The wages of frustration

I am still in rural NSW at the farm where I grew up.  The weekend was a reunion of sorts for my three sisters, their manifold children and me.  It's taken me a while to adjust to sleeping in the deafening silence of the Australian bush after inner London but that absence of noise is one of the things that I am here to rediscover.

On Saturday my brother-in-law gave me the tour of his cattle-raising business.  He's made a number of quite radical changes to the farm since my father has stepped back.  He and my sister are enthusiastic adherents to a more holistic approach to agriculture that is quite close to hard-core environmentalism in terms of protecting  pastures and (especially) soil quality*.  To this layman's eyes it seems as if they're on the right track but they'll only know for sure after a few hard years of poor rainfall and depressed cattle prices.

It's easy to look good in the good times.

And this is something that I'm not sure that my brother-in-law, a smart, hard-working man, quite gets yet.  An understanding of the meaning of prosperity is hard to come by.  If you take the long view of a business in any established industry (and none are more established than food production) then a trendline will emerge; a sense of what a good operator can reasonably achieve with his particular assets can be established.  I say 'established' because it takes time for these trendlines to solidify; no one knows what the DNA sequencing industry will look like yet.

Many companies and most Headcount: 1 / freelancer types misinterpret prosperity.  If you treat the good things (it rained, my client got a big promotion, I got the part in the hot new movie) as luck or even as 'just rewards for all my hard work' then that prosperity is mispriced: -

The good years must compensate you for the emotional damage wrought by the bad ones

None of us gets to relive those bad years but with more money in our pockets.  We don't get that time back.  Our health and the wellbeing of our relationships with family will inevitably have been damaged by both the frustration of not having succeeded yet and the quiet terror of not knowing if you're actually going to succeed at all.  When you hear that someone's eventual success 'feels hollow' it means that the bad years were 'not worth it' (or mispriced).

Hopefully my brother-in-law has it right.  Like many smart farmers of his generation he is adamant about carving out time for his other passions: his family and campdrafting, a very difficult, peculiarly Australian rodeo event.  But the proof will be in whether or not he manages to keep up these other aspects of his life when beef prices tank and the rain refuses to fall.

The current good season will have to pay for some future time of heartbreak and frustration whether he knows it or not.

* This is not to say that my father didn't have a keen appreciation of the relationship between his agricultural practices and his land.  He did.  However, to an outsider it does seem that the thinking has moved even in the last ten years.  Even though he doesn't use that language, my father was a custodian of his land, which is more than you can say for most farmers in most parts of the world.

RIP Drew Leavy, improvisor

I woke up this morning at my family home in country Australia to the news that Drew Leavy, improvisor, had died in London.  He had been battling brain cancer for over eighteen months.

I first met Drew after a Grand Theft Impro show.  GTI have long been the best improv troupe in London and Drew, alongside Phil Whelans, Dylan Emery and later Cariad Lloyd, deliver consistently high quality, innovative shows in an otherwise hit and miss field.  As he was from Canada we bonded in that familiar 'colonials-in-Britain' way.  The last time I saw Drew was about a year ago, also at a GTI show, when I was privileged to perform along side him in what I think was his penultimate show.  He was as anarchic, generous, funny and erudite that night as ever.

As with any great improviser, when you made eye contact with Drew across the stage what you saw in there was a sort of 'deliberate unknowingness'; neither he nor you knew what was about to happen, only that it was going to be fun.

Fixing pharma

Matthew Herper writes at Forbes about health care.  Last week he wrote a piece entitled Big Pharma: What Went Wrong?  Much of the article is a direct quote from Peter deVilbiss an ex-employee of Merck, who makes the obvious and off-stated point about pharma R&D: -

It takes a lot of profits from the few approved drugs that make it to market to pay for all the basic research and failed development candidates that lie beneath the surface and out of view of most people

Herper and many others are calling for two key reforms to 'save' Big Pharma: open source sharing of trial results and an end to direct-to-consumer (DTC) advertising.  I have no problem with either suggestion as either or both would improve the bottom line via a reduction in expenses and, in the case of DTC, improve the industry's American reputation.

