‐ Economic Challenges of Chemotherapy Delivery

Service in melt‐down Sussex Cancer Network

(Final)16th

July 2009

ArdenPan Birmingham

311008

2

ECONOMICS OF CHEMOTHERAPY

DELIVERY

ECONOMICS OF CHEMOTHERAPY

DELIVERY

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash Safety

WCC Priorities

1

Financial Deficits

2

WCC Agendas

3

Mergers PBC etc etc

World Class Commissioningbull Recent criticisms of sustainability of Public Sector

ndash continuing inflexibility of delivery of many public services

ndash rising demand + increasing costs = doubts about sustainability

ndash massive investment without reform

ndash complacent unsafe lsquoJobs for Lifersquo Final Salary Pension Scheme

ndash poor uptake of technology out of touch with international management trends

bull Remedy WCCndash patient needs amp concerns centralndash commissioning is a binding contract with timelines amp deliverables

bull innovation and productivity are expectedbull business cases are explicit on metrics and promptly delivered

HOSPITALS AS lsquoOLD BATTLESHIPSrsquo

COMMUNITY SERVICES DELIVERING MORE ELECTIVE CARE

amp OBVIATING NON‐ELECTIVE ADMISSIONS

8

pound0

pound500000

pound1000000

pound1500000

pound2000000

pound2500000

pound3000000

THE RISING TIDE OF DEMAND FOR CHEMOTHERAPY

BUDGET

EXPEND

The Rock Budget Deficits amp WCC

1

Outcomes2

Contestabitlity

3

Benchmarking4

Contracts

EXPONENTIAL DEMAND FOR HEALTH‐CARE

NATIONAL BUDGETDEFICIT PBR etc

WCC Agendas

1

Commissioning by OutcomesCorporate Value Management

2

Contestability De‐Commissioning Market Management Darzi Care amp Resource

Utilisation Programme Commissioning

3

Benchmarking

4

Contracts HRGTariffs

WCC Agenda 1 Commissioning for Outcomes Corporate Value Management

bull lsquoAreas with higher levels of spending can often have worse outcomes Its not what we do but what is achieved as the

result of what we do that mattersrsquobull lsquoNSFrsquos amp NICE Assessments Peer Review etc will be

implemented and monitoredndash what are we buyingndash what are the chances we get itndash is this the best possible use of tax‐payersrsquo

money

bull lsquoOutcomersquo

Metrics

ndash Audited Monitoring of Activity Performance amp Outcome

bull Who monitors how frequently

PCT legal challenges to NICE 1

Co‐Payment Inequalities Guidance November 2008

ndash Co‐payment allowed but in separate premises

ndash BUT What is the effect on deprivation inequalities

2

NICE Jan 2009 lsquoAppraising life‐extending end of life (gt 2 years) treatmentsrsquo

ndash lsquogive greater weight to QALYs achieved in the later stages of terminal diseases

ndash BUT Is this NICE guidance a perverse incentive to over‐ treat patients

3

NICE May 2009 National Pharma Discounts Cetuximab for 1st

line Metastatic Colorectal Cancer

ndash Manufacturer rebate of 16 on cetuximab used on a per patient basis pound15902 gtgt pound13650

ndash BUT Are all NICE assessments to be re‐assessed

WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme Commissioning

Contestability amp Decommissioning

lsquoRight treatment in the right place at the right timersquobull Yes Legitimate drivers of Demand

bull Demographic ageing population rising incidence amp detection lifestyle choices smoking alcohol street drugs

bull Diagnostic up‐staging (CT PET Fusion) Neo‐adjuvant switches from XRTSurgery

bull Therapeutic Biologicals Genome stem cell bull NO Greedy Hospitals

driving Demand into the wrong location

bull Cancer 3rd

largest source of revenue in the pharma industry forecast to increase at ~ 17 to $49 billion by

2012bull NCEPODAcute Oncology Report

bull palliative chemotherapy which is inappropriate and unsafe

bull 3rd 4th 5th

lines of treatment

15

lsquoProgrammersquo

Commissioning Cancer Commissioning Toolkit

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much can be delivered in the communityWhat does this mean for the workforce

16

WCC Agenda 3 NationalInternational Benchmarking

lsquoPost Codersquo

Variation in access to chemotherapy

bull

Government and independent reports show wide variations across the within the NHS (and across the

EU) for uptake and access to lsquoNICE approvedrsquo

cancer chemotherapy

bull

Data indicate the main reason is variations in the agreement amp implementation of delivery costs

rather than acquisition procurement costs

bull

Commissioners need to understand the causesbull

Inadequate policing of NICE implementation

bull

Slowincompetent business cases

ArdenPan Birmingham

311008

17

WCC Agenda 4CONTRACTS

WCC Agenda 4CONTRACTS

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

ArdenPan Birmingham

311008

2

ECONOMICS OF CHEMOTHERAPY

DELIVERY

ECONOMICS OF CHEMOTHERAPY

DELIVERY

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash Safety

WCC Priorities

1

Financial Deficits

2

WCC Agendas

3

Mergers PBC etc etc

World Class Commissioningbull Recent criticisms of sustainability of Public Sector

ndash continuing inflexibility of delivery of many public services

ndash rising demand + increasing costs = doubts about sustainability

ndash massive investment without reform

ndash complacent unsafe lsquoJobs for Lifersquo Final Salary Pension Scheme

ndash poor uptake of technology out of touch with international management trends

bull Remedy WCCndash patient needs amp concerns centralndash commissioning is a binding contract with timelines amp deliverables

bull innovation and productivity are expectedbull business cases are explicit on metrics and promptly delivered

HOSPITALS AS lsquoOLD BATTLESHIPSrsquo

COMMUNITY SERVICES DELIVERING MORE ELECTIVE CARE

amp OBVIATING NON‐ELECTIVE ADMISSIONS

8

pound0

pound500000

pound1000000

pound1500000

pound2000000

pound2500000

pound3000000

THE RISING TIDE OF DEMAND FOR CHEMOTHERAPY

BUDGET

EXPEND

The Rock Budget Deficits amp WCC

1

Outcomes2

Contestabitlity

3

Benchmarking4

Contracts

EXPONENTIAL DEMAND FOR HEALTH‐CARE

NATIONAL BUDGETDEFICIT PBR etc

WCC Agendas

1

Commissioning by OutcomesCorporate Value Management

2

Contestability De‐Commissioning Market Management Darzi Care amp Resource

Utilisation Programme Commissioning

3

Benchmarking

4

Contracts HRGTariffs

WCC Agenda 1 Commissioning for Outcomes Corporate Value Management

bull lsquoAreas with higher levels of spending can often have worse outcomes Its not what we do but what is achieved as the

result of what we do that mattersrsquobull lsquoNSFrsquos amp NICE Assessments Peer Review etc will be

implemented and monitoredndash what are we buyingndash what are the chances we get itndash is this the best possible use of tax‐payersrsquo

money

bull lsquoOutcomersquo

Metrics

ndash Audited Monitoring of Activity Performance amp Outcome

bull Who monitors how frequently

PCT legal challenges to NICE 1

Co‐Payment Inequalities Guidance November 2008

ndash Co‐payment allowed but in separate premises

ndash BUT What is the effect on deprivation inequalities

2

NICE Jan 2009 lsquoAppraising life‐extending end of life (gt 2 years) treatmentsrsquo

ndash lsquogive greater weight to QALYs achieved in the later stages of terminal diseases

ndash BUT Is this NICE guidance a perverse incentive to over‐ treat patients

3

NICE May 2009 National Pharma Discounts Cetuximab for 1st

line Metastatic Colorectal Cancer

ndash Manufacturer rebate of 16 on cetuximab used on a per patient basis pound15902 gtgt pound13650

ndash BUT Are all NICE assessments to be re‐assessed

WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme Commissioning

Contestability amp Decommissioning

lsquoRight treatment in the right place at the right timersquobull Yes Legitimate drivers of Demand

bull Demographic ageing population rising incidence amp detection lifestyle choices smoking alcohol street drugs

bull Diagnostic up‐staging (CT PET Fusion) Neo‐adjuvant switches from XRTSurgery

bull Therapeutic Biologicals Genome stem cell bull NO Greedy Hospitals

driving Demand into the wrong location

bull Cancer 3rd

largest source of revenue in the pharma industry forecast to increase at ~ 17 to $49 billion by

2012bull NCEPODAcute Oncology Report

bull palliative chemotherapy which is inappropriate and unsafe

bull 3rd 4th 5th

lines of treatment

15

lsquoProgrammersquo

Commissioning Cancer Commissioning Toolkit

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much can be delivered in the communityWhat does this mean for the workforce

16

WCC Agenda 3 NationalInternational Benchmarking

lsquoPost Codersquo

Variation in access to chemotherapy

bull

Government and independent reports show wide variations across the within the NHS (and across the

EU) for uptake and access to lsquoNICE approvedrsquo

cancer chemotherapy

bull

Data indicate the main reason is variations in the agreement amp implementation of delivery costs

rather than acquisition procurement costs

bull

Commissioners need to understand the causesbull

Inadequate policing of NICE implementation

bull

Slowincompetent business cases

ArdenPan Birmingham

311008

17

WCC Agenda 4CONTRACTS

WCC Agenda 4CONTRACTS

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash Safety

WCC Priorities

1

Financial Deficits

2

WCC Agendas

3

Mergers PBC etc etc

World Class Commissioningbull Recent criticisms of sustainability of Public Sector

ndash continuing inflexibility of delivery of many public services

ndash rising demand + increasing costs = doubts about sustainability

ndash massive investment without reform

ndash complacent unsafe lsquoJobs for Lifersquo Final Salary Pension Scheme

ndash poor uptake of technology out of touch with international management trends

bull Remedy WCCndash patient needs amp concerns centralndash commissioning is a binding contract with timelines amp deliverables

bull innovation and productivity are expectedbull business cases are explicit on metrics and promptly delivered

