BOPA & UKONS Conference 2009

BOPA & UKONS Conference 2009

The first ever joint BOPA (British Oncology Pharmacy Association) annual symposium and UKONS (UK Oncology Nursing Society) annual conference took place this month in Brighton. A total of 675 delegates attended over the 4 days, and the busy exhibition hall, which held 53 stands, contributed a vibrant feel to proceedings. But with more than 50 talks, meetings and workshops, not to mention numerous posters, the emphasis was firmly on work.

The overarching feeling of BOPA & UKONS 2009 was one of mutual respect, collaboration and shared priorities—for example, it was abundantly clear that pharmacists and nurses alike want to play an active role in research and drug prescribing. So successful was this first joint venture that it felt like the wedding reception of what promises to be a long and happy marriage.

Managing chemotherapy-induced nausea and vomiting

The first highlight was a double-hander from
Elaine Rankin, Professor of Cancer Medicine, and Alan O’Kane, Specialist Pharmacist, both from Ninewells Hospital, Dundee, on the management of chemotherapy-induced nausea and vomiting. Elaine explained that although nausea and vomiting is one of the most distressing aspects of chemotherapy, it can be controlled in 80% of patients. Unfortunately, many primary care organisations regard modern anti-emetic regimens as costly and unnecessary—despite evidence that inadequate management of nausea and vomiting can lead to reduced or delayed chemotherapy dosage and thus sub-optimal treatment.

During questions, it emerged that a 3-year, nurse-led audit in a Bournemouth hospital had shown anti-emetics were cost neutral if bed days associated with the management of nausea and vomiting were taken into account.

Alan O’Kane presented a survey of adherence to the Multinational Association for Supportive Care in Cancer (MASCC) guidelines on anti-emetic regimens. Adherence to the recommended drug regimens improved symptoms by 20%, a figure that proved statistically significant. The general consensus was that to gain local approval for the use of modern 
anti-emetics, oncology professionals might need to show that these regimens reduce inpatient care.

National policy—challenges and opportunities

Already the mutual admiration between BOPA & UKONS was evident to all, but there was little time to reflect on the seaside romance. Fresh from the National Cancer Survivorship Initiative (NCSI) conference in September, Mike Richards, National Cancer Director for England, delivered an interesting talk on the challenges and opportunities afforded by the new national initiative known as QIPP (Quality, Innovation, Productivity and Prevention). Delivering QIPP will be a serious business, given that the incidence of cancer is still climbing—probably a reflection of our ageing population—as is the number of people living with cancer. Also, according to Mike, early diagnosis in the UK still lags behind Europe, contributing to as many as 10,000 avoidable cancer deaths in the UK annually. He attributed these disappointing statistics to a combination of low public awareness of the early signs of cancer, poor access to GPs, poor diagnosis by GPs, and GPs having poor access to diagnostic services. He proposed the following actions:

• Baseline assessment by primary care organisations
• Raising of community awareness of screening and reporting of cancers
• Primary care audits
• Better diagnostic services

He suggested that the extra cost of these actions would be offset by a reduction in the numbers of patients with late-stage cancers requiring expensive treatments.

Mike finished off his talk with a brief summary of the NCSI’s five key recommendations. These were:

• An attitude change from ‘medical’ to ‘empowerment’, to shift the focus from disease to recovery and wellbeing
• Better provision of information for people living with and beyond cancer
• Assessment and care planning, aimed at understanding individual needs
• Tailored support, based on care planning, starting at the point of diagnosis
• A stronger focus on measuring experience and outcomes for cancer survivors

Answering questions, Mike gave two take-home messages—it helps to be able to demonstrate where you have given benefit, and, that although we are making good progress, we can still improve services without driving up costs.

National policy

Oncology pharmacy perspective

Following on from Mike Richards, Anne Hines, Network Pharmacist at Merseyside and Cheshire Cancer Network, pulled no punches. She began her talk by saying that the recent National Confidential Enquiry into Patient Outcome and Death (NCEPOD), “highlighted complacency and shoddiness throughout the UK.”

