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Cancer: Meeting the challenges

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.

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Cancer: Meeting the challenges

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

  2. 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

  3. 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

  4. Cancer survival in the 1990s

  5. 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

  6. Progress on cancer • Survival rates are improving • Patient experience has improved (large surveys) • Mortality has fallen - especially in people under 75 years

  7. 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

  8. 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

  9. 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

  10. 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 PCTs Community awareness raising Primary care audits Better diagnostic services • Additional costs likely to be offset by reduction in late stage cancer (with expensive drugs). Economic analysis in progress.

  11. 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

  12. 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

  13. Richards Report 2008: Key recommendations • 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 • Patients who choose to pay for unfunded drugs should not be denied NHS care • NHS and private elements of care should be kept separate

  14. 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

  15. 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

  16. 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

  17. 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: william.gray@sheffieldpct.nhs.uk]

  18. 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

  19. 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.

  20. “Acute Oncology” services Problems • 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)

  21. 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

  22. National Cancer Survivorship Initiative Five shifts • Attitudes • From medical model to partnership/empowerment • From focus on disease to focus on recovery and well being • Better information • Individual care planning • Tailored support • Improved measurement

  23. 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

  24. 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’

  25. 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

  26. 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: Quality Innovation Prevention Productivity

  27. QIPP and Cancer: A possible framework

  28. Existing cancer developments and QIPP

  29. Cancer and QIPP: Looking forwards …

  30. 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

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