QIPP: the cancer drugs perspective

Dear Colleagues,

Welcome to the August 2011 issue of Cancer Services Forum.

This month we feature an article on QIPP—Quality, Innovation, Productivity and Prevention—written by Richard Hancox, Chief Operating Officer at Nuneaton and Bedworth Clinical Commissioning Group. Richard looks at QIPP from the perspective of cancer drugs prescribing, and considers how the QIPP agenda is being used to address the current financial problems affecting the NHS.

Look out also for next month’s issue, which will present an NHS and Department of Health update by Carolyn Staines of Succinct Healthcare Communications. These updates provide a useful resource for readers, and are scheduled to become a regular (i.e. bimonthly) feature of Cancer Services Forum.

I hope you enjoy this month’s issue. If you would like to have your say on any of the subjects discussed, please email me at csf@succinctcomms.com or post your comment online at www.canserforum.com.

The Editor

Cancer Services Forum

Richard Hancox, Chief Operating Officer, Nuneaton and Bedworth Clinical Commissioning Group

Introduction

Although the NHS has a settlement that provides an annual inflation uplift on existing budgets for the next 3 years, the financial equation remains very challenging. There are several reasons. For example, the ageing population will make increasing demands on healthcare. In addition, the cost of NHS inflation is driven by technological advance, and is running ahead of general inflation. Indeed, it has been recognised that if the NHS carries on spending as it does now, the potential gap between the resources required and the resources available will be up to £20 billion by 2014/15.¹

In this article, I explore the challenge from the national perspective, and some regional and local plans that focus specifically on cancer drug prescribing.

QIPP: the national agenda

The NHS is required to respond to the current financial challenge by adopting a strategy which recognises that:

• Variations remain in the quality of health, care, and use of healthcare services, and there are opportunities to significantly improve quality through raising ‘the many’ to the levels of ‘the best’
• In many instances, improvement in quality can lead to lower costs, e.g. through reducing rates of disease
• Some NHS activity is of low clinical benefit, and it is inappropriate in times of economic restraint for such activity to be allowed to crowd out activity that offers greater clinical benefit

Nationally, the various aspects of the financial challenge to the NHS have been brought together under the banner of QIPP—Quality, Innovation, Productivity and Prevention—and all local organisations in the NHS have been developing plans to realise the opportunities that it offers.

Expert assessments of the QIPP challenge² have led to the suggestion that, in principle, the opportunities for improvement and the value associated with them can indeed more than bridge the potential financial gap.

Achieving such levels of savings will require an unprecedented degree of cooperation between all organisations in a local ‘health and care system’, working together rather than in isolation.

This need to work together creates an unprecedented leadership challenge for the service.

Regional response: the West Midlands

Each cluster of primary care trusts (PCTs) across the West Midlands has produced a draft system plan, to identify how the QIPP challenge for 2011/12 to 2014/15 will be met within each local health community. These plans show that although all clusters uniformly identify cancer as one of the largest causes of premature death, the contribution towards meeting the QIPP challenge from cancer services is much less uniform across the localities. Only one cluster identifies a potential saving from the redesign of cancer services, and one other earmarks cancer QIPP savings as a potential contingency, should the QIPP plans identified in other service areas deliver insufficient savings.

In a personal review of the system plans in the West Midlands (which are as yet unpublished) I identified the following principal areas of focus for cancer:

• Pathway redesign (e.g. 23-hour breast surgery pathway)
• Improved screening
• Social marketing (raising awareness of the signs and symptoms of cancer)
• Prevention (e.g. schemes to promote tobacco control, reduced alcohol consumption and weight management)
• End-of-life care (e.g. fewer avoidable hospital admissions, reduced hospital stay, effective discharge from hospital)

One cluster highlights the potential to improve quality while reducing cost in relation to cancer prescribing, specifically in relation to high-cost drugs.

Overall, the analysis of the draft system plans in the West Midlands suggests that the potential opportunities to realise QIPP gains from the perspective of cancer drugs commissioning have yet to be fully recognised by NHS commissioners.

Cancer prescribing: network level

Benchmarking

How then can PCT clusters and the new GP commissioning consortia address QIPP in terms of cancer prescribing?

