it is to compare it to a software upgrade on our computers. You get a new operating system, but there are always some little bits of rogue code left behind that cumulatively, over time, take their toll.

behind that cumulatively, over time, take their toll. Your computer never quite works as well as it did when you first pressed the ‘on’ button. The same is true of cell division. It doesn’t always go smoothly, and over time our bodies fill up with tiny bits of misshapen proteins and enzymes that just get in the way of proper functioning.

However, to my mind, the two most fascinating reasons for death come down to genetics and evolution.

You have to understand that from the perspective of our species’ genes, we are simply temporary carriers. We might think we’ve made our own special impact during our time on this planet, but from a biological perspective, once we have procreated and passed our genes on to the next generation, the job of our bodies is complete.

Yes, these squishy, smelly, emotional heaps of flesh and bone have no more biological purpose in life. It’s sad but true.

Humans are very fortunate in that our slightly peculiar long lifespan means that the role of grandparents in our families and societies is almost unique in the animal

kingdom, so you could argue that we have an evolutionary role to play in protecting our genes in a once-removed, family fashion. But purely at the cellular level, when we are no longer involved in human reproduction, we are no longer important in our species’ well-being.

This genetic perspective gives rise to two fascinating and quite subtle influences, and both are driven by evolutionary forces.

The first is that it is far more economical from a resources perspective, to generate and grow a new, healthy body than to constantly maintain and repair an older version. You might think that the resources needed to feed and build a new body might totally outweigh the lower level of nourishment needed in us oldies, but actually, the far greater productivity of new, younger bodies outweighs this consideration.

Clearly in the 21st century this might seem a slightly absurd notion, but for almost the whole history of human existence, life was about survival. A group of early humans wandering the grasslands of Africa could cope with a few

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older members, but to be truly capable of thriving, the speed and strength of youth was vital. So from that perspective, there has never been an evolutionary pressure to repair and maintain our bodies to the level of, say, an adolescent. That’s why we can’t do it naturally now.

Secondly, given that we only exist to pass on our genes to the next generation, then the evolutionary pressure on any species, not just humans, is to keep us healthy until that process is complete. Evolution has driven the ‘fixes’ that are needed to keep us alive in our youth. That’s why serious diseases in childhood, such as cancer, are mercifully rare. Of course there are tragic exceptions to this rule, but they hit home so hard because they are so rare.

So evolution has driven our bodies to be fantastic self-defence machines in the first 20 years or so of our lives. Historically, that’s when we all procreated and that’s why from early adulthood onwards, our bodies are neglected by our genes and begin a slow inexorable decline.

So why do we die?

It turns out that Oscar Wilde was right. It really is all about sex. If we procreated later in life, then over time, we would probably evolve a longer lifespan, but for certain, nobody reading this article will be around to witness that development, if it ever happens at all.

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THE LAST WORD With

MATTHEW DICKINSON Managing Director

Without stealing her thunder, I think it’s worth expanding on a point made by Sandra Laird in her excellent article, ‘The DoubleEdged Sword of Covid-19’ (p43).

Sandra reflects on the triage process that HCPs implemented in immediate response to the pandemic, and how, for all intents and purposes, it was a change that’s been a long time coming.

Of course, HCPs had little choice but to resort to triaging and remote consultations. It was imperative as a means of minimising human contact, containing the spread of the virus and saving lives. However, Covid-19 isn’t the first virus or infectious disease to hit these shores, and it certainly won’t be the last.

Granted few of us have encountered a virus that’s as contagious and deadly (at least not in the UK), yet it still begs the question of why other illnesses haven’t been treated similarly.

The fact it’s taken a global pandemic to rethink patient management is somewhat bittersweet.

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The challenge is to deliver appropriate patient management, but above all else, to care.

Consider the number of times you have walked into a waiting room and felt uncomfortable sharing the space with those who are clearly ill, or potentially with those who are seriously contagious yet not presenting symptoms. How many times could you have been assessed without physically visiting the surgery or hospital? I’m guessing it’s at least a handful.

The fact it’s taken a global pandemic to rethink patient management is somewhat bittersweet. Yes, it’s encouraging to see HCPs embrace digital change, but why wasn’t it embraced sooner? If the traditional approach didn’t make sense, why wasn’t it challenged?

There are no easy answers to these questions, nor is this the place to answer them. However, one could reasonably argue that it stems from a focus on the bigger, ‘shinier’ opportunities, rather than getting the basics right first. It can be

easy to suggest a sophisticated new IT system, yet it’s often the smaller things that make the biggest difference. Things like reducing the burden on A&E by making it easier for non-urgent diagnoses to be made remotely, for example.

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START WITH THE PATIENT I’d like to stress at this point that I’m not advocating or applauding a reduction in face-to-face care. Rather, I’m highlighting the importance of the patient and why, more than ever, they shouldn’t be regarded as a “problem to be solved”.

Now is an opportunity to consider the softer parts of the patient journey – interaction with HCPs or patients experiencing the same illness or longterm condition. There’s a tendency to think that people want as little time with medical professionals as possible, but it may not always be the case. For some patients, particularly the elderly, it may

be the only human contact they have, and could be as vital to their recovery as the treatment itself.

The challenge is to deliver appropriate patient management, but above all else, to care. Let’s not be too hasty in rolling out contactless care if it limits the touchpoints that are crucial to both the physical and mental health of some patients. Instead, let’s allow the patient to determine their own care path, where it is safe to do so.

Reach out to MATTHEW DICKINSON matthew@dice-comms.co.uk

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Experts in pharmaceutical communications We’re a full-service communications agency that uses Pharmacohesion® to help you refine your strategic thinking across all channels.

Combining a thorough, innovative approach with our core communications strengths, we ensure you engage the right people and your brands fulfil the ambition of the scientists who developed them: to transform the lives of patients with an unmet medical need.

We create

Pharmacohesion® is a consistent, unified strategy to ensure your brand makes an impact.

Our work through Pharmacohesion® aims to marshal all the data, opinions and channels at our disposal to help you to build, launch and continually develop your brand within competitive worldwide and regional markets.

There are four stages to Pharmacohesion® – each informing the next in a continuous cycle:

Call us: +44 (0) 1628 397 830 Email: hello@dice-comms.co.uk Website: dice-comms.co.uk Level 2, St Cloud Gate, St Cloud Way, Cookham Road Maidenhead, SL6 8XD, UK 62

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Experts in pharmaceutical communications Your brands were developed to meet a medical need.

We help you make sure their promise is fulfilled.

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A quarterly perspective on pharma

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