As a consultant that works mainly outside the US (although regularly in Canada) and usually in more rarefied therapy areas like renal disease and oncology it strikes me that a lament on the evils of DTC is an analysis that is looking at the obvious rather than the important.  DTC is as much a symptom of the Blockbuster era as a cause.  I doubt that medical advances will ever again be as simple or as widely beneficial as the advent of the statins, COX-2 inhibitors and erectile dysfunction agents.  You won't see much DTC advertising of monoclonal antibodies because they're targeted therapies and the ROI on that sort of ad spend won't be there.

This is not to say that commercial medicine is about to get all classy: get ready for a massive increase and unedifying in TV ads for genetic screening: -

Did you know that you could be one of the millions of Americans who have cancer and don't even know it?  Call this number now...

Form versus function

I am in Australia visiting family and friends for the first time in fifteen months.

I've lived in the UK for over six years now and the trips home get harder not easier.  Life moves on and because there are always new nieces and nephews to meet as well as old friends to catch up with, time becomes absurdly, depressingly precious.  Anyone who's lived away from their home for any length of time can testify to the horrible push-me-pull-you feeling that overwhelms the visitor the minute he gets off the plane.

I have about three weeks on the ground in Australia and my time is divided between family and friends on a 2:1 ratio; with my parents in beautiful Far North Queensland (I'm writing this from Mission Beach), with my sisters and their families on the farm where we grew up in country New South Wales and then with seemingly innumerable old mates in Sydney.

It's seeing the mates that creates the stress.  As time is so short at every turn I'm confronted with a simple choice: -

Do I opt for the form of the relaxed rhythms and banter of the old friendship but by so doing risk not getting a real sense of my friend's life or do I sacrifice some of the familiarity that made us friends in the first place on the functional altar of information expediently exchanged?

One feels too superficial yet the other can be brutally businesslike.  Damned if I do, damned if I don't.

Yet like many of the problems in my life, there are far worse ones to have than how to get on when seeing old friends.  I'm reminded of my favourite Christopher Hitchens quotation: -

"A melancholy lesson of advancing years is the realisation that you can't make old friends." 

A segment of one

The old cliche has it that the world can be divided into two types of people: those that divide the world into two types of people and those that do not.  Typically marketers fall into the former category and salespeople into the latter.  We pay marketers to make sense of the big wide world whereas salesmanship rewards an intense focus on the individual customer.

Much of the time I find that the segmentation strategies operate in much the same way as horoscopes: a point of post hoc analysis more interesting than useful from a sales perspective.

Segmentation strategies, predicated on the assumption that a market can be divided into discrete, identifiable, predictable (and thus exploitable) blocs, are like catnip to marketers.  There's nothing a product manager wants to cultivate more than an aura of prescience, omniscience if that can be managed.  There are plenty of strategic research consultancies who will happily take your money whilst promising you that aura.

Things are different in pharma.  Because the major comms channel available to marketers in most markets is the sales team, broad-brush segmentation models often clash with the salesperson's worldview wherein each prescribing doctor is unique.  Imposing a segmentation strategy on a sales team often adds an unneeded element of complexity into the mix and I'm often brought in to assist translating the marketing speak into sales action.  My question for marketers is this: -

A segmentation model implies that different customers will respond to different messages.  How many conversations do you want the sale rep to carry around in her head?

At the moment I'm involved in several such segmentation projects of varying degrees of sophistication.  The most unfortunate of these went live with the sales team recently.  A ham-fisted marketing presentation managed to be patronising of the sales team, which was in attendance, and contemptuous of the doctors, who were not.  It's generally a bad idea to portray a segment of your customer base as "just wanting a quiet life and more interested in his golf game than his patients".  It's an even worse idea to illustrate your point with cartoon imagery usually associated with Covent Garden street artists.

The sales team in question took it with a grain of salt, which is what experienced sales teams do when confronted with overwrought marketing efforts.  If each customer represents a segment of one then the return on effort for fashioning a plan for an individual is far higher than that for memorising 4-5 separate conversations that will apparently 'push the buttons' of the different types before deciding into which segment each customer belongs.

