Cancer: Meeting the challenges Professor Mike Richards October 2009 BOPA/UKONS Brighton

Cancer:Meeting the challenges

Professor Mike Richards

October 2009

BOPA/UKONS

Brighton

Meeting the challenges: Overview

• Brief review of progress on cancer over the past decade

• Current and future challenges and priorities

• Emphasis on chemotherapy and patient-centred care

Cancer: 10-15 years ago• Long waiting times

• Lack of infrastructure (CT, MRI, Linacs, staff)

• Lack of specialisation

• Fragmented care within hospitals (surgeons, pathologists, radiologists, oncologists etc. not working together)

• Poor communication between 1º, 2º and 3º care

• Poor survival rates

• Poor experience of care for patients

Cancer survival in the 1990s

Cancer: What have we done?• Reduced smoking rates

• Improved screening

• Reduced waits: 14/31/62

• Invested in staff and equipment

• Established multidisciplinary team working

• Reconfigured services in line with NICE ‘IOGs’

• Established networks across 1º, 2º and 3º care

• Improved treatment (S, RT, CT)

• Improved supportive and palliative care

Progress on cancer

• Survival rates are improving

• Patient experience has improved (large surveys)

• Mortality has fallen - especially in people under 75 years

50

70

90

110

130

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170

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005

Standardised death rate (SDR) per 100,000 population

France

EU average

EU-15

England

Sweden

EU-12new

Best EU-15 countryWorst EU-15 countryEnglandEU average (all countries in the EU)EU-15 (member countries before 2004)EU-12new (member countries from 2004)

KEY

Male premature mortality from cancerAged under 65 years, England, EU-15 countries and selected averages

Source: England ONS Mortality data. Web link http://www.statistics.gov.uk/statbase/Product.asp?vlnk=6725 analysed by DH Analysts.All other countries - WHO, Health For All Database-Jul 2008. Web link http://www.euro.who.int/hfadb

Chart 3.13:

50

70

90

110

130

150

170

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005


France

EU average

EU-15

England

Sweden

EU-12new


KEYBest EU-15 countryWorst EU-15 countryEnglandEU average (all countries in the EU)EU-15 (member countries before 2004)EU-12new (member countries from 2004)


KEY

Male premature mortality from cancerAged under 65 years, England, EU-15 countries and selected averages


Chart 3.13:

40

50

60

70

80

90

100

110

120

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005

Denmark

EU average

EU-15

England

Greece

EU-12new


KEY

Female premature mortality from cancerAged under 65 years, England, EU-15 countries and selected averages



Chart 3.15:

40

50

60

70

80

90

100

110

120

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005

Denmark

EU average

EU-15

England

Greece

EU-12new


KEYBest EU-15 countryWorst EU-15 countryEnglandEU average (all countries in the EU)EU-15 (member countries before 2004)EU-12new (member countries from 2004)


KEY

Female premature mortality from cancerAged under 65 years, England, EU-15 countries and selected averages



Chart 3.15:

Cancer: Looking forwards

• The economic downturn will inevitably impact on the NHS and on cancer

• We know that we still have a long way to go to deliver our goal of world class outcomes

• Different approaches will be needed if we are to continue driving up quality

• This is the QIPP agenda: Quality, Innovation, Productivity and Prevention

Cancer: Challenges

• Increasing incidence (1.5% pa) and prevalence (3%pa)

• Survival rates are improving but are still poor cf. Europe

• Mortality is not falling as fast in older people as in younger people

• Inequalities persist (race, age, gender, deprivation, religion, sexual orientation)

• New technologies may improve outcomes, but some will be expensive

Cancer: A huge agenda• Prevention

• Awareness and early diagnosis

• Waiting times (e.g. for breast symptoms)

• Surgery – achieving optimal quality

• Radiotherapy – introducing new technologies

• Chemotherapy – ensuring quality and safety– improving access to new medicines

• Survivorship

• Reducing inequalities

• Transforming inpatient care

• Driving quality improvement through intelligence

• Stronger commissioning

National Awareness and Early Diagnosis Initiative• Late diagnosis results in 5,000-10,000 avoidable deaths from

cancer each year

• A combination of factors is almost certainly responsible Low public awareness Difficulty accessing GP services GPs missing diagnosis GPs having poor access to diagnostics

• Actions needed: Baseline assessments by PCTsCommunity awareness raisingPrimary care auditsBetter diagnostic services

• Additional costs likely to be offset by reduction in late stage cancer (with expensive drugs). Economic analysis in progress.

Chemotherapy

• Improving Access to Medicines for NHS Patients (Richards Report, November 2008)

• NCEPOD Report (November 2008)

• National Chemotherapy Advisory Group report (August 2009)

Elective chemotherapy – back to basics on assessment, delivery, monitoring etc.

