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

9. 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

10. 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

11. 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

12. 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.

13. 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

14. 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

15. 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

16. 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

17. International variations in drug usage (1) DH Advisory Group Co-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

18. 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

19. 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]

20. NCEPOD report (November 2008) Review of case notes of 546 patients who died within 30 days of chemotherapy Overall standard of care 35%Good 49%Room for improvement (mostly clinical) 8%Less than satisfactory 8%Insufficient data In 27% chemotherapy was judged to have caused or hastened death Problems identified at each step in the chemotherapy process

21. 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.

22. “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)

23. 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

24. National Cancer Survivorship Initiative Five 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

25. 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

26. 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’

27. 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

28. 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

29. QIPP and Cancer: A possible framework QIPP Category Quality, 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)

30. Existing cancer developments and QIPP QualityInnovationProductivityPrevention Action on smoking  Screening improvements  Waiting times  MDT working  Clinical nurse specialists  ?? Surgical training programmes  Radiotherapy upgrading  ()() New drugs  Palliative care improvements 

31. 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

32. 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