UK-USA Models of Chemotherapy Service Delivery

1. UK-USA Models of Chemotherapy Service Delivery Professor Roger James Clinical Director, Kent & Medway Cancer Network Rem: Birmingham, June 25th 2003

2. Summary - 1 • What is already known ? • Rapid change (ASCO), patient-driven • Worldwide exponential growth in the uptake of chemotherapy (quantity) introduces a quality risk (adverse events) • 30% of ‘first treatments’ are chemotherapy • lung, upper GI, ovary • implications for waiting times data • protocols are national or international • most chemotherapy delivered in the ‘ambulatory’ setting • USA mostly office-based • UK mostly Hospital-based

3. Summary - 2 • What does our research add ? • Deficiencies in both the UK and USA models • Similarities between the UK and USA models • USA ‘Disease management’ contains elements of UK ‘Clinical governance’

4. Background - 1 • UK chemotherapy model • emerged through radiotherapy centres/departments (hospitals) • now added units • National service framework • JCCO documents • Standards/accreditation • Intrathecal Policies • NICE

5. UK traditional system- hospital-based (Cancer Centre) • Disadvantages • Demand outstrips capacity • Patients travel large distance • Non Cancer Services • (Emergency room etc) • ‘clogs’ system • Outpatients inappropriate • No meeting rooms LARGE GENERAL HOSPITAL

6. Background - 2 • USA chemotherapy model • 70% office-based • Funding • Insurance-funded by multiple institutions • 1994 - defeat of Clinton Healthcare reform act • 1995-2000 - defeat of ‘managed care’ • 2000 - emergence of ‘disease management’

7. USA traditional system- office based insurance reimbursed chemotherapy • Disadvantages • No radiology/pathology services • No pharmacy reconstitution • Discourages pre-booking • No meeting facilities • Practitioner isolated • No protocol control O F F I C E S

8. What did we do ? • Collaborative UK/USA research • multiple visits to 11 units • Kent • 7 NHS units • 2 Private Sector Units • New York • 2 ‘ambulatory’ Units • Process mapping • decision-tree mapping (oncology/nurse/pharmacy) • collection of forms

9. What did we find ?1 - good features of practice • Similarities (good practices seen in both UK and USA) • Paper-based protocolised care • Policies for practice • Disease management • Differences (good practices seen in either the UK or the USA) • UK - National guidance/networks • USA - Nurse practitioners/IT billing/’ambulatory centres’/ research is ‘good’

10. What did we find ?1 - bad features of practice • Similarities (bad practices seen in both UK and USA) • few electronic protocols • no QA systems • Differences (bad practices seen in either the UK or the USA) • UK - isolated, unco-ordinated units, oncologists often based in Centres, research centralised • USA - Office-based practice drives pharmaceutical industry

11. Moving Closer

12. UK modernised system Network of ‘cancer units’ + off-site reconstitution

13. USA modernised system Network of ‘one-stop’ shops + off-site reconstitution

14. Kent & Medway Network - work completed • Drugs/Therapeutics Committee • standard DOG protocols • NICE commissioning • Chief Execs • agree risk-management project - 2 posts, committee • Action sheet • network standardised, collects date of decision to treat • Reconstitution project • Electronic prescribing project

15. Kent & Medway network- work to do • Risk management project • agree goals/timelines • agree ‘ambulatory’ model (24/7) • develop new network standards (TQA, clinical trial[NCRN], intrathecal) • Workforce/training • re-skilling/accreditation • Implement Reconstitution • Implement Network-based Electronic Prescribing

16. New Standards

17. Summary - 2 • What does our research add ? • Deficiencies in both the UK and USA models • Similarities between the UK and USA models • USA ‘Disease management’ contains elements of UK ‘Clinical governance’ • Can we share our experience ?