The unspoken challenge in all of this is that even if the strategy is correct and the market can be broken into four or five segments the salesperson still has to dumb down her knowledge of the customer so that he or she conforms to a certain segment.  If you can close your eyes and visualise an individual doctor then a cliched overview is going to be of partial value to you at best.

The stories we tell

For the last five years I've served on the board of trustees for a West London charity. We offer adult education in the form of Numeracy & Literacy and Information Communication Technology (ICT, aka 'computer skills') to unemployed and otherwise excluded people in North Kensington. The charity has been in operation for 28 years and the chief function of the board is to support our inspirational (and formidable) CEO.

As with all charities everywhere, attracting adequate funding is a constant battle. Our geography counts against us we are located in one of the most deprived wards in London (Golbourne) but that ward is in the richest borough in Britain (Kensington & Chelsea). This incongruence means that we attract less funding than similar organisations in the east of the city even though our students, many of whom are refugees and asylum seekers from places like Ethiopia, Somalia, the Sudan and Iraq, are equally deserving.

Lately I've been making a renewed effort to get friends and acquaintances to help us out financially; my strange, schizophrenic social circle includes quite a number of City Types who, at first glance, would be ideal benefactors to an organisation that is doing good work in their own back yard.

Not so much.

This is not to say that my friends aren't generous but rather that as you'd expect your typical City Type finds himself constantly targeted by a bewildering selection of charities representing good causes ranging from small theatres to the Guide Dogs to the local school to disabled kids to the alma mater. With wealth comes the right to pick and choose where you bestow your munificence.

In marketing terms this amounts to: -

Whose story moves me the most?

What I've learned is that even people with even moderately right wing views are not moved by the origin tales of foreigners. An entreaty that highlights a benighted past can result in a shrug of the shoulders or even something uglier. I've learned to save the stories of famine and refugee camps and even the obscene oppression of women for my lefty mates.

The narrative that motivates the right wingers is not where the beneficiary is from but where she's going. They are no less generous but words like 'motivation', 'integration' and 'aspiration' resonate where 'deserving', 'justified' and even 'humanity' fail.

As with any sales pitch it's all about the story; I've learned to distinguish what has already happened from what is yet to come.

Cold-calling a falling man

In these straitened times every client of mine is under pressure all the time.  The cultures of every pharma company pulse with implicit threat: -

Do more with less.  Do it sooner.  Do it right the first time or else...

Some days all of this makes self-employment feel a little better.  It feels as though I have more control over my destiny.  Arrant nonsense, of course, as there's nothing like a job scare to encourage a sales team to attempt a little DIY training.

This pressure on expenses is doubly felt by the pharmaceutical industry; not only is the sector going through the same GFC as everyone else but it faces a systemic threat in the number of hugely popular products that are coming off patent.  A branded medication can expect to lose as much as 80% of its sales within six months of patent expiry and by some calculations the big research companies (aka 'my clients') will lose a further $100 billion in sales to generic manufacturers in the next three years.

This is old news and the industry is responding.  Pfizer is closing research facilities in the UK and invest in sales teams in China.  Novartis has been positioning itself in the generics game with Sandoz since 2002.  Roche completed a takeover of Genentech in 2009 to try and dominate the biologics market.  This year Sanofi-Aventis has bought Genzyme and Takeda has bought Nycomed.  The M&A industry has plenty of reasons to love pharma.

This can make life a little tricky for a Headcount: 1 consultant trying a few cold calls but with one eye on his summer holidays.  Here's an ex-client's response to my friendly hi-how's-it-going email: -

Yes i do remember you.  It is probably not the right time to come in -- we have just been taken over by XXXX so things are a little unsettled at the moment.  Sorry can't help at this time

 Not my finest moment as a salesman.

How to dress like a consultant

In the past I've mused about the dangers of overdressing for meetings.  The reverse is also true; the Epicurean Dealmaker usually blogs on the inner workings of Wall Street but this week he's taken aim at a risible WSJ article on women's 'business fashion'.  In the consultancy game, whether you're a man or a woman, this is advice is worth heeding: -

Clients of professional service organizations generally do not want the people who work for them to be flashy, extravagant, or prone to calling attention to themselves.  They want service.  They want reliability.  They want sobriety.  Calling excess attention to yourself in any way that is not directly related to identifying, analyzing, and solving the client's needs is both offputting and counterproductive.