HOSPITALS AS lsquoOLD BATTLESHIPSrsquo

COMMUNITY SERVICES DELIVERING MORE ELECTIVE CARE

amp OBVIATING NON‐ELECTIVE ADMISSIONS

8

pound0

pound500000

pound1000000

pound1500000

pound2000000

pound2500000

pound3000000

THE RISING TIDE OF DEMAND FOR CHEMOTHERAPY

BUDGET

EXPEND

The Rock Budget Deficits amp WCC

1

Outcomes2

Contestabitlity

3

Benchmarking4

Contracts

EXPONENTIAL DEMAND FOR HEALTH‐CARE

NATIONAL BUDGETDEFICIT PBR etc

WCC Agendas

1

Commissioning by OutcomesCorporate Value Management

2

Contestability De‐Commissioning Market Management Darzi Care amp Resource

Utilisation Programme Commissioning

3

Benchmarking

4

Contracts HRGTariffs

WCC Agenda 1 Commissioning for Outcomes Corporate Value Management

bull lsquoAreas with higher levels of spending can often have worse outcomes Its not what we do but what is achieved as the

result of what we do that mattersrsquobull lsquoNSFrsquos amp NICE Assessments Peer Review etc will be

implemented and monitoredndash what are we buyingndash what are the chances we get itndash is this the best possible use of tax‐payersrsquo

money

bull lsquoOutcomersquo

Metrics

ndash Audited Monitoring of Activity Performance amp Outcome

bull Who monitors how frequently

PCT legal challenges to NICE 1

Co‐Payment Inequalities Guidance November 2008

ndash Co‐payment allowed but in separate premises

ndash BUT What is the effect on deprivation inequalities

2

NICE Jan 2009 lsquoAppraising life‐extending end of life (gt 2 years) treatmentsrsquo

ndash lsquogive greater weight to QALYs achieved in the later stages of terminal diseases

ndash BUT Is this NICE guidance a perverse incentive to over‐ treat patients

3

NICE May 2009 National Pharma Discounts Cetuximab for 1st

line Metastatic Colorectal Cancer

ndash Manufacturer rebate of 16 on cetuximab used on a per patient basis pound15902 gtgt pound13650

ndash BUT Are all NICE assessments to be re‐assessed

WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme Commissioning

Contestability amp Decommissioning

lsquoRight treatment in the right place at the right timersquobull Yes Legitimate drivers of Demand

bull Demographic ageing population rising incidence amp detection lifestyle choices smoking alcohol street drugs

bull Diagnostic up‐staging (CT PET Fusion) Neo‐adjuvant switches from XRTSurgery

bull Therapeutic Biologicals Genome stem cell bull NO Greedy Hospitals

driving Demand into the wrong location

bull Cancer 3rd

largest source of revenue in the pharma industry forecast to increase at ~ 17 to $49 billion by

2012bull NCEPODAcute Oncology Report

bull palliative chemotherapy which is inappropriate and unsafe

bull 3rd 4th 5th

lines of treatment

15

lsquoProgrammersquo

Commissioning Cancer Commissioning Toolkit

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much can be delivered in the communityWhat does this mean for the workforce

16

WCC Agenda 3 NationalInternational Benchmarking

lsquoPost Codersquo

Variation in access to chemotherapy

bull

Government and independent reports show wide variations across the within the NHS (and across the

EU) for uptake and access to lsquoNICE approvedrsquo

cancer chemotherapy

bull

Data indicate the main reason is variations in the agreement amp implementation of delivery costs

rather than acquisition procurement costs

bull

Commissioners need to understand the causesbull

Inadequate policing of NICE implementation

bull

Slowincompetent business cases

ArdenPan Birmingham

311008

17

WCC Agenda 4CONTRACTS

WCC Agenda 4CONTRACTS

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash Safety

WCC Priorities

1

Financial Deficits

2

WCC Agendas

3

Mergers PBC etc etc

World Class Commissioningbull Recent criticisms of sustainability of Public Sector

ndash continuing inflexibility of delivery of many public services

ndash rising demand + increasing costs = doubts about sustainability

ndash massive investment without reform

ndash complacent unsafe lsquoJobs for Lifersquo Final Salary Pension Scheme

ndash poor uptake of technology out of touch with international management trends

bull Remedy WCCndash patient needs amp concerns centralndash commissioning is a binding contract with timelines amp deliverables

bull innovation and productivity are expectedbull business cases are explicit on metrics and promptly delivered

HOSPITALS AS lsquoOLD BATTLESHIPSrsquo

COMMUNITY SERVICES DELIVERING MORE ELECTIVE CARE

amp OBVIATING NON‐ELECTIVE ADMISSIONS

8

pound0

pound500000

pound1000000

pound1500000

pound2000000

pound2500000

pound3000000

THE RISING TIDE OF DEMAND FOR CHEMOTHERAPY

BUDGET

EXPEND

The Rock Budget Deficits amp WCC

1

Outcomes2

Contestabitlity

3

Benchmarking4

Contracts

EXPONENTIAL DEMAND FOR HEALTH‐CARE

NATIONAL BUDGETDEFICIT PBR etc

WCC Agendas

1

Commissioning by OutcomesCorporate Value Management

2

Contestability De‐Commissioning Market Management Darzi Care amp Resource

Utilisation Programme Commissioning

3

Benchmarking

4

Contracts HRGTariffs

WCC Agenda 1 Commissioning for Outcomes Corporate Value Management

bull lsquoAreas with higher levels of spending can often have worse outcomes Its not what we do but what is achieved as the

result of what we do that mattersrsquobull lsquoNSFrsquos amp NICE Assessments Peer Review etc will be

implemented and monitoredndash what are we buyingndash what are the chances we get itndash is this the best possible use of tax‐payersrsquo

money

bull lsquoOutcomersquo

Metrics

ndash Audited Monitoring of Activity Performance amp Outcome

bull Who monitors how frequently

PCT legal challenges to NICE 1

Co‐Payment Inequalities Guidance November 2008

ndash Co‐payment allowed but in separate premises

ndash BUT What is the effect on deprivation inequalities

2

NICE Jan 2009 lsquoAppraising life‐extending end of life (gt 2 years) treatmentsrsquo

ndash lsquogive greater weight to QALYs achieved in the later stages of terminal diseases

ndash BUT Is this NICE guidance a perverse incentive to over‐ treat patients

3

NICE May 2009 National Pharma Discounts Cetuximab for 1st

line Metastatic Colorectal Cancer

ndash Manufacturer rebate of 16 on cetuximab used on a per patient basis pound15902 gtgt pound13650

ndash BUT Are all NICE assessments to be re‐assessed

WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme Commissioning

Contestability amp Decommissioning

lsquoRight treatment in the right place at the right timersquobull Yes Legitimate drivers of Demand

bull Demographic ageing population rising incidence amp detection lifestyle choices smoking alcohol street drugs

bull Diagnostic up‐staging (CT PET Fusion) Neo‐adjuvant switches from XRTSurgery

bull Therapeutic Biologicals Genome stem cell bull NO Greedy Hospitals

driving Demand into the wrong location

bull Cancer 3rd

largest source of revenue in the pharma industry forecast to increase at ~ 17 to $49 billion by

2012bull NCEPODAcute Oncology Report

bull palliative chemotherapy which is inappropriate and unsafe

bull 3rd 4th 5th

lines of treatment

15

lsquoProgrammersquo

Commissioning Cancer Commissioning Toolkit

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much can be delivered in the communityWhat does this mean for the workforce

16

WCC Agenda 3 NationalInternational Benchmarking

lsquoPost Codersquo

Variation in access to chemotherapy

bull

Government and independent reports show wide variations across the within the NHS (and across the

EU) for uptake and access to lsquoNICE approvedrsquo

cancer chemotherapy

bull

Data indicate the main reason is variations in the agreement amp implementation of delivery costs

rather than acquisition procurement costs

bull

Commissioners need to understand the causesbull

Inadequate policing of NICE implementation

bull

Slowincompetent business cases

ArdenPan Birmingham

311008

17

WCC Agenda 4CONTRACTS

WCC Agenda 4CONTRACTS

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

World Class Commissioningbull Recent criticisms of sustainability of Public Sector

ndash continuing inflexibility of delivery of many public services

ndash rising demand + increasing costs = doubts about sustainability

ndash massive investment without reform

ndash complacent unsafe lsquoJobs for Lifersquo Final Salary Pension Scheme

ndash poor uptake of technology out of touch with international management trends

bull Remedy WCCndash patient needs amp concerns centralndash commissioning is a binding contract with timelines amp deliverables

bull innovation and productivity are expectedbull business cases are explicit on metrics and promptly delivered

HOSPITALS AS lsquoOLD BATTLESHIPSrsquo

COMMUNITY SERVICES DELIVERING MORE ELECTIVE CARE

amp OBVIATING NON‐ELECTIVE ADMISSIONS

8

pound0

pound500000

pound1000000

pound1500000

pound2000000

pound2500000

pound3000000

THE RISING TIDE OF DEMAND FOR CHEMOTHERAPY

BUDGET

EXPEND

The Rock Budget Deficits amp WCC

1

Outcomes2

Contestabitlity

3

Benchmarking4

Contracts

EXPONENTIAL DEMAND FOR HEALTH‐CARE

NATIONAL BUDGETDEFICIT PBR etc

WCC Agendas

1

Commissioning by OutcomesCorporate Value Management

2

Contestability De‐Commissioning Market Management Darzi Care amp Resource

Utilisation Programme Commissioning

3

Benchmarking

4

Contracts HRGTariffs

WCC Agenda 1 Commissioning for Outcomes Corporate Value Management

bull lsquoAreas with higher levels of spending can often have worse outcomes Its not what we do but what is achieved as the

result of what we do that mattersrsquobull lsquoNSFrsquos amp NICE Assessments Peer Review etc will be

implemented and monitoredndash what are we buyingndash what are the chances we get itndash is this the best possible use of tax‐payersrsquo

money

bull lsquoOutcomersquo

Metrics

ndash Audited Monitoring of Activity Performance amp Outcome

bull Who monitors how frequently

PCT legal challenges to NICE 1

Co‐Payment Inequalities Guidance November 2008

ndash Co‐payment allowed but in separate premises

ndash BUT What is the effect on deprivation inequalities

2

NICE Jan 2009 lsquoAppraising life‐extending end of life (gt 2 years) treatmentsrsquo

ndash lsquogive greater weight to QALYs achieved in the later stages of terminal diseases

ndash BUT Is this NICE guidance a perverse incentive to over‐ treat patients

3

NICE May 2009 National Pharma Discounts Cetuximab for 1st

line Metastatic Colorectal Cancer

ndash Manufacturer rebate of 16 on cetuximab used on a per patient basis pound15902 gtgt pound13650

ndash BUT Are all NICE assessments to be re‐assessed

WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme Commissioning

Contestability amp Decommissioning

lsquoRight treatment in the right place at the right timersquobull Yes Legitimate drivers of Demand

bull Demographic ageing population rising incidence amp detection lifestyle choices smoking alcohol street drugs

bull Diagnostic up‐staging (CT PET Fusion) Neo‐adjuvant switches from XRTSurgery

bull Therapeutic Biologicals Genome stem cell bull NO Greedy Hospitals

driving Demand into the wrong location

bull Cancer 3rd

largest source of revenue in the pharma industry forecast to increase at ~ 17 to $49 billion by