Experience in the Arden cluster has shown the benefit of using benchmarking to gain an understanding of the potential savings that may be achieved through pursuing specific schemes in specific service areas. Once the scale of the potential benefit has been identified, the next step is to use local intelligence or other available data to spotlight aspects of that service where there is a quality concern, a potential high spend, or both, and design a work programme, with clear objectives and milestones.

Some examples of QIPP cancer medicines workstreams might include:

• Review of predicted versus actual use of highcost oncology drugs
• Review of whether local prescribing of highcost oncology drugs is in line with guidance from the National Institute for Health and Clinical Excellence (NICE)
• Identification of savings to be made through a shift from branded to generic preparations
• Seeking agreement with providers on the management of patient-access schemes to deliver cost savings on oncology drugs
• Audit of the benefit of continued prescribing of cancer drugs for particular indications—with a view to creating new access policies
• Implementation of electronic prescribing, to provide robust chemotherapy data for PCTs and to support the national Systemic anti-cancer therapy dataset³

One limitation of this approach to the QIPP agenda is that the workstreams may find minimal variation and strong compliance with NICE recommendations, and hence little potential for significant cost and quality benefits. Also, the potential cost savings may be at least in part dependent on agreement with provider organisations (e.g. agreement on patient-access schemes).

Cancer networks D&T committees

A good starting point for the identification of potential QIPP savings in cancer prescribing are the cancer networks—and more specifically each network’s drug and therapeutic (D&T) committee.

Why, you might ask, would hospital clinicians on network D&T committees come up with plans to reduce prescribing costs? The simple response, based on my own past experience as Cancer Network Director in Arden, is that the whole raison d’etre of the cancer network is to improve the quality of cancer services. Cancer clinicians understand the need to iron out unacceptable variations in clinical practice and to stick to local and national best-practice guidelines, including those from NICE. There is also a growing recognition within hospitals of the absolute need to reduce waste and prioritise spending (bearing in mind that the QIPP savings target for trusts is typically twice that of their commissioning cluster or PCT counterparts).

Taking a longer-term view

An area that is less well explored within QIPP is the role of cancer drugs in preventing disease progression, thus potentially saving resources at the same time as improving health outcomes. There may be some concern about the inevitable delay between the initial outlay and the realisation of the planned benefits. However, the system plans in the West Midlands take a medium-term financial view (4 years), which allows greater latitude than the traditional 1-year focus of the NHS operating plan⁴ or local delivery plans.

The challenge to the pharma-oncology industry will be to become skilled in developing robust business cases, working closely with the NHS and in particular the cancer networks. It is essential that these business cases identify the relative costs and savings associated with cancer drugs, including a realistic assessment of the service savings—to providers and commissioners—in terms of the reduced cost of care further along the cancer pathway, as well as offsetting the costs of existing, less effective treatments. In this way, the industry would be able to demonstrate the cost savings over the relevant investment-return period, while simultaneously highlighting the extent of quality improvement to patients.

Conclusion

In the current financial challenge facing the NHS, there is no reason why cancer drugs prescribing cannot provide good opportunities for achieving QIPP gains. Furthermore, there is no reason to assume that such opportunities will mean withholding new cancer drugs. We need to look at the long-term picture, and ask whether investment up-front in effective, possibly high-cost treatments will pay dividends later in the form of reduced inpatient care and lack of disease progression—as well as enhancing the quality of patient care and outcomes.

References

1. Parliament.uk. Performance on productivity. Available at: http://www.publications. parliament.uk/pa/cm201011/cmselect/ cmpubacc/741/74105.htm (accessed August 2011).
2. Nicholson D. Letter: Equity and excellence: liberating the NHS - managing the transition. Available at: http://www.dh.gov.uk/ prod_consum_dh/groups/dh_digitalassets/ documents/digitalasset/dh_117406.pdf (accessed August 2011).
3. National Cancer Intelligence Network. Systemic anti-cancer therapy dataset (chemotherapy). Available at: http://www. ncin.org.uk/collecting_and_using_data/data_ collection/chemotherapy.aspx (accessed August 2011).
4. Department of Health. The operating framework for the NHS in England 2010/11. London: NHS, 2009.