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Commissioning Cancer Drugs and Services: Shared Strategies For A Common Goal

May 2008

Commissioning cancer drugs and services: shared strategies for a common goal

In the previous issue of Cancer Services Forum, the Cancer Reform Strategy was outlined and then commented upon by Mr Dominic Conlin, from a commissioner’s perspective, and Dr Alison Jones, from a clinician’s perspective, thereby providing a summary of the topics discussed at the morning session of the London Cancer New Drugs Group (LCNDG) meeting that took place earlier this year. To view that issue, please click here.

In this issue of Cancer Services Forum, commissioning of cancer drugs is explored in more detail, specifically with respect to prioritisation of new treatments from a public, ethical and legal perspective. This focus reflects the afternoon session of the LCNDG conference.

Contributors to this issue are:

There is no doubt that this year’s LCNDG meeting was well received by the delegates, whose feedback highlights particularly the store placed in the opportunity offered by the event to share experiences and discuss developments with colleagues from across the UK. Indeed, from the melange of commissioners, including almost 100 representatives from primary care organisations (PCO), many pertinent points and pointed questions were raised.

If you have a point to make or a question to ask, on any aspect of cancer services provision, please write to Abbie Pound, Editor, Cancer Services Forum. Letters should be no more than 150 words and submitted to csf@succinctcomms.com. Letters received will be considered for publication in a future issue of Cancer Services Forum.

  

Whither public confidence in the NHS?

Provided by Jonathan Nicholls, Research Director—Health and NHS, Ipsos MORI Social Research Institute (jonathan.nicholls@ipsos-mori.com)

It goes without saying that the NHS will always have a high political profile. Any service that spends £100 billion (that’s 0.3% of the total GDP of the planet), that has tripled its investment over a decade and that employs 1.3m people is bound to be one that ministers pay attention to.

The tough question is why the public remain so sceptical about it. We know from Ipsos MORI’s tracking data that when you ask people who have been patients of the NHS, 70–80% say they’re satisfied with it. But despite these relatively high ratings from the people who use the service, the proportion of the general public who say they are satisfied with the NHS is much lower. And our data also show that public pessimism about the NHS is greater than for any other service in the public sector (see Figure 1). It seems that even when patients report having a good experience of the NHS, they put that down to ‘I was lucky’; they do not seem to generalise from these experiences to a more positive view of the NHS as a whole. The question is why?

Figure 1

Figure 1

 

Figure 2

Our review of the data has identified a number of factors that appear to drive public dissatisfaction, and these go some way towards explaining the relatively low levels of public satisfaction (see Figure 2).

  

However, an emerging hypothesis is that public dissatisfaction is also being driven by the public’s expectations of the NHS being unrealistically high. This is particularly true in relation to people’s expectations about what treatments should be available through the NHS: nearly three quarters believe the NHS should be providing its treatments regardless of cost (see Figure 3).

Little wonder then that some of the stories that hit the press appear to generate such outrage. If people expect drugs to be provided regardless of cost, then when the NHS is unable to prescribe such drugs, this may be seen as the NHS denying people their rights. This takes it out of the domain of an economic debate about what the NHS can afford, and into more emotive territory, what some may interpret as a breach of trust by the NHS.

And it may be this goes some way to explaining the paradox noted at the start of this comment. Even when patients like the service they are getting, the public are feeling increasingly pessimistic about the NHS: it’s no longer doing what it ought to be doing—and people are feeling let down. (And by the way, even if funding decisions are made by other bodies like NICE or the Department of Health, it’s likely to be that—in the public’s eye at least—the NHS will take the rap.)

For the moment this is conjecture—and currently we are actively looking to see what evidence supports this. But, if true, it should give real cause for concern: the ageing population and increase in conditions like obesity are going to put more pressure on the service, and more tough decisions about what the NHS can afford will need to be made. As this starts to bite, then no matter how good the quality of service given to individual patients, expect pessimism about the NHS to increase.

Figure 3

So how does the NHS break out of this cycle? The answers are clearly not easy, but an important part of the solution is surely for the NHS to get the public more actively engaged in this debate. At the moment, decisions on drugs are made centrally, and feel like they are ‘done to’ the public. To break out of this, there needs to be a much more active debate with the public about what it’s reasonable to expect from the NHS, and what the health system should and should not realistically fund. Who knows, maybe an engaged public will make the same decisions. The point is, the more the public are engaged in these debates, the less it can be seen as the NHS denying people treatments, which can be an important backstop in shoring up public confidence in the NHS.