2012bull NCEPODAcute Oncology Report

bull palliative chemotherapy which is inappropriate and unsafe

bull 3rd 4th 5th

lines of treatment

15

lsquoProgrammersquo

Commissioning Cancer Commissioning Toolkit

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much can be delivered in the communityWhat does this mean for the workforce

16

WCC Agenda 3 NationalInternational Benchmarking

lsquoPost Codersquo

Variation in access to chemotherapy

bull

Government and independent reports show wide variations across the within the NHS (and across the

EU) for uptake and access to lsquoNICE approvedrsquo

cancer chemotherapy

bull

Data indicate the main reason is variations in the agreement amp implementation of delivery costs

rather than acquisition procurement costs

bull

Commissioners need to understand the causesbull

Inadequate policing of NICE implementation

bull

Slowincompetent business cases

ArdenPan Birmingham

311008

17

WCC Agenda 4CONTRACTS

WCC Agenda 4CONTRACTS

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

HOSPITALS AS lsquoOLD BATTLESHIPSrsquo

COMMUNITY SERVICES DELIVERING MORE ELECTIVE CARE

amp OBVIATING NON‐ELECTIVE ADMISSIONS

8

pound0

pound500000

pound1000000

pound1500000

pound2000000

pound2500000

pound3000000

THE RISING TIDE OF DEMAND FOR CHEMOTHERAPY

BUDGET

EXPEND

The Rock Budget Deficits amp WCC

1

Outcomes2

Contestabitlity

3

Benchmarking4

Contracts

EXPONENTIAL DEMAND FOR HEALTH‐CARE

NATIONAL BUDGETDEFICIT PBR etc

WCC Agendas

1

Commissioning by OutcomesCorporate Value Management

2

Contestability De‐Commissioning Market Management Darzi Care amp Resource

Utilisation Programme Commissioning

3

Benchmarking

4

Contracts HRGTariffs

WCC Agenda 1 Commissioning for Outcomes Corporate Value Management

bull lsquoAreas with higher levels of spending can often have worse outcomes Its not what we do but what is achieved as the

result of what we do that mattersrsquobull lsquoNSFrsquos amp NICE Assessments Peer Review etc will be

implemented and monitoredndash what are we buyingndash what are the chances we get itndash is this the best possible use of tax‐payersrsquo

money

bull lsquoOutcomersquo

Metrics

ndash Audited Monitoring of Activity Performance amp Outcome

bull Who monitors how frequently

PCT legal challenges to NICE 1

Co‐Payment Inequalities Guidance November 2008

ndash Co‐payment allowed but in separate premises

ndash BUT What is the effect on deprivation inequalities

2

NICE Jan 2009 lsquoAppraising life‐extending end of life (gt 2 years) treatmentsrsquo

ndash lsquogive greater weight to QALYs achieved in the later stages of terminal diseases

ndash BUT Is this NICE guidance a perverse incentive to over‐ treat patients

3

NICE May 2009 National Pharma Discounts Cetuximab for 1st

line Metastatic Colorectal Cancer

ndash Manufacturer rebate of 16 on cetuximab used on a per patient basis pound15902 gtgt pound13650

ndash BUT Are all NICE assessments to be re‐assessed

WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme Commissioning

Contestability amp Decommissioning

lsquoRight treatment in the right place at the right timersquobull Yes Legitimate drivers of Demand

bull Demographic ageing population rising incidence amp detection lifestyle choices smoking alcohol street drugs

bull Diagnostic up‐staging (CT PET Fusion) Neo‐adjuvant switches from XRTSurgery

bull Therapeutic Biologicals Genome stem cell bull NO Greedy Hospitals

driving Demand into the wrong location

bull Cancer 3rd

largest source of revenue in the pharma industry forecast to increase at ~ 17 to $49 billion by

2012bull NCEPODAcute Oncology Report

bull palliative chemotherapy which is inappropriate and unsafe

bull 3rd 4th 5th

lines of treatment

15

lsquoProgrammersquo

Commissioning Cancer Commissioning Toolkit

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much can be delivered in the communityWhat does this mean for the workforce

16

WCC Agenda 3 NationalInternational Benchmarking

lsquoPost Codersquo

Variation in access to chemotherapy

bull

Government and independent reports show wide variations across the within the NHS (and across the

EU) for uptake and access to lsquoNICE approvedrsquo

cancer chemotherapy

bull

Data indicate the main reason is variations in the agreement amp implementation of delivery costs

rather than acquisition procurement costs

bull

Commissioners need to understand the causesbull

Inadequate policing of NICE implementation

bull

Slowincompetent business cases

ArdenPan Birmingham

311008

17

WCC Agenda 4CONTRACTS

WCC Agenda 4CONTRACTS

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

COMMUNITY SERVICES DELIVERING MORE ELECTIVE CARE

amp OBVIATING NON‐ELECTIVE ADMISSIONS

8

pound0

pound500000

pound1000000

pound1500000

pound2000000

pound2500000

pound3000000

THE RISING TIDE OF DEMAND FOR CHEMOTHERAPY

BUDGET

EXPEND

The Rock Budget Deficits amp WCC

1

Outcomes2

Contestabitlity

3

Benchmarking4

Contracts

EXPONENTIAL DEMAND FOR HEALTH‐CARE

NATIONAL BUDGETDEFICIT PBR etc

WCC Agendas

1

Commissioning by OutcomesCorporate Value Management

2

Contestability De‐Commissioning Market Management Darzi Care amp Resource

Utilisation Programme Commissioning

3

Benchmarking

4

Contracts HRGTariffs

WCC Agenda 1 Commissioning for Outcomes Corporate Value Management

bull lsquoAreas with higher levels of spending can often have worse outcomes Its not what we do but what is achieved as the

result of what we do that mattersrsquobull lsquoNSFrsquos amp NICE Assessments Peer Review etc will be

implemented and monitoredndash what are we buyingndash what are the chances we get itndash is this the best possible use of tax‐payersrsquo

money

bull lsquoOutcomersquo

Metrics

ndash Audited Monitoring of Activity Performance amp Outcome

bull Who monitors how frequently

PCT legal challenges to NICE 1

Co‐Payment Inequalities Guidance November 2008

ndash Co‐payment allowed but in separate premises

ndash BUT What is the effect on deprivation inequalities

2

NICE Jan 2009 lsquoAppraising life‐extending end of life (gt 2 years) treatmentsrsquo

ndash lsquogive greater weight to QALYs achieved in the later stages of terminal diseases

ndash BUT Is this NICE guidance a perverse incentive to over‐ treat patients

3

NICE May 2009 National Pharma Discounts Cetuximab for 1st

line Metastatic Colorectal Cancer

ndash Manufacturer rebate of 16 on cetuximab used on a per patient basis pound15902 gtgt pound13650

ndash BUT Are all NICE assessments to be re‐assessed

WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme Commissioning

Contestability amp Decommissioning

lsquoRight treatment in the right place at the right timersquobull Yes Legitimate drivers of Demand

bull Demographic ageing population rising incidence amp detection lifestyle choices smoking alcohol street drugs

bull Diagnostic up‐staging (CT PET Fusion) Neo‐adjuvant switches from XRTSurgery

bull Therapeutic Biologicals Genome stem cell bull NO Greedy Hospitals

driving Demand into the wrong location

bull Cancer 3rd

largest source of revenue in the pharma industry forecast to increase at ~ 17 to $49 billion by

2012bull NCEPODAcute Oncology Report

bull palliative chemotherapy which is inappropriate and unsafe

bull 3rd 4th 5th

lines of treatment

15

lsquoProgrammersquo

Commissioning Cancer Commissioning Toolkit

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much can be delivered in the communityWhat does this mean for the workforce

16

WCC Agenda 3 NationalInternational Benchmarking

lsquoPost Codersquo

Variation in access to chemotherapy

bull

Government and independent reports show wide variations across the within the NHS (and across the