From her pharmacy perspective, the recently finalised recommendations on acute oncology services, issued by the National Chemotherapy Advisory Group (NCAG), represent huge challenges, but also opportunities. With more patients being treated closer to home or on non-specialist wards—by non-specialist pharmacists—Anne raised concerns about accurate communication of drugs and therapy regimens. She was also concerned about the sources of pharmacy advice available to support out-of-hours care. Previously, it was the pharmacist and the oncology nurse who checked chemotherapy before any drug was given, but traditional roles and boundaries are becoming blurred.

In response to these worries, Anne revealed details of a 3-year plan from BOPA, to include web-based education and training at both a local and a regional level, with relevant accreditation. Additionally, she recognised the desire for pharmacists to carry out research and proposed that there should be a BOPA research network, as well as a BOPA research award. She also commented that the Cancer Network Pharmacists Forum was looking at better commissioning and suggested that pharmacists need to raise their game on horizon scanning, policies, procedures and alerts, as well as NICE appraisals and patient access schemes.

She stated that recent reports, such as the document from NCAG, far from being “all doom and gloom”, were actually empowering nurses and pharmacists to ask awkward questions, check everything and have the courage of their convictions. Together, she felt sure nurses and pharmacists could achieve great things.

Nursing perspective

Taking the baton from Anne was Elaine Lennan, Nurse Consultant, Southampton University Hospitals. She also saw NCAG as an opportunity for nurses and was optimistic about acute oncology services going online by 2012. One area for improvement, she envisaged, was management of treatment complications, which could be dramatically improved by proactive monitoring. Febrile neutropenia (FN) was a matter of particular concern and an opportunity for nurse triage—with the goal being a door-to-needle time of 1 hour. The obvious benefits of proactive nursing and prevention of FN would include a huge reduction in bed days as a result of fewer hospital admissions associated with these side effects. 

Accurate monitoring of FN and other complications would enable nurses to assess their performance and demonstrate their worth. However, nurse involvement could go even further, to include liaison with commissioners—to inform them about the complexities of chemotherapy—and of course, prescribing. 

As a non-medical prescriber, Elaine insisted she was not seeking to “take over” from doctors, or to initiate a turf war with pharmacists; rather, she would like to see greater collaboration and team spirit. And, as she pointed out, with increasing delivery of chemotherapy outside of the oncology ward—in outreach centres, in the patients’ own homes, and even on the ‘chemobus’—the most appropriate person to prescribe may be the cancer nurse specialist (CNS) who is actually present.

Delivering high-quality care

The main reference point of the presentation by National Clinical Director for Hospital Pharmacy, Martin Stephens, was Lord Darzi’s pharmacy White Paper High Quality Care for All, published in January 2009. His first concern was that pharmacy’s contribution would be seen as mainstream rather than peripheral. With regard to cancer care, he felt that BOPA should become a professional body akin to a royal college, and exert a real influence on government policy. 

The latest thinking is that there should be clinical pharmacy teams across the whole health community, and Martin wanted to see this reflected in oncology. Quoting the White Paper, he said that there was a need for “robust mechanisms for chemotherapy at home”—something that BOPA should tackle. The move to primary care and home care needs to be safe and effective, but the huge growth in chemotherapy has not always been matched by resources—and this is where the challenge lies. Martin cited several contributory challenges, ranging from practical issues such as correct preparation and delivery of chemotherapy drugs in the community rather than on the ward, to strategic issues such as supporting procurement teams. 