Jonathan Nicholls is a Research Director at Ipsos MORI, and head of NHS and Public Health Research. He can be contacted at jonathan.nicholls@ipsos-mori.com or on 020 7347 3110.

To comment on this article please click here.

  

Improving outcomes

Provided by Abbie Pound, Editorial and Publications Manager at Succinct Healthcare Communications and Consultancy

Not so long ago, the North East NHS was receiving a lot of criticism for failure to prioritise cancer drugs effectively—individual cases highlighting through high-profile media coverage the pressures facing the decision makers. Today, however, cancer networks across the country recognise they have a lot to learn from the North of England Cancer Drug Approvals Group (NECDAG). At the LCNDG conference, the Network Director of the North of England Cancer Network, Moira Davison, explained about the group.

When considering the introduction of a new cancer drug, it is critical to first assess its clinical and cost effectiveness and also to determine whether the local healthcare economy can afford the budget impact. While consistency of approach is crucial, each drug must also be assessed on its own merits.

NECDAG was formed in May 2005 to facilitate equitable access among patients with cancer in the North East Cancer Networks to a clinically defined, appropriate range of cancer medicines. Acting as an expert body within the North East, the group makes decisions about the availability of new and existing cancer drugs. For NICE recommended drugs, NECDAG provides advice to PCTs with respect to the likely financial and service impact of their introduction, while for those not due to be reviewed by NICE for at least 6 months it gives a ruling for or against their use—on average, this decision is made 6–9 months pre-NICE. To this end, the group actively horizon scans for new drugs (encouraging their use in clinical trials as appropriate), prioritising potentially curative drugs and those with palliative properties, but also supports and then evaluates implementation through audits, which feed the decision making process and also determine the appropriateness of decisions made, disinvestment following where appropriate.

As well as new drugs for cancer, NECDAG considers new indications for old drugs, new combinations of drugs, hormonal, supportive and other licensed new or novel treatments and unlicensed medicines (though only in exceptional circumstances). It also reviews policy on medicines used for unlicensed indications, e.g. FEC-T for breast cancer. Recommendations are made, according to the process shown in Figure 1.

  

The group meets four or five times a year and decisions are based on 75% majority among a group within which at least three of the five PCT clusters in the North East are represented. Crucial to the success of the group is the level of commitment—discussion is often arduous and difficult, with clinical, cost and patient implications all considered at the same meeting. In the event of lack of unity, the final vote rests with PCT commissioners. Submissions are sent to the group for consideration electronically on the ‘New Product Request’ form and are presented to the group by a nominated member of the Tumour Site-Specific Group. Network pharmacists provide cost analysis and support. Once a decision has been reached, PCTs or Trusts are informed of it within 7 days. Of note, the public and press are kept informed about when the group is meeting, what they will be discussing and all decisions made via the NECDAG website.

Since its inception, many valuable lessons have been learnt. The group is effective because of the commitment made by those involved to abide by decisions (PCTs and commissioners—e.g. funds follow decisions) and the level of representation within the group (action at chief executive level), but also because of the transparent nature of NECDAG and the tough decisions made—clinicians and patients view the process as a fair one and are generally happy to accept the group’s rulings. NICE standards are used for assessing evidence and NICE decisions ultimately adhered to. Looking forward, to continue to be able to offer patients in the North East the best medicines, mechanisms are needed to:

 

  

There are many challenges still to be faced, marginal benefit, patient and public pressure, the issue of co-payment and increased scrutiny in response to higher profile, to mention but a few. Generally though, NECDAG is proving both effective and credible. There is no reason why such a group cannot be set up elsewhere; however, a regional approach is essential. Those considering this approach should also bear in mind certain caveats—while NECDAG has improved equity of access to cancer drugs within the North East, for example, regional postcode prescribing remains an issue because of differences in prescribing elsewhere in the country.