EU) for uptake and access to lsquoNICE approvedrsquo

cancer chemotherapy

bull

Data indicate the main reason is variations in the agreement amp implementation of delivery costs

rather than acquisition procurement costs

bull

Commissioners need to understand the causesbull

Inadequate policing of NICE implementation

bull

Slowincompetent business cases

ArdenPan Birmingham

311008

17

WCC Agenda 4CONTRACTS

WCC Agenda 4CONTRACTS

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

8

pound0

pound500000

pound1000000

pound1500000

pound2000000

pound2500000

pound3000000

THE RISING TIDE OF DEMAND FOR CHEMOTHERAPY

BUDGET

EXPEND

The Rock Budget Deficits amp WCC

1

Outcomes2

Contestabitlity

3

Benchmarking4

Contracts

EXPONENTIAL DEMAND FOR HEALTH‐CARE

NATIONAL BUDGETDEFICIT PBR etc

WCC Agendas

1

Commissioning by OutcomesCorporate Value Management

2

Contestability De‐Commissioning Market Management Darzi Care amp Resource

Utilisation Programme Commissioning

3

Benchmarking

4

Contracts HRGTariffs

WCC Agenda 1 Commissioning for Outcomes Corporate Value Management

bull lsquoAreas with higher levels of spending can often have worse outcomes Its not what we do but what is achieved as the

result of what we do that mattersrsquobull lsquoNSFrsquos amp NICE Assessments Peer Review etc will be

implemented and monitoredndash what are we buyingndash what are the chances we get itndash is this the best possible use of tax‐payersrsquo

money

bull lsquoOutcomersquo

Metrics

ndash Audited Monitoring of Activity Performance amp Outcome

bull Who monitors how frequently

PCT legal challenges to NICE 1

Co‐Payment Inequalities Guidance November 2008

ndash Co‐payment allowed but in separate premises

ndash BUT What is the effect on deprivation inequalities

2

NICE Jan 2009 lsquoAppraising life‐extending end of life (gt 2 years) treatmentsrsquo

ndash lsquogive greater weight to QALYs achieved in the later stages of terminal diseases

ndash BUT Is this NICE guidance a perverse incentive to over‐ treat patients

3

NICE May 2009 National Pharma Discounts Cetuximab for 1st

line Metastatic Colorectal Cancer

ndash Manufacturer rebate of 16 on cetuximab used on a per patient basis pound15902 gtgt pound13650

ndash BUT Are all NICE assessments to be re‐assessed

WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme Commissioning

Contestability amp Decommissioning

lsquoRight treatment in the right place at the right timersquobull Yes Legitimate drivers of Demand

bull Demographic ageing population rising incidence amp detection lifestyle choices smoking alcohol street drugs

bull Diagnostic up‐staging (CT PET Fusion) Neo‐adjuvant switches from XRTSurgery

bull Therapeutic Biologicals Genome stem cell bull NO Greedy Hospitals

driving Demand into the wrong location

bull Cancer 3rd

largest source of revenue in the pharma industry forecast to increase at ~ 17 to $49 billion by

2012bull NCEPODAcute Oncology Report

bull palliative chemotherapy which is inappropriate and unsafe

bull 3rd 4th 5th

lines of treatment

15

lsquoProgrammersquo

Commissioning Cancer Commissioning Toolkit

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much can be delivered in the communityWhat does this mean for the workforce

16

WCC Agenda 3 NationalInternational Benchmarking

lsquoPost Codersquo

Variation in access to chemotherapy

bull

Government and independent reports show wide variations across the within the NHS (and across the

EU) for uptake and access to lsquoNICE approvedrsquo

cancer chemotherapy

bull

Data indicate the main reason is variations in the agreement amp implementation of delivery costs

rather than acquisition procurement costs

bull

Commissioners need to understand the causesbull

Inadequate policing of NICE implementation

bull

Slowincompetent business cases

ArdenPan Birmingham

311008

17

WCC Agenda 4CONTRACTS

WCC Agenda 4CONTRACTS

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

The Rock Budget Deficits amp WCC

1

Outcomes2

Contestabitlity

3

Benchmarking4

Contracts

EXPONENTIAL DEMAND FOR HEALTH‐CARE

NATIONAL BUDGETDEFICIT PBR etc

WCC Agendas

1

Commissioning by OutcomesCorporate Value Management

2

Contestability De‐Commissioning Market Management Darzi Care amp Resource

Utilisation Programme Commissioning

3

Benchmarking

4

Contracts HRGTariffs

WCC Agenda 1 Commissioning for Outcomes Corporate Value Management

bull lsquoAreas with higher levels of spending can often have worse outcomes Its not what we do but what is achieved as the

result of what we do that mattersrsquobull lsquoNSFrsquos amp NICE Assessments Peer Review etc will be

implemented and monitoredndash what are we buyingndash what are the chances we get itndash is this the best possible use of tax‐payersrsquo

money

bull lsquoOutcomersquo

Metrics

ndash Audited Monitoring of Activity Performance amp Outcome

bull Who monitors how frequently

PCT legal challenges to NICE 1

Co‐Payment Inequalities Guidance November 2008

ndash Co‐payment allowed but in separate premises

ndash BUT What is the effect on deprivation inequalities

2

NICE Jan 2009 lsquoAppraising life‐extending end of life (gt 2 years) treatmentsrsquo

ndash lsquogive greater weight to QALYs achieved in the later stages of terminal diseases

ndash BUT Is this NICE guidance a perverse incentive to over‐ treat patients

3

NICE May 2009 National Pharma Discounts Cetuximab for 1st

line Metastatic Colorectal Cancer

ndash Manufacturer rebate of 16 on cetuximab used on a per patient basis pound15902 gtgt pound13650

ndash BUT Are all NICE assessments to be re‐assessed

WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme Commissioning

Contestability amp Decommissioning

lsquoRight treatment in the right place at the right timersquobull Yes Legitimate drivers of Demand

bull Demographic ageing population rising incidence amp detection lifestyle choices smoking alcohol street drugs

bull Diagnostic up‐staging (CT PET Fusion) Neo‐adjuvant switches from XRTSurgery

bull Therapeutic Biologicals Genome stem cell bull NO Greedy Hospitals

driving Demand into the wrong location

bull Cancer 3rd

largest source of revenue in the pharma industry forecast to increase at ~ 17 to $49 billion by

2012bull NCEPODAcute Oncology Report

bull palliative chemotherapy which is inappropriate and unsafe

bull 3rd 4th 5th

lines of treatment

15

lsquoProgrammersquo

Commissioning Cancer Commissioning Toolkit

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much can be delivered in the communityWhat does this mean for the workforce

16

WCC Agenda 3 NationalInternational Benchmarking

lsquoPost Codersquo

Variation in access to chemotherapy

bull

Government and independent reports show wide variations across the within the NHS (and across the

EU) for uptake and access to lsquoNICE approvedrsquo

cancer chemotherapy

bull

Data indicate the main reason is variations in the agreement amp implementation of delivery costs

rather than acquisition procurement costs

bull

Commissioners need to understand the causesbull

Inadequate policing of NICE implementation

bull

Slowincompetent business cases

ArdenPan Birmingham

311008

17

WCC Agenda 4CONTRACTS

WCC Agenda 4CONTRACTS

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

EXPONENTIAL DEMAND FOR HEALTH‐CARE

NATIONAL BUDGETDEFICIT PBR etc

WCC Agendas

1

Commissioning by OutcomesCorporate Value Management

2

Contestability De‐Commissioning Market Management Darzi Care amp Resource

Utilisation Programme Commissioning

3

Benchmarking

4

Contracts HRGTariffs

WCC Agenda 1 Commissioning for Outcomes Corporate Value Management

bull lsquoAreas with higher levels of spending can often have worse outcomes Its not what we do but what is achieved as the

result of what we do that mattersrsquobull lsquoNSFrsquos amp NICE Assessments Peer Review etc will be

implemented and monitoredndash what are we buyingndash what are the chances we get itndash is this the best possible use of tax‐payersrsquo

money

bull lsquoOutcomersquo

Metrics

ndash Audited Monitoring of Activity Performance amp Outcome

bull Who monitors how frequently

PCT legal challenges to NICE 1

Co‐Payment Inequalities Guidance November 2008

ndash Co‐payment allowed but in separate premises

ndash BUT What is the effect on deprivation inequalities

2

NICE Jan 2009 lsquoAppraising life‐extending end of life (gt 2 years) treatmentsrsquo

ndash lsquogive greater weight to QALYs achieved in the later stages of terminal diseases

ndash BUT Is this NICE guidance a perverse incentive to over‐ treat patients

3

NICE May 2009 National Pharma Discounts Cetuximab for 1st

line Metastatic Colorectal Cancer

ndash Manufacturer rebate of 16 on cetuximab used on a per patient basis pound15902 gtgt pound13650

ndash BUT Are all NICE assessments to be re‐assessed

WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme Commissioning

Contestability amp Decommissioning

lsquoRight treatment in the right place at the right timersquobull Yes Legitimate drivers of Demand

bull Demographic ageing population rising incidence amp detection lifestyle choices smoking alcohol street drugs

bull Diagnostic up‐staging (CT PET Fusion) Neo‐adjuvant switches from XRTSurgery

bull Therapeutic Biologicals Genome stem cell bull NO Greedy Hospitals

driving Demand into the wrong location

bull Cancer 3rd

largest source of revenue in the pharma industry forecast to increase at ~ 17 to $49 billion by

2012bull NCEPODAcute Oncology Report

bull palliative chemotherapy which is inappropriate and unsafe

bull 3rd 4th 5th

lines of treatment

15

lsquoProgrammersquo

Commissioning Cancer Commissioning Toolkit

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much can be delivered in the communityWhat does this mean for the workforce

16

WCC Agenda 3 NationalInternational Benchmarking

lsquoPost Codersquo

Variation in access to chemotherapy

bull

Government and independent reports show wide variations across the within the NHS (and across the

