Crea&ng a treatment pathway for the modern NHS (an example)

Transcription

1 Crea&ng a treatment pathway for the modern NHS (an example) Vanessa Burgess, Assistant director, Medicines & LTC s NHS Lambeth Clinical Commissioning Group Dr Bu Hayee Consultant Gastroenterologist Kings College Hospital FoundaAon Trust This Satellite is sponsored by

2 Creating a Treatment Pathway for the Modern NHS: Inflammatory Bowel Disease Radisson Blu Portman Hotel, London, 20th November 2015 Vanessa Burgess Chief Pharmacist, Assistant Director Long Term Conditions Lambeth CCG Dr Bu Hussain Hayee Honorary Senior Lecturer Lead for IBD, Clinical Lead for Gastroenterology Kings College Hospital This meeang has been sponsored by AbbVie AXHUG151687b Date of prepara&on : November 2015

3 Disclosure Statements Dr Bu Hussain Hayee Honoraria for conferences and/or advisory boards from AbbVie, Actavis, Almirall, MSD, Roche/Genentech, Shire, Symprove, Takeda and Warner Chilcott as well as financial support from AbbVie, Actavis, Symprove, Takeda and Warner Chilcott for scientific and clinical research over the last 3 years. Vanessa Burgess Honoraria for advisory boards from Janssen, Takeda, Roche, Warner Chillcott, Abbvie and Napp. NHS Lambeth CCG Medical Educational grant from Abbvie to faciliate patient engagement in IBD (2013). AXHUG151687b Date of prepara&on : November

4 National strategies hdp:// pharmacy- pdfs/helping- paaents- make- the- most- of- their- medicines.pdf AXHUG151687b Date of prepara&on : November

5 Affordability challenge Increased people with more complex conditions Costs of care grow faster than inflation 5YFV - 30 billion challenge by 2020/21. Local authority saving of 40% over next 3-4 years. AXHUG151687b Date of prepara&on : November

6 Illustrative of the amount of health and social care resource used as a person moves up the model AXHUG151687b Date of prepara&on : November 2015 UNDERSTANDING OUR POPULATION AND ITS NEEDS SEL model EoL (1%) 3+LTC (9%) Early stages of LTC (25%) People experiencing inequalities or putting their health at risk (50%) Health and wellbeing group (16%) People with multiple complex needs where standard services are not effective who need personalised care.

7 & Medicines?... Given the growing demand for medicines that comes with an ageing population and budget constraints, it is more important than ever that the NHS and patients get the best value, in terms of money and outcomes, from our substantial investment in medicines. NHS England/ABPI workshops 2015 AXHUG151687b Date of prepara&on : November

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10 Principle 2 : Evidence Based Choice of Medicines & Outcome Based Approach South East London Area Prescribing Committee IBD pathway Documents/Clinical%20guidelines/IBD%20pathways%20Jan % pdf Value Based Approach AXHUG151687b Date of prepara&on : November

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12 Commissioning pathways of care: A clinician s perspective Bu Hussain Hayee Honorary Senior Lecturer Lead for IBD Clinical Lead for Gastroenterology b.hayee@nhs.net AXHUG151687b Date of prepara&on : November 2015 IBD

13 AXHUG151687b Date of prepara&on : November 2015 Planning in the current climate TDM Validate treatment and Op&mise adherence I just want to be able to prescribe biologics in UC Build and staff an MDT What kind of IBD service do you want to provide? Prevent A&E auendance Maximise informa&on and data collec&on Outcomes monitoring and repor1ng Research; IBD database;?telemedicine Commercial trials Streamline the pa&ent pathway Access to a consistent opinion Rapid access clinics Streamline surgical input Post- surgical follow- up

14 How should IBD be managed? Cancer Check genotype Staging Histologic grade Targetted, intensive therapy Tailored to cancer genetics Objective assessment of outcome Strict surveillance Well-staffed services CNS Pathway co-ordinator 2WW co-ordinator Outcomes/audit officer IBD Assess location and extent Trial and error treatment Start with weak treatment first Treat all the same Some allowance for behaviour Symptom-based outcome Ad hoc surveillance Poorly-staffed support CNS if you are lucky AXHUG151687b Date of prepara&on : November 2015