An old truism of the theatre is that you shouldn't ever perform in front of anything more interesting than your act.  In front of the client it's just as important to be more interesting than your clothes.

In life, actually.

White coats in far flung lands

No reader of this site would be unaware of the placebo effect (aka the 'white coat effect') which is usually defined as something like: -

The measurable, observable, or felt improvement in health or behavior not attributable to a medication or invasive treatment that has been administered

Your attitude to placebos is probably driven by your overall attitude to health care.  One side of the argument is that that anything that offers a sick person a respite from the effects of his disease has value.  People holding this view are renaming the phenomenon the placebo response; whatever it is that's going on is broadly on our side.  The opposing view is that what's being peddled is fraud and false hope; we're tricking the patient into believing that something substantial is being done and the fact that the patient's own brain is in on the ruse doesn't excuse anyone.

The placebo effect / response is the bete noir of pharmaceutical research.  If you've sunk upwards of half a billion dollars into developing a drug then 'no better than placebo' is not want you want to hear at the end of Phase III trials.  The brutal logic is that there's no point in subjecting the patient to an expensive treatment that is undoubtedly accompanied by a raft of side-effects when with a little encouragement the patient's own body can achieve the same response on its own.

And apparently we're seeing a strange increase in the placebo effect.  A few years ago Wired Magazine ran a great Steve Silbermen article entitled Placebos Are Getting More Effective.  Drugmakers Are Desperate To Know Why.  It tracks the work done by Dr William Potter, a researcher at Eli Lilly, who observed that new antidepressant and antianxiety medications were actually being overtaken by placebos in as many as nine out of ten trials.  Potter questioned two assumptions that are pivotal to clinical trials: -

1. If a trial is managed correctly, a medication will perform as well or badly anywhere in the world
2. The standard tests used to gauge volunteers' improvement in trials yield consistent results

It turns out that part of the problem stems from (surprise, surprise) the pharma industry's habit of scouring the globe for the cheapest option to undertake any necessary work; more and more clinical trials are using centres in Eastern Europe, Russia, China, India and Africa.  Something that's of great concern to the hand-wringing lefties of this week's Guardian: -

Places such as South Africa – where mostly vulnerable poor with low literacy levels are recruited and the culture is to accept authority without question – are fertile land for ethical misconduct

I accept that ethical misconduct of every kind is more likely in the less developed world (viz. Nestle infant formula) but I reject the knee-jerk implication that such exploitation is inevitable.  The irony is that the problem of the spreading placebo effect may be a result of exploitation in the opposite direction: -

A patient's hope of getting better and expectation of expert care—the primary placebo triggers in the brain—are particularly acute in societies where volunteers are clamoring to gain access to the most basic forms of medicine. "The quality of care that placebo patients get in trials is far superior to the best insurance you get in America," says psychiatrist Arif Khan, principal investigator in hundreds of trials for companies like Pfizer and Bristol-Myers Squibb. "It's basically luxury care."

Wired, ibid

When a Big Pharma company grandly states that its mission is to 'improve the lives of people across the world', I strongly doubt that the promotion of the placebo effect is what it has in mind.

The unreasonable man

Whereas back in UK the 1.7million-person cost containment system known as the NHS continues to frustrate all who encounter it, both within and without.

I've long been of the view that the scarcest resource in the entire network is human energy required of a health care professional who will fight for the good of the patient.  This is not to say that there's malice or even negligence at work but rather an inertia that elevates older and cheaper therapies over newer, more expensive ones.  Doctors are soothingly told to be reasonable, to avoid cruelly raising a patient's expectations with talk of state-of-the-art treatments.  All of which brings to mind the great GBS: -

"The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself.  Therefore all progress depends on the unreasonable man."

George Bernard Shaw

Which is certainly true of the NHS; drug budget blow-outs are avoided due to the reasonableness (read: exhaustion) of the staff.  An entirely unspoken aspect of the British pharma representative's job is to locate that rare unreasonable man.