EU) for uptake and access to lsquoNICE approvedrsquo

cancer chemotherapy

bull

Data indicate the main reason is variations in the agreement amp implementation of delivery costs

rather than acquisition procurement costs

bull

Commissioners need to understand the causesbull

Inadequate policing of NICE implementation

bull

Slowincompetent business cases

ArdenPan Birmingham

311008

17

WCC Agenda 4CONTRACTS

WCC Agenda 4CONTRACTS

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

WCC Agendas

1

Commissioning by OutcomesCorporate Value Management

2

Contestability De‐Commissioning Market Management Darzi Care amp Resource

Utilisation Programme Commissioning

3

Benchmarking

4

Contracts HRGTariffs

WCC Agenda 1 Commissioning for Outcomes Corporate Value Management

bull lsquoAreas with higher levels of spending can often have worse outcomes Its not what we do but what is achieved as the

result of what we do that mattersrsquobull lsquoNSFrsquos amp NICE Assessments Peer Review etc will be

implemented and monitoredndash what are we buyingndash what are the chances we get itndash is this the best possible use of tax‐payersrsquo

money

bull lsquoOutcomersquo

Metrics

ndash Audited Monitoring of Activity Performance amp Outcome

bull Who monitors how frequently

PCT legal challenges to NICE 1

Co‐Payment Inequalities Guidance November 2008

ndash Co‐payment allowed but in separate premises

ndash BUT What is the effect on deprivation inequalities

2

NICE Jan 2009 lsquoAppraising life‐extending end of life (gt 2 years) treatmentsrsquo

ndash lsquogive greater weight to QALYs achieved in the later stages of terminal diseases

ndash BUT Is this NICE guidance a perverse incentive to over‐ treat patients

3

NICE May 2009 National Pharma Discounts Cetuximab for 1st

line Metastatic Colorectal Cancer

ndash Manufacturer rebate of 16 on cetuximab used on a per patient basis pound15902 gtgt pound13650

ndash BUT Are all NICE assessments to be re‐assessed

WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme Commissioning

Contestability amp Decommissioning

lsquoRight treatment in the right place at the right timersquobull Yes Legitimate drivers of Demand

bull Demographic ageing population rising incidence amp detection lifestyle choices smoking alcohol street drugs

bull Diagnostic up‐staging (CT PET Fusion) Neo‐adjuvant switches from XRTSurgery

bull Therapeutic Biologicals Genome stem cell bull NO Greedy Hospitals

driving Demand into the wrong location

bull Cancer 3rd

largest source of revenue in the pharma industry forecast to increase at ~ 17 to $49 billion by

2012bull NCEPODAcute Oncology Report

bull palliative chemotherapy which is inappropriate and unsafe

bull 3rd 4th 5th

lines of treatment

15

lsquoProgrammersquo

Commissioning Cancer Commissioning Toolkit

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much can be delivered in the communityWhat does this mean for the workforce

16

WCC Agenda 3 NationalInternational Benchmarking

lsquoPost Codersquo

Variation in access to chemotherapy

bull

Government and independent reports show wide variations across the within the NHS (and across the

EU) for uptake and access to lsquoNICE approvedrsquo

cancer chemotherapy

bull

Data indicate the main reason is variations in the agreement amp implementation of delivery costs

rather than acquisition procurement costs

bull

Commissioners need to understand the causesbull

Inadequate policing of NICE implementation

bull

Slowincompetent business cases

ArdenPan Birmingham

311008

17

WCC Agenda 4CONTRACTS

WCC Agenda 4CONTRACTS

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

WCC Agenda 1 Commissioning for Outcomes Corporate Value Management

bull lsquoAreas with higher levels of spending can often have worse outcomes Its not what we do but what is achieved as the

result of what we do that mattersrsquobull lsquoNSFrsquos amp NICE Assessments Peer Review etc will be

implemented and monitoredndash what are we buyingndash what are the chances we get itndash is this the best possible use of tax‐payersrsquo

money

bull lsquoOutcomersquo

Metrics

ndash Audited Monitoring of Activity Performance amp Outcome

bull Who monitors how frequently

PCT legal challenges to NICE 1

Co‐Payment Inequalities Guidance November 2008

ndash Co‐payment allowed but in separate premises

ndash BUT What is the effect on deprivation inequalities

2

NICE Jan 2009 lsquoAppraising life‐extending end of life (gt 2 years) treatmentsrsquo

ndash lsquogive greater weight to QALYs achieved in the later stages of terminal diseases

ndash BUT Is this NICE guidance a perverse incentive to over‐ treat patients

3

NICE May 2009 National Pharma Discounts Cetuximab for 1st

line Metastatic Colorectal Cancer

ndash Manufacturer rebate of 16 on cetuximab used on a per patient basis pound15902 gtgt pound13650

ndash BUT Are all NICE assessments to be re‐assessed

WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme Commissioning

Contestability amp Decommissioning

lsquoRight treatment in the right place at the right timersquobull Yes Legitimate drivers of Demand

bull Demographic ageing population rising incidence amp detection lifestyle choices smoking alcohol street drugs

bull Diagnostic up‐staging (CT PET Fusion) Neo‐adjuvant switches from XRTSurgery

bull Therapeutic Biologicals Genome stem cell bull NO Greedy Hospitals

driving Demand into the wrong location

bull Cancer 3rd

largest source of revenue in the pharma industry forecast to increase at ~ 17 to $49 billion by

2012bull NCEPODAcute Oncology Report

bull palliative chemotherapy which is inappropriate and unsafe

bull 3rd 4th 5th

lines of treatment

15

lsquoProgrammersquo

Commissioning Cancer Commissioning Toolkit

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much can be delivered in the communityWhat does this mean for the workforce

16

WCC Agenda 3 NationalInternational Benchmarking

lsquoPost Codersquo

Variation in access to chemotherapy

bull

Government and independent reports show wide variations across the within the NHS (and across the

EU) for uptake and access to lsquoNICE approvedrsquo

cancer chemotherapy

bull

Data indicate the main reason is variations in the agreement amp implementation of delivery costs

rather than acquisition procurement costs

bull

Commissioners need to understand the causesbull

Inadequate policing of NICE implementation

bull

Slowincompetent business cases

ArdenPan Birmingham

311008

17

WCC Agenda 4CONTRACTS

WCC Agenda 4CONTRACTS

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

PCT legal challenges to NICE 1

Co‐Payment Inequalities Guidance November 2008

ndash Co‐payment allowed but in separate premises

ndash BUT What is the effect on deprivation inequalities

2

NICE Jan 2009 lsquoAppraising life‐extending end of life (gt 2 years) treatmentsrsquo

ndash lsquogive greater weight to QALYs achieved in the later stages of terminal diseases

ndash BUT Is this NICE guidance a perverse incentive to over‐ treat patients

3

NICE May 2009 National Pharma Discounts Cetuximab for 1st

line Metastatic Colorectal Cancer

ndash Manufacturer rebate of 16 on cetuximab used on a per patient basis pound15902 gtgt pound13650

ndash BUT Are all NICE assessments to be re‐assessed

WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme Commissioning

Contestability amp Decommissioning

lsquoRight treatment in the right place at the right timersquobull Yes Legitimate drivers of Demand

bull Demographic ageing population rising incidence amp detection lifestyle choices smoking alcohol street drugs

bull Diagnostic up‐staging (CT PET Fusion) Neo‐adjuvant switches from XRTSurgery

bull Therapeutic Biologicals Genome stem cell bull NO Greedy Hospitals

driving Demand into the wrong location

bull Cancer 3rd

largest source of revenue in the pharma industry forecast to increase at ~ 17 to $49 billion by

2012bull NCEPODAcute Oncology Report

bull palliative chemotherapy which is inappropriate and unsafe

bull 3rd 4th 5th

lines of treatment

15

lsquoProgrammersquo

Commissioning Cancer Commissioning Toolkit

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much can be delivered in the communityWhat does this mean for the workforce

16

WCC Agenda 3 NationalInternational Benchmarking

lsquoPost Codersquo

Variation in access to chemotherapy

bull

Government and independent reports show wide variations across the within the NHS (and across the

EU) for uptake and access to lsquoNICE approvedrsquo

cancer chemotherapy

bull

Data indicate the main reason is variations in the agreement amp implementation of delivery costs

rather than acquisition procurement costs

bull

Commissioners need to understand the causesbull

Inadequate policing of NICE implementation

bull

Slowincompetent business cases

ArdenPan Birmingham

311008

17

WCC Agenda 4CONTRACTS

WCC Agenda 4CONTRACTS

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme Commissioning

Contestability amp Decommissioning

lsquoRight treatment in the right place at the right timersquobull Yes Legitimate drivers of Demand

bull Demographic ageing population rising incidence amp detection lifestyle choices smoking alcohol street drugs

bull Diagnostic up‐staging (CT PET Fusion) Neo‐adjuvant switches from XRTSurgery

bull Therapeutic Biologicals Genome stem cell bull NO Greedy Hospitals

driving Demand into the wrong location

bull Cancer 3rd

largest source of revenue in the pharma industry forecast to increase at ~ 17 to $49 billion by

2012bull NCEPODAcute Oncology Report

bull palliative chemotherapy which is inappropriate and unsafe

bull 3rd 4th 5th

lines of treatment

15

lsquoProgrammersquo

Commissioning Cancer Commissioning Toolkit

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much can be delivered in the communityWhat does this mean for the workforce

16

WCC Agenda 3 NationalInternational Benchmarking

lsquoPost Codersquo

Variation in access to chemotherapy

bull

Government and independent reports show wide variations across the within the NHS (and across the

EU) for uptake and access to lsquoNICE approvedrsquo

cancer chemotherapy

bull

Data indicate the main reason is variations in the agreement amp implementation of delivery costs

rather than acquisition procurement costs

bull

Commissioners need to understand the causesbull

Inadequate policing of NICE implementation

bull

Slowincompetent business cases

ArdenPan Birmingham

311008

17

WCC Agenda 4CONTRACTS

WCC Agenda 4CONTRACTS

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

15

lsquoProgrammersquo

Commissioning Cancer Commissioning Toolkit

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much can be delivered in the communityWhat does this mean for the workforce

16

WCC Agenda 3 NationalInternational Benchmarking

lsquoPost Codersquo

Variation in access to chemotherapy

bull

Government and independent reports show wide variations across the within the NHS (and across the

EU) for uptake and access to lsquoNICE approvedrsquo

cancer chemotherapy

bull

Data indicate the main reason is variations in the agreement amp implementation of delivery costs

rather than acquisition procurement costs

bull

Commissioners need to understand the causesbull

Inadequate policing of NICE implementation

bull

Slowincompetent business cases

ArdenPan Birmingham

311008

17

WCC Agenda 4CONTRACTS

WCC Agenda 4CONTRACTS

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

16

WCC Agenda 3 NationalInternational Benchmarking

lsquoPost Codersquo

Variation in access to chemotherapy

bull

Government and independent reports show wide variations across the within the NHS (and across the