The core of Martin’s talk was the balance between quality and efficiency. He defined quality as a combination of safety, effectiveness and good patient experience. By safety he meant that “never events” must remain “never events”. (The NHS defines “never events” as serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented). Effectiveness, he said, should be defined more precisely through outcomes-based research, and patient experience would be improved by:

• Involving patients in treatment choices
• Basing treatment on the patient, not on products
• Ensuring that patient dignity is upheld

According to Martin, there are four 'states' when it comes to quality and efficiency:

1. Concentrating on efficiency delivers successful cost containment, leading to improved productivity in narrow terms, but also poorer quality care
2. Improving quality without regard to cost, leads to cost inflation and inefficiency
3. Making poor cost-containment decisions leads to restricted resources, reduced quality and poorer productivity—a vicious circle of worsening cancer care provision
4. Improving quality eliminates waste and drives up efficiency. This ‘virtuous circle’ is achievable only by concentrating on quality—not efficiency

Patient access schemes

Introduced (tongue-in-cheek) as a heated debate by Sean McGrath of Succinct Healthcare Communications, the session entitled: “Access schemes in oncology—do they work?” promised to be a major event of the conference. As it turned out, the protagonists were eminently reasonable and considered—and as a consequence generated more light than heat.

First up was Matt Harpur, Senior Policy Manager, Medicines, Pharmacy and Industry Group, Department of Health, who gave a thorough account of patient access schemes (PASs) and why he thinks they are necessary. His main argument was that because of international reference pricing, companies were more likely to ignore the UK market than lower their list prices to suit our budgets—furthermore, he suggested that although there is sometimes uncertainty about patient response or duration of treatment, there is also potential for patients to benefit from innovative medicines. In these cases, patient access schemes are helpful—particularly in areas of unmet need.

Whilst proposing that PASs were useful and necessary, Matt did acknowledge that they came with an obvious cost burden—and an administrative burden. He suggested that all PASs should be clinically robust, have measurable outcomes where appropriate (e.g., bortezomib given to patients with relapsed multiple myeloma, where response to the drug is measured by serum M protein), and should not impose a disproportionate administrative or financial burden on the NHS. He also acknowledged that a proliferation of subtly different special offers and dose caps could cause difficulties, as could the uncertainty around NHS uptake of PASs currently in NICE appraisals.

Steve Williamson, Consultant Pharmacist, North of England Cancer Network, then took the floor to tell us that whilst he had been happy, initially, that North of England Cancer Drug Approval Group (NECDAG) was an early adopter of PASs, thereby acquiring drugs before they received NICE approval, he now urges caution because of the heavy administrative burden these schemes impose. He described PASs as “The Good, The Bad and The Ugly”, backing up this description with the results of a cold survey he undertook into the administrative burden. The additional administrative time required varied from an acceptable 16 minutes per patient to a more problematic 37 minutes. Steve suggested that a good scheme would be one where transparency and a range of options were built in, and which had a minimum impact on workload. He concluded that PASs were here to stay and the real question was not ‘do they work?’, but ‘how do we make them work?’

In the open discussion the speakers agreed that for PASs to work there had to be a reduction in the administrative burden, something Matt Harpur said was going to be dealt with by a PAS liaison unit (PAS-LU), that would be separate to other NICE endeavours. There was also a general consensus that dialogue was vital and it would be useful if pharmacists could talk to the pharmaceutical companies before NICE became involved.

BOPA Chairman, David Thomson, added it was important for industry to communicate with PAS-LU rather than with individual pharmacists, to ensure a central, consistent approach. This met with approval from all sides and the debate ended with no one harbouring any lingering doubt that PASs were here to stay.

BOPA 2010

So that was BOPA & UKONS 2009—the first joint annual event for the two bodies and a very successful seaside rendezvous. The common themes were of collaboration and mutual respect, a desire to be more involved in research and prescribing, and a recognition that better ways of working will be required to face the challenges of the new economic climate. Next year’s 13th Annual BOPA Symposium is set to be held at the Manchester Central Conference Centre between Friday the 15th and Sunday the 17th of October 2010. The hope is very much that UKONS will be there too.