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Type and Title of Submission


Title:

Ensuring equitable access to cancer treatments in the East Midlands - a collaborative approach

Description:

This paper describes how cancer treatments are commissioned in the East Midlands. A joint approach between the East Midlands Specialised Commissioning Group and the East Midlands Cancer Network involves timely reviews of all new cancer treatments including those due to be reviewed by NICE. Working alongside clinicians to prioritise those treatments that provide significant benefit to our population this collaborative approach ensures that funding is made available without delay and that all patients residing in the East Midlands have equal and timely access to cancer treatments.

Category:

Clinical

Does the submission relate to the general implementation of all NICE guidance?

No

Does the submission relate to the implementation of a specific piece of NICE guidance?

Yes

Full title of NICE guidance:

Cancer guidelines -

Category(s) that most closely reflects the nature of the submission:

Implementation policy
Financial plan
Audit tool

Is the submission industry-sponsored in any way?

No


Description of submission


Aim

The East Midlands Specialised Commissioning Group (EMSCG) was formed in 2007 and is responsible for commissioning those services relating to specialised treatments on behalf of its nine member PCTs. As part of its remit and to provide an East Midland wide overview our member PCTs agreed that the EMSCG should commission all cancer therapies, in the main because they are currently excluded to national tariff payments and therefore require additional resource. Each year commissioners are required to review services and to prioritise funding for the following year through the local operational plan (LOP). In 2008, the EMSCG and East Midlands Cancer Network (EMCN) agreed to jointly review all new cancer treatments likely to be licensed and/or reviewed by NICE in the subsequent 18 months. This approach was to ensure that all clinicians involved in cancer services within the East Midlands were given the opportunity to highlight new therapies which might require investment in their particular speciality. Once identified, our aim was to review all requests and prioritise those with the greatest benefit. The final list of prioritised treatments would then be presented to our member PCTs for final approval and investment for 2009/2010.

Objectives

1.That all clinicians involved in cancer services in the East Midlands had the opportunity to present their priorities for investment for the new financial year - all treatments requiring investment to be prioritised through the cancer network by clinicians with a final sign off made jointly by representatives of the EMSCG, EMCN and clinicians. 2.That all cancer treatments with a pending NICE technology appraisal review had been identified and prioritised appropriately. In the case of non NICE treatments that those were prioritised using similar criteria to those used by NICE - once identified the prioritised treatments to be funded and implemented on the day of technology appraisal publication or sooner if possible. 3.That all funded treatments have an East Midlands commissioning policy which includes starting and stopping criteria and audit requirements - policies to be ratified by the EMSCG Board following approval by the EMCN Drug User Group.

Context

Prior to the establishment of the EMSCG and EMCN, cancer treatments would have been reviewed by individual PCTs and investments made depending on local priorities. In general prioritisation would have been led by clinicians, particularly in the larger cancer centres with little or no input from commissioners. Those treatments supported by NICE would be implemented on an ad hoc basis again largely through Providers starting treatments and invoicing PCTs for the new costs on the basis that all cancer treatments are excluded from national tariff. This put enormous pressure on PCTs as in year investment would not have been identified and resource may have had to be reallocated to ensure funding for NICE guidance. Clinicians would also be frustrated as some would not have access to treatments that colleagues working for Providers in other EM PCTs had. This was highlighted, for example, by an audit undertaken by EMCN which showed differential access to oral cancer treatments recently approved by NICE. Given this inequity it was deemed essential to have an EM wide approach to commissioning cancer treatments and hence a collaborative approach between commissioners and clinicians involved in the provision of service was agreed and implemented (please refer to process map attached).