EU) for uptake and access to lsquoNICE approvedrsquo

cancer chemotherapy

bull

Data indicate the main reason is variations in the agreement amp implementation of delivery costs

rather than acquisition procurement costs

bull

Commissioners need to understand the causesbull

Inadequate policing of NICE implementation

bull

Slowincompetent business cases

ArdenPan Birmingham

311008

17

WCC Agenda 4CONTRACTS

WCC Agenda 4CONTRACTS

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

ArdenPan Birmingham

311008

17

WCC Agenda 4CONTRACTS

WCC Agenda 4CONTRACTS

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

WCC Contracts agreeing lsquocoinagersquo Attendances or PBRHRG 4

Hourly Rate or Job‐Rate

Attendances1

encourages

attendances

2

assumes all chemotherapy

regimens have the same complexity

3

Drug Procurement (acquisition) costs are

commissioned separately

4

perverse financial incentive not to switch

iv to oral

PBR1

encourages results

2

encourages codingbull ICD 10 amp regimen

3

Drug Procurement (acquisition) costs are

explicit and linked to delivery bands

4

Oral income band is comparable to iv

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

World Class Commissioning (WCC)

amp the NCAG ReportNCAG Report

1

Exponential Demandndash Capacity Planning

Business Cases

ndash Service re‐designbull Devolved services

bull Work Force

2

NCEPODAcute Oncology

ndash SafetyAcute Oncology

WCC Priorities

bull Financial Deficitsndash Contracts

bull 6 Agendasbull Mergers PBC etc etc

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

NCEPODAcute Oncology audit For Better Or Worse 2008

bull 47000 chemotherapy patients treated JuneJuly 2006

ndash (= 500000 pa)bull 1044 (2) died within 30 daysbull 63 questionnaires returnedbull 52 case notes returnedbull Lowest rate of response of any NCEPODAcute

Oncology audit

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

NCEPODAcute Oncology 1044 patients died within 30 days

bull 50 had previous programme of chemotherapy

bull 86 palliative treatment intent

bull ECOG PSndash 0 or 1 38

ndash 2

41

ndash 3 or 4

21

bull Location of chemo

ndash 35 IPndash 57 OPndash 8 home

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

NCEPODAcute Oncology 1044 patients died within 30 days verdict on care

bull 35 good

bull 49 room for improvement

bull 8 less than satisfactory care

bull 8 insufficient data

bull 27 treatment caused or hastened death

Questionsndash Were these 27 predictablepreventable

ndash What did the other 73 die ofbull Was their death predictable

ndash How many other admissions were related to chemo

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

WCC Clinical Risk Pyramids

DEATHS

CLINICAL INCIDENTS

UNSAFE PRACTICES

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

24

End‐stage (palliative) Chemotherapy

bull What are the problems highlighted by NCEPODAcute Oncology

ndashcancer hospital deathsndashunplanned admissions

ndashlsquoend‐stage (palliative) chemotherapy

Are World Class Commissioners reasonable in questioning the appropriateness and safety of

chemotherapy services

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

Palliative chemotherapy for progressivemetastatic disease

bulllt 2 years left

Terminal careamp death

UnplannedAcute MedicalAdmissions

20 First contact with NHS

60receive

1st 2nd 3rd

lines ofpalliative

chemotherapy

2years

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

26

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

bull lsquoAcute Oncologyrsquondashpalliative chemotherapy costs

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

lsquoAcute Oncologyrsquo

unplanned admissions 1

National Picturebull 273000 emergency admissions with diagnosis of

cancer in 20067 up by 30 from 19978ndash 44 initially under care of medicine 22 under surgery

23 under onchaem

bull Equivalent to 750 emergency admissions per day across England (pop 50 million)

bull Typical Trust serving 05 million at least 5 emergency admissions with cancer per day

ndash 2 under medicine 1 under surgery 1 under onchaem and 1 lsquootherrsquo

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

28

lsquoAcute Oncologyrsquo

unplanned admissions 2 National Oncology Bed Census

RCR Faculty of Clinical Oncology

Midnight 150505

1265 patientsbull ~ 60 Elective bull ~ 40 Non Elective

ndash 3 awaiting discharge to the community

ndash 14 side‐effects of treatment

ndash 21 control of symptoms not specifically related to treatment

ndash 2 for end of life care

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

29

lsquoAcute Oncologyrsquo

unplanned admissions 3 East Kent Acute DGH Census

September 2005 Population 06 million Beds 968

How many oncology registered patients were admitted bull 83 oncology admissions over the 4 four week period

ndash 43 (52) were for patients admitted for palliation social care

end of life care or a variety of reasons unconnected with oncology treatment

ndash 10 died during that admission

bull 25 of admissions arranged by oncologist most during working hours

ndash 75 emergency unplanned admissions from home through AampE MAU

ConclusionRisk of unplanned (emergency) admission of Oncology registered patients is

~ 100 per month per million population

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

30

End‐stage (palliative) Chemotherapy

bull What is the problem

ndashcancer hospital deathsndashunplanned admissions

ndashpalliative chemotherapy costs

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

Inappropriate Chemotherapy

bull UK Cancer incidence ~ 300000 pabull UK Cancer deaths ~ 200000 pabull UK chemo treatments ~300000 pa

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

32

Inappropriate Palliative Chemotherapy USA (Medicare) Canadian and UK Data suggests many patients

receive palliative chemotherapy within one month of death

bull lsquoOf those who received chemotherapy in the last six months 16 received chemotherapy in the last two weeks of lifersquo

(1)

bull lsquoIn Massachusetts 33 of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life 23 in the last 3 months and 9 in the last monthrsquo

(2)

1

Barbera L Paszat L Chartier C 2006 Indicators of poor quality end‐of‐life cancer care in Ontario J Palliat

Care 2006 Spring22(1)12‐7

2

Ezekiel J Emanuel MD PhD Yinong Young‐Xu MA Norman G Levinsky MD Gail Gazelle et al 2003

Chemotherapy Use among Medicare Beneficiaries at the End of Life

Volume 138 Issue 8 | Pages 639‐643

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

ArdenPan Birmingham

311008

34

ECONOMICS OF CHEMOTHERAPY

DELIVERY

ECONOMICS OF CHEMOTHERAPY

DELIVERY

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Structures devolvedoutreach

Service Line BudgetingCapacity Activity Demand

Productivity Business Cases

Costing AampE admissionsExplicit non‐elective acute

oncology contracting

Operational Audited Standard Operational Procedures

Protocols Medical RecordsWorkforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical Incidents

Professional performace issues

NCEPODAcute Oncology

36

CENTRE

UNITUNIT

UNITUNIT

UNIT

StructuresIncreasingly chemotherapy takes place

outside the Cancer Centre

poundpoundpound poundpoundpound

poundpoundpoundpoundpoundpound

poundpoundpound

Funding should follow patients through negotiated SLArsquos

Reacting to demand is dangerous

Planning and predicting demand is safer

Business Intelligence Definitions

bull Capacityndash all the resources available on the chemotherapy

lsquoproduction linersquo

to deliver drugs to individual patients

bull Activityndash all the work done each day

bull Demandndash all the referrals received each day

Productivity

= ActivityCapacity

C‐PORT Predictive modelling of Integrated Care Pathways ‐

measures currentpredicted activity and matches it to

existing resources

39

CapacityRe

sources

Predicted

demandCurrent

activity

WCC arbitration on the tariff ‐

are these Reference Costs reasonable

‐

is this level of profit reasonable

40

Blood Pharmacy IV NurseOncologist

pound20 pound50 pound30 pound30Fixed Costs

Other Costs + pound20 Utilities Secretaries etc

Total pound150IncomeDay-case pound600Attendance

Profit per attendancepound450

( assuming drug procurement costs are funded separately)

Productivity streamlining the integrated care pathway

Rate limiting steps

Wait10m Process

sample 30m

Wait 35mSample

4m

Con15m Pharmacy 30m

Chemo prep20m Admin

6m

Blood testDoctor

consultationPharmacy preparation

C‐PORT uses the algorithm of the Integrated Care Pathway to lsquoflight‐simulatersquo

a series of options

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Service Level AgreementsService Line BudgetingCapacity Activity Demand

ProductivityBusiness Cases

Costing AampE admissions

Operational SOPS Protocols Medical Records

Workforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical

Incidents Professional performace issues

NCEPODAcute Oncology

Why should I write a business‐case and how do I do it

Chaptersbull Executive Summary Introduction bull Current Situationbull Strategic Context National International Drivers bull Current Practice Case for Change Projected benefits

realization time‐scales Understanding of Commissioning Perspective

bull Data Analysis Capacity Planning Implications of Data for the Future

bull Options and Options Appraisal Preferred Option Proposed Service Model

bull Proposed Implementation of Projectbull Post‐Project Report bull Referencesbull Appendices

Cetuximab for 1st

line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million

Costs for 48 patients in KMCNKRAS testing (only wild‐type

(unmutated) KRAS)pound9500 - pound20500 (testing 68 patients)

(applicable from 2010)

Procurement Cetuximab (14 weeks)

pound550000 (pound462000 with Merck Serono rebate scheme)

Delivery (14 weeks treatment ndash 7 additional day-case chemo costs)Based on day case chemotherapy tariffs of pound536 (Medway) pound720-810 (MTW)

pound180000 - pound272000

Liver resections (10 additional resections at pound8744)

pound87500

Total pound827000 - pound930000

pound739000 - pound842000 (with drug rebate)(the costs of second line chemotherapy will be offset in those patients whose liver metastases are resected successfully)

Cetuximab 1st

line Metastatic Colorectal

When can we start prescribingWCC Commissioning answer when you have in place

1

the machinery for policing the NICE commissioning recommendation

ndash ie KRAS positive Liver only Primary resected

2

the Business Case for KRAS testing setting out

ndash which patients are we paying for

ndash all newly diagnosed or all metastatic

ndash which organisations initiates amp carry out the testing process

3

the Business Cases for implementing delivery costs (oncologist pharmacist nurse job‐plans)

All of this will delay treatment and cause lsquopost‐codersquo variations

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Structures devolvedoutreach

Service Line BudgetingCapacity Activity Demand

Productivity Business Cases

Costing AampE admissionsExplicit non‐elective acute

oncology contracting

Operational Audited Standard Operational Procedures

Protocols Medical RecordsWorkforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical Incidents

Professional performace issues

NCEPODAcute Oncology

47

Acute Oncology amp End‐stage (palliative)