More thoughts on Greece

Thinking further about the situation in Greece, Simon Kuper wrote an especially poignant piece in the weekend FT that compares the ordeal about to be thrust upon middle class Greeks with that of Argentinians in 2002.

And there was my Argentine friend who lost her mother.  The mother, a nurse, had fallen ill, deteriorated, and then died without ever being diagnosed.  Afterwards, my friend deduced that she had had a brain trauma.  Being a nurse, the mother had apparently diagnosed it herself, decided that treatment would be too expensive, and quietly died.  All these people felt disbelief.  This couldn’t be happening to them.  It turned out that there was no safety net, no benevolent state.

This goes well beyond what the pharma industry can alleviate: if there's no money for basic health care there's certainly no money for biologic agents.

The callous disinterestedness of the NHS

In the last month I've been out ‘on the road’ for three days observing sales representatives selling into the NHS.  As with any sales job the days are long and usually frustrating.  Busy doctors are always cancelling appointments.  The rest of the time gets filled with the strange burden of minor expectations that health care professionals, from the most senior doctor to the student nurse, have of the pharmaceutical industry.  Branded pens and Post-It notes have been banned but the ‘drug rep’ is still the conduit for funding for educational meetings here and abroad and for sandwiches (“We prefer a selection of wraps from M&S”) at least once a week.

What struck me hardest was the visible level of stress being carried by every NHS employee.  It had been a couple of years since I’d been out in the UK system and I was surprised by the universal interest in the price of the drug being sold.  Once upon a time only pharmacists and payers bothered to discuss cost; doctors and nurses didn’t sully their minds with such mundane financial matters.  But last week I watched a junior nurse, who is years away from prescriber status, quiz the rep about the comparative cost of rival treatments.  The nurse didn’t seem to be aggressive or point-scoring nor was he being clever for the sake of it; he just saw it as part of his job to understand the treatment options from a financial as well as a scientific-clinical standpoint.

I can’t think of another government department anywhere in the world where cost-consciousness pervades so thoroughly through the hierarchy as in the NHS.  Of course everywhere there are low-ranking teachers, police and perhaps even soldiers who are aware of their departmental budgets but not so consistently across an entire system.  By some counts the NHS is the second largest employer on the planet and every one of those employees has been trained to count the pennies. 

The taxpayer in me supposes that this is a good thing but I'm also sure that this cost-consciousness contributes significantly to the stress levels I saw in English hospitals.  No one ever went into the caring professions because they enjoyed the budgeting process yet this is now a substantial part of the job.

The reps I shadowed were selling expensive drugs.  This is true by definition: the only cheap drugs are ‘off-patent’ and so with insufficient margins to justify the formidable expense of a sales team.  With the NHS set up the way it is, any conversation with a drug rep is going to end with him asking for something that is difficult financially.  The medicine in question may amount to a revolution in the fight against a given disease but the health care professional is still left with the same old zero-sum game: - 

I cannot treat any patient as well as I would like to treat every patient

This has seeped into the organisation’s DNA.  Last year when the new Coalition government announced its Cancer Drugs Fund (CDF) the idea was for doctors to stop acting as financial comptrollers and get back to practicing medicine.  Yet the initial budget of £50,000,000 for the first twelve months will be underspent by a considerable margin.  This is not because Britain doesn’t have enough cancer sufferers to justify the money but because doctors across the country are genuinely suspicious about the long-term consequences of adopting newer, more advanced treatments in case the funding is later withdrawn

I've sat in on those sales calls.  I've seen doctors agree that there are patients under their care who would benefit from the drug in question.  But when the CDF is mentioned I've watched them narrow their eyes and ask for assurance that they weren't being tricked into changing their practice in an ultimately unsustainable way.  The logic being that it would be better to deny all current patients a better treatment if future patients would be denied it also.

 At the heart of the global financial crisis is the dawning realisation that for the first time in centuries we have to accept that future generations may lead less happy lives than us.  We are faced with the fact that the constant improvement in general wellbeing that the West has enjoyed since the mid-18^th Century is not inexorable.  If you work in the NHS then every day you're learning this unpalatable truth first hand: Britain cannot afford to keep offering every citizen continually improving health care.

By God that’s a stressful way to work.