Of course, NECDAG along with similar groups countrywide would not be necessary if NICE were more timely—the recommendation of the Cancer Reform Strategy and the Department of Health Select Committee that NICE review all drugs in line with licensing approval is the ultimate goal.

Prioritisation in London and Herts

Provided by Alastair Whitington, Network Director, SE London Cancer Network, London

The role of NICE is to ensure that all patients have access to clinically appropriate and cost effective treatments. Once recommendations are made, they are expected to be implemented; however, the process of gathering and reviewing evidence takes an average of 18 months and, in the event of appeals, final guidance may take up to 3 years to be published.

In the absence of NICE guidance, it is for the PCT to determine whether or not to fund a drug for their population. This process has historically been managed through applications for non-NICE approved drugs being referred for consideration by PCT panels for funding as Exceptional Treatment Authorisations (ETAs). With each PCT operating independently and varying degrees of expertise in the gathering and assessment of available information, inconsistencies of approach inevitably arose, resulting in postcode prescribing.

An LCNDG analysis of London expenditure on new cancer drugs showed a 430% increase in overall investment in new NICE approved cancer drugs over the past 7 years. In addition, over the past 4 years, there has been a significant increase in expenditure on non-NICE approved drugs, suggesting a rise in the number of ETA requests and an associated increased potential risk of individual PCTs funding drugs, which have little clinical benefit.

An analysis of the prioritisation and approval process for non-NICE approved drugs in the five London and Mount Vernon cancer Networks (the LCNDG sponsors) revealed a variety of approaches, although all inevitably featured a significant reliance upon the ETA process.

Every year, Network management teams used to facilitate a horizon scanning exercise. They assessed new non-NICE approved drugs and looked at changes in indications of existing drugs based upon LCNDG recommendations and local knowledge. The aim? To determine which drugs are likely to impact upon the Network over the next financial year.

  

In Hertfordshire, the process included consideration of the wider health needs (beyond cancer) of the PCT population and involved looking at four key areas:

Some PCTs simply used the horizon scanning exercise to understand the case in preparation for ETAs rather than to approve drugs in advance. Furthermore, in financially challenged times when PCTs found they could only fund NICE mandatory recommendations, horizon scanning became redundant.

The horizon scanning was undertaken by either individual Site-Specific Groups or collectively by the Network or Cancer Centres Drugs and Therapeutics Advisory Committees (DTAC), enabling clinical engagement in the process.

Although clinicians engaged in the prioritisation process can find discussions on palliative versus curative treatments painful, overall there have been positive benefits in their owning the outcome and being clear as to the rationale behind any decision.

Efforts had been made to estimate the financial cost of each individual drug; however, this proved to be an imprecise science, and a ‘basket approach’ (calculation based upon total estimated cost of all new drugs) was considered a safer option.

Following the horizon scanning exercise, the conclusions and supporting evidence were presented to the PCTs, and Networks were able to indicate the financial provision PCTs would need to make in the forthcoming year. Although Network management might encourage PCTs to ‘risk share’ the potential costs by the ‘pooling’ of funding, PCTs generally decided to carry their own risk and individually decide what would be funded, though often this was only determined following the outcome of the ETA process. Although PCTs always hold responsibility to determine funding priorities, by acting independently, with a heavy reliance upon the ETA process, they risked inconsistency in decision making and inequity both between and within Networks.

  

In SE London, the increasing number of ETA requests, time involved in processing them and the wish for equity and consistency of approach lead the PCT Commissioners to seek a process that would enable PCTs to prioritise investment in new non-NICE approved drugs prior to the year’s commencement rather than deal with them ad hoc through the ETA process. The task to develop this process was delegated to the Network management.

The LCNDG has, over the past 6 years, come to be recognised as a valuable source of information and an organisation that can help to make decisions about the use of new treatments where NICE guidance is not available. Having established the appraisal of evidence, the Network management developed a tool in conjunction with the clinicians to assess and prioritise LCNDG recommendations. The prioritisation was undertaken at a meeting attended by clinicians and commissioners and culminated in the SE London Executive Commissioning Group agreeing to fund LCNDG recommended drugs and those highly prioritised drugs that the LCNDG have approved or will review in 2008/9.

This process, seen as fair and transparent, was welcomed by both clinicians and commissioners and provides a clear understanding as to the provision of new drugs in 2008/9.