Chemotherapy

bull What is the problem ndash cancer hospital deaths chemotherapy‐

related deaths

ndashunplanned admissions lsquoAcute Oncologyrsquo

ndashpalliative chemotherapy treating too late

What is the Remedy

NCEPODAcute Oncology Remedies 1 Clinical risk management

incident (IR1) reporting

bull Deaths by final chemotherapy dosendash how many deaths occurred within one month

within three months and within six months of the final chemotherapy treatment

ndash how many had an IR1 raised

bull Unplanned admissionsndash in the last six months how many patients receiving

chemotherapy experienced an unplanned admission months

ndash what was their length of stayndash how many had an IR1rsquos were raised

NCEPODAcute Oncology Remedies 2 ISO 9000

bull Run the Chemo Unit as a proper business ISO 9000

bull Intelligence = better ITbull Web‐based records

bull Define operational Multi disciplinary team

bull Demand Managementndash Community‐based symptom‐control for advanced

metastatic cancer

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

ArdenPan Birmingham

311008

34

ECONOMICS OF CHEMOTHERAPY

DELIVERY

ECONOMICS OF CHEMOTHERAPY

DELIVERY

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Structures devolvedoutreach

Service Line BudgetingCapacity Activity Demand

Productivity Business Cases

Costing AampE admissionsExplicit non‐elective acute

oncology contracting

Operational Audited Standard Operational Procedures

Protocols Medical RecordsWorkforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical Incidents

Professional performace issues

NCEPODAcute Oncology

36

CENTRE

UNITUNIT

UNITUNIT

UNIT

StructuresIncreasingly chemotherapy takes place

outside the Cancer Centre

poundpoundpound poundpoundpound

poundpoundpoundpoundpoundpound

poundpoundpound

Funding should follow patients through negotiated SLArsquos

Reacting to demand is dangerous

Planning and predicting demand is safer

Business Intelligence Definitions

bull Capacityndash all the resources available on the chemotherapy

lsquoproduction linersquo

to deliver drugs to individual patients

bull Activityndash all the work done each day

bull Demandndash all the referrals received each day

Productivity

= ActivityCapacity

C‐PORT Predictive modelling of Integrated Care Pathways ‐

measures currentpredicted activity and matches it to

existing resources

39

CapacityRe

sources

Predicted

demandCurrent

activity

WCC arbitration on the tariff ‐

are these Reference Costs reasonable

‐

is this level of profit reasonable

40

Blood Pharmacy IV NurseOncologist

pound20 pound50 pound30 pound30Fixed Costs

Other Costs + pound20 Utilities Secretaries etc

Total pound150IncomeDay-case pound600Attendance

Profit per attendancepound450

( assuming drug procurement costs are funded separately)

Productivity streamlining the integrated care pathway

Rate limiting steps

Wait10m Process

sample 30m

Wait 35mSample

4m

Con15m Pharmacy 30m

Chemo prep20m Admin

6m

Blood testDoctor

consultationPharmacy preparation

C‐PORT uses the algorithm of the Integrated Care Pathway to lsquoflight‐simulatersquo

a series of options

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Service Level AgreementsService Line BudgetingCapacity Activity Demand

ProductivityBusiness Cases

Costing AampE admissions

Operational SOPS Protocols Medical Records

Workforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical

Incidents Professional performace issues

NCEPODAcute Oncology

Why should I write a business‐case and how do I do it

Chaptersbull Executive Summary Introduction bull Current Situationbull Strategic Context National International Drivers bull Current Practice Case for Change Projected benefits

realization time‐scales Understanding of Commissioning Perspective

bull Data Analysis Capacity Planning Implications of Data for the Future

bull Options and Options Appraisal Preferred Option Proposed Service Model

bull Proposed Implementation of Projectbull Post‐Project Report bull Referencesbull Appendices

Cetuximab for 1st

line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million

Costs for 48 patients in KMCNKRAS testing (only wild‐type

(unmutated) KRAS)pound9500 - pound20500 (testing 68 patients)

(applicable from 2010)

Procurement Cetuximab (14 weeks)

pound550000 (pound462000 with Merck Serono rebate scheme)

Delivery (14 weeks treatment ndash 7 additional day-case chemo costs)Based on day case chemotherapy tariffs of pound536 (Medway) pound720-810 (MTW)

pound180000 - pound272000

Liver resections (10 additional resections at pound8744)

pound87500

Total pound827000 - pound930000

pound739000 - pound842000 (with drug rebate)(the costs of second line chemotherapy will be offset in those patients whose liver metastases are resected successfully)

Cetuximab 1st

line Metastatic Colorectal

When can we start prescribingWCC Commissioning answer when you have in place

1

the machinery for policing the NICE commissioning recommendation

ndash ie KRAS positive Liver only Primary resected

2

the Business Case for KRAS testing setting out

ndash which patients are we paying for

ndash all newly diagnosed or all metastatic

ndash which organisations initiates amp carry out the testing process

3

the Business Cases for implementing delivery costs (oncologist pharmacist nurse job‐plans)

All of this will delay treatment and cause lsquopost‐codersquo variations

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Structures devolvedoutreach

Service Line BudgetingCapacity Activity Demand

Productivity Business Cases

Costing AampE admissionsExplicit non‐elective acute

oncology contracting

Operational Audited Standard Operational Procedures

Protocols Medical RecordsWorkforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical Incidents

Professional performace issues

NCEPODAcute Oncology

47

Acute Oncology amp End‐stage (palliative)

Chemotherapy

bull What is the problem ndash cancer hospital deaths chemotherapy‐

related deaths

ndashunplanned admissions lsquoAcute Oncologyrsquo

ndashpalliative chemotherapy treating too late

What is the Remedy

NCEPODAcute Oncology Remedies 1 Clinical risk management

incident (IR1) reporting

bull Deaths by final chemotherapy dosendash how many deaths occurred within one month

within three months and within six months of the final chemotherapy treatment

ndash how many had an IR1 raised

bull Unplanned admissionsndash in the last six months how many patients receiving

chemotherapy experienced an unplanned admission months

ndash what was their length of stayndash how many had an IR1rsquos were raised

NCEPODAcute Oncology Remedies 2 ISO 9000

bull Run the Chemo Unit as a proper business ISO 9000

bull Intelligence = better ITbull Web‐based records

bull Define operational Multi disciplinary team

bull Demand Managementndash Community‐based symptom‐control for advanced

metastatic cancer

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Structures devolvedoutreach

Service Line BudgetingCapacity Activity Demand

Productivity Business Cases

Costing AampE admissionsExplicit non‐elective acute

oncology contracting

Operational Audited Standard Operational Procedures

Protocols Medical RecordsWorkforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical Incidents

Professional performace issues

NCEPODAcute Oncology

36

CENTRE

UNITUNIT

UNITUNIT

UNIT

StructuresIncreasingly chemotherapy takes place

outside the Cancer Centre

poundpoundpound poundpoundpound

poundpoundpoundpoundpoundpound

poundpoundpound

Funding should follow patients through negotiated SLArsquos

Reacting to demand is dangerous

Planning and predicting demand is safer

Business Intelligence Definitions

bull Capacityndash all the resources available on the chemotherapy

lsquoproduction linersquo

to deliver drugs to individual patients

bull Activityndash all the work done each day

bull Demandndash all the referrals received each day

Productivity

= ActivityCapacity

C‐PORT Predictive modelling of Integrated Care Pathways ‐

measures currentpredicted activity and matches it to

existing resources

39

CapacityRe

sources

Predicted

demandCurrent

activity

WCC arbitration on the tariff ‐

are these Reference Costs reasonable

‐

is this level of profit reasonable

40

Blood Pharmacy IV NurseOncologist

pound20 pound50 pound30 pound30Fixed Costs

Other Costs + pound20 Utilities Secretaries etc

Total pound150IncomeDay-case pound600Attendance

Profit per attendancepound450

( assuming drug procurement costs are funded separately)

Productivity streamlining the integrated care pathway

Rate limiting steps

Wait10m Process

sample 30m

Wait 35mSample

4m

Con15m Pharmacy 30m

Chemo prep20m Admin

6m

Blood testDoctor

consultationPharmacy preparation

C‐PORT uses the algorithm of the Integrated Care Pathway to lsquoflight‐simulatersquo

a series of options

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Service Level AgreementsService Line BudgetingCapacity Activity Demand

ProductivityBusiness Cases

Costing AampE admissions

Operational SOPS Protocols Medical Records

Workforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical

Incidents Professional performace issues

NCEPODAcute Oncology

Why should I write a business‐case and how do I do it

Chaptersbull Executive Summary Introduction bull Current Situationbull Strategic Context National International Drivers bull Current Practice Case for Change Projected benefits

realization time‐scales Understanding of Commissioning Perspective

bull Data Analysis Capacity Planning Implications of Data for the Future

bull Options and Options Appraisal Preferred Option Proposed Service Model

bull Proposed Implementation of Projectbull Post‐Project Report bull Referencesbull Appendices

Cetuximab for 1st

line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million

Costs for 48 patients in KMCNKRAS testing (only wild‐type

(unmutated) KRAS)pound9500 - pound20500 (testing 68 patients)

(applicable from 2010)

Procurement Cetuximab (14 weeks)

pound550000 (pound462000 with Merck Serono rebate scheme)

Delivery (14 weeks treatment ndash 7 additional day-case chemo costs)Based on day case chemotherapy tariffs of pound536 (Medway) pound720-810 (MTW)

pound180000 - pound272000

Liver resections (10 additional resections at pound8744)

pound87500

Total pound827000 - pound930000

pound739000 - pound842000 (with drug rebate)(the costs of second line chemotherapy will be offset in those patients whose liver metastases are resected successfully)

Cetuximab 1st

line Metastatic Colorectal

When can we start prescribingWCC Commissioning answer when you have in place

1

the machinery for policing the NICE commissioning recommendation

ndash ie KRAS positive Liver only Primary resected

2

the Business Case for KRAS testing setting out

ndash which patients are we paying for

ndash all newly diagnosed or all metastatic

ndash which organisations initiates amp carry out the testing process

3

the Business Cases for implementing delivery costs (oncologist pharmacist nurse job‐plans)