Acute oncology – more effective management of acute complications of chemotherapy

Richards Report 2008: Background

• Some cancer drugs which were available in other countries were not being funded by the NHS

• Variations in decision making within England (PCTs) during interval between licensing and NICE decision

• Some patients who were choosing to buy unfunded drugs were then being denied NHS care

• “Top-ups” became a major issue for patients, clinicians, NHS managers and the public/media

Richards Report 2008: Key recommendations

1. NHS patients should have greater access to new medicines:

PCT processes to be improved

Improved timeliness of NICE appraisals

Flexible pricing (PPRS)

Greater flexibility from NICE for ‘end of life’ drugs

2. Patients who choose to pay for unfunded drugs should not be denied NHS care

3. NHS and private elements of care should be kept separate

Richards Report 2008: Other recommendations

• The extent and causes of international variations in drug usage should be investigated

• SHAs should ensure that … revised guidance is implemented properly

• The use of unfunded drugs should be audited

• Patients should be given balanced information

• Clinicians should be given extra communication skills training

International variations in drug usage (1)

• DH Advisory GroupCo-chairs: Mike Richards (DH) & John Melville (Roche)+ ABPI, pharma, clinicians and patients

• Looking at around 12 countries

• IMS Health as primary data source – with validation by individual companies

• Broad spectrum of conditions/drugs

International variations in drug usage (2)

• Cancer: ‘New’, intermediate and ‘old’

• CVD: Statins and thrombolytics

• Mental health: Anti-psychotics

• LTC: Arthritis, osteoporosis, MS

• Older people: Dementia

• Children: Drugs for RSV

• Ophthalmology: Wet AMD

• Infections: Drugs for hepatitis C

Audit of drug usage• Scope

Drugs turned down or restricted by NICE

Drugs approved through the NICE ‘end of life’ scheme

• Q1: How widely are these drugs being used? (IMS Health)

• Q2: Are commissioners being asked to approve unfunded drugs as exceptional cases? (PCTs)

• Q3: Who is paying for unfunded drugs? (Trusts)e.g. NHS, insurance or individuals

• Q4: What information are patients being given?

[Contact: [email protected]]

NCEPOD report (November 2008)

• Review of case notes of 546 patients who died within 30 days of chemotherapy

• Overall standard of care35% Good49% Room for improvement (mostly clinical)8% Less than satisfactory8% Insufficient data

• In 27% chemotherapy was judged to have caused or hastened death

• Problems identified at each step in the chemotherapy process

Chemotherapy Services in England: Ensuring Quality and Safety

• NCAG report published August 2009

• Recommendations related to:

Elective chemotherapy processes (chemotherapy care pathway)

Acute oncology

Infrastructure: Leadership, governance, training etc.

“Acute Oncology” servicesProblems

• Increasing emergency admissions of cancer patients

• Many have complications following chemotherapy

• Poor communication between general medicine and oncology services

• Long lengths of stay and poor care

Solution

• All acute hospitals to establish an ‘acute oncology’ service – bringing together A&E, General Medicine, Oncologists and Oncology Nurse Practitioners

• Improved quality and reduced costs (e.g. Whittington Hospital)

Living with and beyond cancer(Chapter 5 of the CRS)

• Patient information

• Communication skills

• Implementation of NICE supportive and palliative care guidance

• National Cancer Survivorship Initiative

• Patient Survey Programme

• Quality in nursing initiatives

• End of Life Care

National Cancer Survivorship InitiativeFive shifts

1. Attitudes

• From medical model to partnership/empowerment

• From focus on disease to focus on recovery and well being

2. Better information

3. Individual care planning

4. Tailored support

5. Improved measurement

Reducing Inequalities (Chapter 6)

• Understanding inequalities in incidence, survival and mortality by race, age, gender, disability, religion, sexual orientation, deprivation, rurality etc.

• Important new reports from NCIN (e.g. on men and cancer; ethnicity; age)

• Lifestyle factors are likely to account for most of the differences in incidence

• Late diagnosis appears to be a significant contributor to poor survival for ethnic minorities, older people and socially deprived

• Older people may be undertreated

Transforming inpatient care (Chapter 7)

• Ensure day case surgery is adopted whenever appropriate (wide variations in practice)

• Elective inpatient surgery

Enhanced Recovery Programme

• Emergency admissions

Avoid where possible

Streamline care

‘Acute oncology’

Enhanced Recovery Programme• A ‘new’ approach to elective surgery

• Applications to colorectal, orthopaedic, gynae and urological surgery (and probably other areas)

• Different preoperative, perioperative and postoperative care

• Good evidence base

• Clinical champions

• Potential to improve quality and reduce bed days (e.g. colorectal 13 6 days)

Challenge: To implement enhanced recovery across England within 2 years

QIPP and cancer

• The economic downturn will inevitably impact on the NHS

• Different approaches will be needed if we are to continue driving up quality

QIPP: QualityInnovationPreventionProductivity

QIPP and Cancer: A possible framework

QIPP CategoryQuality, innovation and/or prevention

Productivity

A Cost saving

B Cost neutral

C Low cost per QALY(e.g. <£5-10k per QALY)

D Higher cost per QALY(e.g. £10-30k per QALY)

Existing cancer developments and QIPP

Quality Innovation Productivity Prevention

Action on smoking

Screening improvements

Waiting times

MDT working

Clinical nurse specialists ?

Surgical training programmes

Radiotherapy upgrading ()

New drugs

Palliative care improvements

Cancer and QIPP: Looking forwards …

Qual. Inn. Prev. Prod.

• Enhanced recovery Cost-saving

• Acute oncology Cost-saving

• Cervical screening redesign Cost-saving

• Digital mammography ?Cost-saving

• Robotic surgery ?Cost-saving

• National Awareness and Early Diagnosis Initiative

?Low cost/QALY

• Radiotherapy ?Low cost/QALY

• New drugs High cost/QALY

Summary

• We have made good progress on quality of cancer services – but there is still a lot to do

• There are major opportunities for improving quality and productivity through innovation even during the financial downturn

Documents

Cancer: Meeting the challenges Professor Mike Richards October 2009 BOPA/UKONS Brighton