15 King s IBD Service Relatively unformed before 2012; 1 WTE IBD nurse Once-weekly specialist IBD clinic 3 consultant lists floating x1 Rapid access appointments (1/52) IBD nurse 3 WTE; IBD dietitian; IBD psychologist; 2 research nurses Subspecialist combined clinics and defined Surgical input Weekly post-clinic debrief; Monthly team meeting Diagnostics: MRE, SICUS, 3D-ERUS, DBE, MCE, EMR/ESD IBD helpline telephone and via nhs.net Once-monthly complex MDM with Surg / Radiology Virtual validation and FU of anti-tnf prescribing AXHUG151687b Date of prepara&on : November 2015

16 AXHUG151687b Date of prepara&on : November 2015 Engage with commissioners

17 What! THEM AXHUG151687b Date of prepara&on : November 2015 US

18 The emphasis has changed Emphasis traditionally on cost rather than patient experience Disconnect between budget holders and clinicians: fettered practice Trusts in deficit; Money for new services/staff?elsewhere Opportunity to influence CCGs They need and want to hear from specialists Opportunity to commission specifics (standard of care) Greater patient involvement (PROMs / QIPP) Research opportunities extending into the community GP representatives are more likely to want to listen A learning experience (even about your own service) AXHUG151687b Date of prepara&on : November 2015

19 AXHUG151687b Date of prepara&on : November 2015 What bothers you most about the IBD service? Van der Valk ME, et al. Gut 2014;63(1):72-79

20 AXHUG151687b Date of prepara&on : November 2015 A foot in the door Shared care guidelines for AZA GPs are awarded QIP for drug monitoring in primary care Greater (lines of) communication between GP and hospital Better deal for patients Identified problems / frustrations / fears for GPs Spin-off invitations for IBD update days WE ARE TALKING YOUR LANGUAGE AND WANT TO LISTEN TO YOU TOO

21 Step 1 The IBD working AXHUG151687b Date of prepara&on : November 2015 party Inaugural meeting initiated via CCG/APC 1 clinician and 1 pharmacist from each acute Trust Introduction of key concepts Elephant in the room Waiting times for flaring IBD patients Trips to A&E Patient engagement Specialist nurses IBD pathway

22 AXHUG151687b Date of prepara&on : November 2015 Step 2 An easy win Overhaul of mesalazine formulary Conflicting information from acute Trusts in the region Switching may or may not trouble you; not a sexy topic CCGs get worked up about it to relatively consistent degree The best 5-ASA is the one that patients take Cost-savings for OD prescribing attractive to MMG / CCG Arguments for brand-prescribing attractive to clinicians WE WANT A BETTER DEAL FOR OUR PATIENTS WE RECOGNISE THE COST PRESSURES TO MMG WE WANT TO INCREASE ADHERENCE MINIMISE RELAPSE WE ARE PATIENT- CENTRED (rather than ivory tower) THIS IS HOW WE CAN WORK TOGETHER (short lead &me) WE CAN REASSURE YOU ABOUT RUNAWAY COSTS

23 AXHUG151687b Date of prepara&on : November 2015 What do patients want?

24 Step 3 Patient engagement day Day organised by CCG and external PPI company Extremely useful tool Dispelled myths Emphasis on specialist nurse involvement Psychological services Continuity of care, ideally with Consultant-delivered service Relieved pressure on GPs able to concentrate acute services into secondary care increase non F2F / rapid access AXHUG151687b Date of prepara&on : November 2015

25 AXHUG151687b Date of prepara&on : November 2015 Patients gave us the framework Primary care knowledge of IBD is poor results in delays to referral to specialist Junior Dr knowledge about IBD is patchy depends on who they see in clinic Accessing medicines no consistency in access to shared care Would welcome improvement in arrangements for monitoring and optimisation Routes into care are multiple A&E, NHS Direct, GP Lack of access to path lab results across primary and secondary care. Time to follow up between tests and OPD appts. Can primary care support in the meantime to optimise therapy? What happens when the meds don t work long time to get an appointment? Two possible routes once in specialist care surgical team or gastro; communication and pt flow between specialities. Lack of primary care knowledge of steroids in IBD not the same as asthma Inconsistent access to counselling services Patients not attending for monitoring of medicines do blood tests all at once Waiting times in clinics up to 2 hours Biologics screening completed after pt discussion and MDT assessment for biologics (do before?); Access to biologics NICE set certain restrictions Relapse need instant access into specialist care, variable. Community Pharmacy lack of confidential space, lack of rapport.

