As the National Health Service in England approaches its 70th birthday, the pressures it faces are arguably greater than at any time since its creation. A growing and ageing population with increasingly complex health needs is placing the service under significant financial and operational pressure. This is before we consider funding new treatments that offer the prospect of patients living longer and healthier lives. Despite planned year-on-year increases in the NHS budget, the service estimates that it will face an annual funding gap of around £20bn by 2020.
The NHS Five Year Forward View, published in October 2014, recognised these challenges and set out a vision for how the NHS needs to evolve. It placed emphasis on improving prevention and public health and developing new approaches to delivering healthcare by breaking down the barriers that exist between hospitals and community settings. The ambition is for a more collaborative and integrated approach to the delivery of healthcare with more services provided closer to where patients live.
Amgen – a worldwide leader in biotechnology – believes that the pharmaceutical industry can play an important role in supporting the NHS to respond to these unprecedented challenges. According to John Kearney, Managing Director for Amgen UK and Ireland: “We believe that the government, NHS and the life sciences industry have a collective responsibility to work collaboratively to improve patient care and health outcomes. This view has been reinforced by the growing appetite from local NHS organisations to work with us on this shared agenda”.
The Cancer Vanguard was established in the NHS to pilot and roll out new ways of delivering cancer care in order to improve diagnosis and detection, patient outcomes and experience of care as well as reducing variations in treatment. Spearheaded by leading cancer hospitals in London and Greater Manchester, the aim of the Cancer Vanguard is to develop transformational healthcare services that can be replicated nationally.
As part of its programme, the Cancer Vanguard is aiming to improve access to chemotherapy and other medications used in treating patients with cancer. Many of these modern treatments can be used outside of hospital, enabling new services to be developed closer to where patients live.
As Mr Kearney explains “When appropriate, providing treatments closer to patients’ own homes – or even at their homes – may be more convenient and improve their treatment experience. It can be positive for their family and carers as well. Patients can be relieved of the burden of potentially long journeys, waiting times in hospital and the need to delegate some of their personal commitments like work or childcare to others. They can also be spared the costs of travel to and from outpatient appointments”. The latter can be significant, with Macmillan Cancer Support estimating that patients treated for cancer spend on average £170 per month on travel.
The National Cancer Survivorship Initiative (NCSI), a partnership between the Department of Health in England, NHS Improvement and Macmillan Cancer Support, has proposed a ‘risk stratified’ approach to care planning. Patients who are regarded as high risk would continue to be managed by specialist teams, those at low risk are supported to self-manage, while those at moderate risk have their care shared between hospital and community based organisations. One of the key principles highlighted by the NCSI is the need for a shift from a ‘one size fits all’ approach to a personalised approach based on a holistic assessment of each individual patient’s needs, risks and preferences. As a general rule decisions on starting a course of treatment will continue to be taken by cancer specialists and the treatment is usually initiated in hospital before transferring to a community-based service with the patient and their carers fully involved in making an informed choice.
As part of its ‘Pharma Challenge’ initiative, the Cancer Vanguard invited pharmaceutical partners to submit innovative proposals that would quickly deliver an improved patient experience while increasing the effective use of NHS resources. A cross-functional and multi-agency panel that included chief pharmacists, hospital medical staff, local NHS leaders and patient representatives evaluated the proposals.
Amgen was selected by the Cancer Vanguard to work with University College London Hospital NHS Foundation Trust (UCLH) to look at the out of hospital administration of an injectable medication used to help prevent serious bone problems in patients with advanced breast cancer or other solid tumours who have developed bone metastases. This injection is commonly given to patients in hospital chemotherapy units even after patients have completed their chemotherapy treatment.
The project explored how out-of-hospital treatment allows patient care to be delivered closer to where a patient lives building on the principles of enhancing patient choice and improving treatment experience. These new services may also reduce pressure within hospital departments where cancer care is currently provided.
The project tested the efficiency of a range of out of hospital services that have the potential to be replicated at other NHS locations. The services included: primary care-led administration; a community outreach model; specialist nurse administration at home; home administration under the responsibility of a healthcare professional, and district nurse-led administration.
Project success relied on an experienced team of multi-disciplinary professionals, guided by specialist input from the NHS. This was fundamental to exploring how different healthcare providers can work together collectively towards an agreed common goal.
UCLH pharmacist Pinkie Chambers, who co-chairs the chemotherapy expert reference group for North Central and East London and West Essex, said: “Throughout this process, we have found that being able to overcome some of the system-wide barriers to implementing new models of care is crucial to our success in improving the delivery of cancer medicines to patients. We are excited to be working with Amgen to potentially bring the administration of medication closer to patients’ homes where appropriate.”
A simulation model was a key component. The model developed using insight and data from London and Manchester allows health commissioners and hospitals across the country to understand how medicines can be administered in the best way possible for patients and the NHS.
An Options Appraisal Document describes the out-of-hospital possibilities that have been considered. This includes practicalities, financial and workload implications for health managers locally to decide the suitability of each option for their own local service. Insights from the hospitals that have introduced new services are also provided in the form of case study reports, which include information on barriers to implementation and lessons learned. Patient feedback has been very positive with convenience and reduced travel and costs a common theme in those that favour out-of-hospital options.
The simulation and supporting materials have been made available to healthcare managers across England. As Dr Robert Urquhart, Head of Pharmacy and Divisional Clinical Director at UCLH reports: “This novel partnership between the NHS and the pharmaceutical industry has the potential to both improve patient outcomes and experience, whilst potentially saving the NHS money. Combining the first-hand experience and expertise of both the NHS and industry has been crucial to delivering a valuable outcome.
“The simulation model for out-of-hospital delivery will facilitate others in developing their own ways of delivering cancer medicines closer to home, for patients that wish to participate.”
As Mr Kearney concludes: “It is clear that the NHS challenge of improving patient care and health outcomes at a time when the demands on the service are only going to increase is not going to go away anytime soon. A collaborative approach between government, the NHS and the life sciences sector gives us the best chance of navigating these challenges and it will take leadership from all of us to make this a reality.”
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Nick Bruce is the director of value, access and policy at Amgen.
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