Methods

1.The EMCN met with clinicians from across the EM to identify and prioritise treatments that required investment for 2009/10. Over 120 treatments were highlighted by clinicians. 21 treatments were identified by the cancer clinicians as having the greatest benefit for our patients and therefore the highest priority for investment. 2.The EMSCG and EMCN had a second meeting with clinicians to discuss the actual financial impact of each of the 21 treatments prioritised. The key to this meeting was to ensure that clinicians were fully briefed about the potential investment available. In addition, colleagues from PCTs also needed to be convinced that any allocated investment would be value for money. 3.8 treatments were prioritised for funding for the new financial year (4 to be implemented pre final NICE recommendation, 3 pending NICE approval and 1 that would not be reviewed by NICE). A further 7 were placed on a risk register (all pending NICE approval) and the remainder were not prioritised for funding. 4.All 8 treatments, prioritised through this process, were supported for funding by our member PCTs. This in part was due to the involvement of representatives from the PCT?s at all stages of the prioritisation process. This resulted in an overall investment of just over 7M. 5.As part of the overall process, the EMCN agreed to produce commissioning policies for those treatments that received investment. Commissioning policies have now been produced for Chronic Myeloid Leukaemia (Imatanib: guidance no TA70, Dasatinib and Nilotinib (TA to be published), Multiple Myeloma (Lenalidomide: guidance no TA171, Bortezomib: guidance no TA129) and Chronic Lymphocytic Leukaemia (Rituximab: guidance no TA174 and Alemtuzumab (not under review by NICE)). In addition, audit requirements for Erlotinib: guidance no TA162; have been agreed and implemented. (Please refer to two EM policies attached as examples).

Results and evaluation

All commissioning policies relating to the appraisal guidance have now been published and funding made available, in many cases before the guidance was published. All commissioning policies contain monitoring requirements and where required starting and stopping criteria. The intention will be to review use of the newly funded treatments as an ongoing process. Evaluation of the uptake of funding will be two-fold: 1.To ensure equity of access across the East Midlands. 2.To ensure that the drug is prescribed according to agreed criteria utilising the monitoring requirements outlined in the commissioning policy. Specific monitoring forms will be introduced to supplement the audit process. This is to ensure that allocated funding is utilised to its maximal effect, that patients within the East Midlands have full and equitable access to cancer treatments supported by NICE and that treatments are within the scope of what is considered value for money. Feedback from clinicians has been very positive. In particular clinicians have found the process beneficial in knowing when investment will be available. This has enabled forward planning with patient pathways and establishing new clinics where required.

Key learning points

Key learning points from the commissioning process described above include: 1.Start the process as early as possible. In reality this is an ongoing process that never stops. However, given most resource is only allocated once a year and, as a response to the Richards report, it is paramount that planning is achieved early in the year so that adequate funding is identified to ensure equity of access and reduce the requirements for individual case requests. This year we have already started identifying possible investment needs with a meeting due to be held in October to prioritise funding. 2.Always involve clinicians at the earliest stage possible. In our case both the EMSCG and the EMCN worked collaboratively with clinicians to identify as early as possible those treatments that were the highest priority for the next financial year. 3.Ensure Provider Organisations are fully briefed regarding the process. This is to ensure that all services are prioritised against each other and avoids less prominent services being squeezed out. 4.Involve patients in the process - this was achieved through the Cancer Network although more work needs to be done here to sense check our agreed priorities with the population as a whole rather than just patients who will have a vested interest. 5.Once agreed make sure that investment is delivered - an enormous amount of time and energy is put into this process and clinicians will want to see that those efforts provide the right outcome. This is absolutely vital as we expect clinicians to identify those treatments that are not value for money and assist commissioners in prioritising investment as not all treatments are either cost effective or affordable.

View the supporting material

Contact Details

Name:Malcolm Qualie
Job Title:Head of Health Policy/Pharmaceutical Advisor
Organisation:East Midlands Specialised Commissioning Group
Address:Lakeside House, Grove Park
Town:Leicester
County:Leicestershire
Postcode:LE19 1SS
Phone:0116 2950862
Email:malcolm.qualie@emscg.nhs.uk

 

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.