26 AXHUG151687b Date of prepara&on : November 2015 Pathways

27 Pathway 1 AXHUG151687b Date of prepara&on : November 2015

28 Pathway 2

29 Pathway 3 AXHUG151687b Date of prepara&on : November 2015

30 AXHUG151687b Date of prepara&on : November 2015 Pathway 4

31 AXHUG151687b Date of prepara&on : November 2015 Bottom line cost savings ~ 250k saving per acute Trust pa Drug & treatment costs, A&E costs More responsive primary-secondary care interface Streamlined decision-making Unfettered (not unmonitored) prescribing More cost-effective in short and long-term Stronger links with CCG and Acute Trusts

32 AXHUG151687b Date of prepara&on : November 2015 Biosimilars

33 AXHUG151687b Date of prepara&on : November 2015 Biosimilars Little to fear, much to gain Benefits for health economy are too great to be ignored Clinician familiarity / agreement must be a priority Gain share should be adopted as best practice IBD: Remicade vs Remsima/Inflectra

34 Biosimilars were not part of the Pathway Project Official position of BSG remains against swapping June 2015 notified CCG: 20 swaps by end of Oct 2015 Gain share agreed at regional, CCG and Trust level 50:50 with Trust; 80% of that to Dept Swapping principle agreed in IBD team: MDM decision 2 year agreement for gain share per patient PPPY: 2539 AXHUG151687b Date of prepara&on : November 2015

35 AXHUG151687b Date of prepara&on : November 2015 What we want is what they want Greater control - disease activity - Quality of life eg EQ-5D Early referral, quick assessment Regular medicines optimisation (NICE). Improved mental wellbeing More time spent living life Quality & Outcomes Clinical outcomes Clinical safety Life outcomes Value Cost Activity rate Per capita cost Cost growth Experience Citizen Carer Staff NHS Outcomes Framework Improved experience of hospital care More coordinated care shared care for medicines Greater information sharing between care settings Greater understanding for self-management care plans Someone to turn to in crisis - hotlines Reduced A&E adendance by improving the stability of paaents health and paaents ability to self- manage Reduced hospital admissions, OP adendance, length of stay and increased discharge by improving paaents self efficacy, the effecaveness of clinical intervenaons, and condiaon management Cost effecave medicine choices, opamising doses (TGN and TNF anabody tesang).

36 AXHUG151687b Date of prepara&on : November 2015 Conclusion Investment of time is worth it Increased profile of IBD at commissioning level Supported the development of our service Commissioning of agreed best practice (care bundles / specifics) Increased specialist nurse and AHP staffing Facilitates funding decisions; Removes frustrations around prescribing Has streamlined anti-tnf prescribing Ultimately a better deal for patients

37 Commissioning Outcomes. Pathway implementation : Commissioning of Infliximab level testing Restricted use of vedolizumab in a pre-specified cohort. SEL Biosimilars position and gainshare (came in after the pathway) network aided implementation. AXHUG151687b Date of prepara&on : November

38 Avoidance of cohorts via IFRs in the short term. Immediately aligned with NICE. AXHUG151687b Date of prepara&on : November

39 Outcomes Framework agreed October Patient Experience and working days lost Cost savings vial sharing, infliximab levels, use of s/c biologics, TGN levels Registry and annual MDT review. AXHUG151687b Date of prepara&on : November

40 Ulcera&ve Coli&s 40,000 35,000 30,000 25,000 20,000 15,000 Vedolizumab Infliximab Adalimumab 10,000 5, / /16 High Cost Drugs Charging to SEL CCGs 2 key acute providers Restricted Use Vedolizumab Approved Jan 2015, now in line with NICE TA Pathway Approved January (Month 1) 2015 AXHUG151687b Date of prepara&on : November

41 Crohns Disease 160, , , ,000 80,000 60,000 Vedolizumab Infliximab Adalimumab 40,000 20, / /16 High Cost Drugs Charging to SEL CCGs 2 key acute providers Restricted Use Vedolizumab approved Nov 2014, now in line with NICE TA Pathway Approved January (Month 1) AXHUG151687b Date of prepara&on : November

42 Dose banding of infliximab audit at GSTfT 100% of patients receiving infliximab at GSTT are dose banded From April 2015 to June 2015 inclusive - total saved was 56, Extrapolated to a drug cost saving of 250,000 per year from GSTT. AXHUG151687b Date of prepara&on : November

43 What s next? ² Mapping of Pathway Patient views, Self Management and Patients in Control. ² Outcome monitoring ongoing ² Community/outreach models and education aligned with Local Care Network development AXHUG151687b Date of prepara&on : November

44 Thank you With thanks and acknowledgements to ; SEL Area Prescribing CommiDee SEL APC Inflammatory Bowel Disease Working Group CiAzens adending the IBD PaAent Engagement Event 44 AXHUG151687b Date of prepara&on : November 2015

45 Ques&ons? #pharmanforum