All of this will delay treatment and cause lsquopost‐codersquo variations

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Structures devolvedoutreach

Service Line BudgetingCapacity Activity Demand

Productivity Business Cases

Costing AampE admissionsExplicit non‐elective acute

oncology contracting

Operational Audited Standard Operational Procedures

Protocols Medical RecordsWorkforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical Incidents

Professional performace issues

NCEPODAcute Oncology

47

Acute Oncology amp End‐stage (palliative)

Chemotherapy

bull What is the problem ndash cancer hospital deaths chemotherapy‐

related deaths

ndashunplanned admissions lsquoAcute Oncologyrsquo

ndashpalliative chemotherapy treating too late

What is the Remedy

NCEPODAcute Oncology Remedies 1 Clinical risk management

incident (IR1) reporting

bull Deaths by final chemotherapy dosendash how many deaths occurred within one month

within three months and within six months of the final chemotherapy treatment

ndash how many had an IR1 raised

bull Unplanned admissionsndash in the last six months how many patients receiving

chemotherapy experienced an unplanned admission months

ndash what was their length of stayndash how many had an IR1rsquos were raised

NCEPODAcute Oncology Remedies 2 ISO 9000

bull Run the Chemo Unit as a proper business ISO 9000

bull Intelligence = better ITbull Web‐based records

bull Define operational Multi disciplinary team

bull Demand Managementndash Community‐based symptom‐control for advanced

metastatic cancer

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

36

CENTRE

UNITUNIT

UNITUNIT

UNIT

StructuresIncreasingly chemotherapy takes place

outside the Cancer Centre

poundpoundpound poundpoundpound

poundpoundpoundpoundpoundpound

poundpoundpound

Funding should follow patients through negotiated SLArsquos

Reacting to demand is dangerous

Planning and predicting demand is safer

Business Intelligence Definitions

bull Capacityndash all the resources available on the chemotherapy

lsquoproduction linersquo

to deliver drugs to individual patients

bull Activityndash all the work done each day

bull Demandndash all the referrals received each day

Productivity

= ActivityCapacity

C‐PORT Predictive modelling of Integrated Care Pathways ‐

measures currentpredicted activity and matches it to

existing resources

39

CapacityRe

sources

Predicted

demandCurrent

activity

WCC arbitration on the tariff ‐

are these Reference Costs reasonable

‐

is this level of profit reasonable

40

Blood Pharmacy IV NurseOncologist

pound20 pound50 pound30 pound30Fixed Costs

Other Costs + pound20 Utilities Secretaries etc

Total pound150IncomeDay-case pound600Attendance

Profit per attendancepound450

( assuming drug procurement costs are funded separately)

Productivity streamlining the integrated care pathway

Rate limiting steps

Wait10m Process

sample 30m

Wait 35mSample

4m

Con15m Pharmacy 30m

Chemo prep20m Admin

6m

Blood testDoctor

consultationPharmacy preparation

C‐PORT uses the algorithm of the Integrated Care Pathway to lsquoflight‐simulatersquo

a series of options

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Service Level AgreementsService Line BudgetingCapacity Activity Demand

ProductivityBusiness Cases

Costing AampE admissions

Operational SOPS Protocols Medical Records

Workforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical

Incidents Professional performace issues

NCEPODAcute Oncology

Why should I write a business‐case and how do I do it

Chaptersbull Executive Summary Introduction bull Current Situationbull Strategic Context National International Drivers bull Current Practice Case for Change Projected benefits

realization time‐scales Understanding of Commissioning Perspective

bull Data Analysis Capacity Planning Implications of Data for the Future

bull Options and Options Appraisal Preferred Option Proposed Service Model

bull Proposed Implementation of Projectbull Post‐Project Report bull Referencesbull Appendices

Cetuximab for 1st

line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million

Costs for 48 patients in KMCNKRAS testing (only wild‐type

(unmutated) KRAS)pound9500 - pound20500 (testing 68 patients)

(applicable from 2010)

Procurement Cetuximab (14 weeks)

pound550000 (pound462000 with Merck Serono rebate scheme)

Delivery (14 weeks treatment ndash 7 additional day-case chemo costs)Based on day case chemotherapy tariffs of pound536 (Medway) pound720-810 (MTW)

pound180000 - pound272000

Liver resections (10 additional resections at pound8744)

pound87500

Total pound827000 - pound930000

pound739000 - pound842000 (with drug rebate)(the costs of second line chemotherapy will be offset in those patients whose liver metastases are resected successfully)

Cetuximab 1st

line Metastatic Colorectal

When can we start prescribingWCC Commissioning answer when you have in place

1

the machinery for policing the NICE commissioning recommendation

ndash ie KRAS positive Liver only Primary resected

2

the Business Case for KRAS testing setting out

ndash which patients are we paying for

ndash all newly diagnosed or all metastatic

ndash which organisations initiates amp carry out the testing process

3

the Business Cases for implementing delivery costs (oncologist pharmacist nurse job‐plans)

All of this will delay treatment and cause lsquopost‐codersquo variations

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Structures devolvedoutreach

Service Line BudgetingCapacity Activity Demand

Productivity Business Cases

Costing AampE admissionsExplicit non‐elective acute

oncology contracting

Operational Audited Standard Operational Procedures

Protocols Medical RecordsWorkforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical Incidents

Professional performace issues

NCEPODAcute Oncology

47

Acute Oncology amp End‐stage (palliative)

Chemotherapy

bull What is the problem ndash cancer hospital deaths chemotherapy‐

related deaths

ndashunplanned admissions lsquoAcute Oncologyrsquo

ndashpalliative chemotherapy treating too late

What is the Remedy

NCEPODAcute Oncology Remedies 1 Clinical risk management

incident (IR1) reporting

bull Deaths by final chemotherapy dosendash how many deaths occurred within one month

within three months and within six months of the final chemotherapy treatment

ndash how many had an IR1 raised

bull Unplanned admissionsndash in the last six months how many patients receiving

chemotherapy experienced an unplanned admission months

ndash what was their length of stayndash how many had an IR1rsquos were raised

NCEPODAcute Oncology Remedies 2 ISO 9000

bull Run the Chemo Unit as a proper business ISO 9000

bull Intelligence = better ITbull Web‐based records

bull Define operational Multi disciplinary team

bull Demand Managementndash Community‐based symptom‐control for advanced

metastatic cancer

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

Reacting to demand is dangerous

Planning and predicting demand is safer

Business Intelligence Definitions

bull Capacityndash all the resources available on the chemotherapy

lsquoproduction linersquo

to deliver drugs to individual patients

bull Activityndash all the work done each day

bull Demandndash all the referrals received each day

Productivity

= ActivityCapacity

C‐PORT Predictive modelling of Integrated Care Pathways ‐

measures currentpredicted activity and matches it to

existing resources

39

CapacityRe

sources

Predicted

demandCurrent

activity

WCC arbitration on the tariff ‐

are these Reference Costs reasonable

‐

is this level of profit reasonable

40

Blood Pharmacy IV NurseOncologist

pound20 pound50 pound30 pound30Fixed Costs

Other Costs + pound20 Utilities Secretaries etc

Total pound150IncomeDay-case pound600Attendance

Profit per attendancepound450

( assuming drug procurement costs are funded separately)

Productivity streamlining the integrated care pathway

Rate limiting steps

Wait10m Process

sample 30m

Wait 35mSample

4m

Con15m Pharmacy 30m

Chemo prep20m Admin

6m

Blood testDoctor

consultationPharmacy preparation

C‐PORT uses the algorithm of the Integrated Care Pathway to lsquoflight‐simulatersquo

a series of options

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Service Level AgreementsService Line BudgetingCapacity Activity Demand

ProductivityBusiness Cases

Costing AampE admissions

Operational SOPS Protocols Medical Records

Workforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical

Incidents Professional performace issues

NCEPODAcute Oncology

Why should I write a business‐case and how do I do it

Chaptersbull Executive Summary Introduction bull Current Situationbull Strategic Context National International Drivers bull Current Practice Case for Change Projected benefits

realization time‐scales Understanding of Commissioning Perspective

bull Data Analysis Capacity Planning Implications of Data for the Future

bull Options and Options Appraisal Preferred Option Proposed Service Model

bull Proposed Implementation of Projectbull Post‐Project Report bull Referencesbull Appendices

Cetuximab for 1st

line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million

Costs for 48 patients in KMCNKRAS testing (only wild‐type

(unmutated) KRAS)pound9500 - pound20500 (testing 68 patients)

(applicable from 2010)

Procurement Cetuximab (14 weeks)

pound550000 (pound462000 with Merck Serono rebate scheme)

Delivery (14 weeks treatment ndash 7 additional day-case chemo costs)Based on day case chemotherapy tariffs of pound536 (Medway) pound720-810 (MTW)

pound180000 - pound272000

Liver resections (10 additional resections at pound8744)

pound87500

Total pound827000 - pound930000

pound739000 - pound842000 (with drug rebate)(the costs of second line chemotherapy will be offset in those patients whose liver metastases are resected successfully)

Cetuximab 1st

line Metastatic Colorectal

When can we start prescribingWCC Commissioning answer when you have in place

1

the machinery for policing the NICE commissioning recommendation

ndash ie KRAS positive Liver only Primary resected

2

the Business Case for KRAS testing setting out

ndash which patients are we paying for

ndash all newly diagnosed or all metastatic

ndash which organisations initiates amp carry out the testing process

3

the Business Cases for implementing delivery costs (oncologist pharmacist nurse job‐plans)

All of this will delay treatment and cause lsquopost‐codersquo variations

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Structures devolvedoutreach

Service Line BudgetingCapacity Activity Demand

Productivity Business Cases

Costing AampE admissionsExplicit non‐elective acute

oncology contracting

Operational Audited Standard Operational Procedures

Protocols Medical RecordsWorkforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical Incidents

Professional performace issues

NCEPODAcute Oncology

47

Acute Oncology amp End‐stage (palliative)

Chemotherapy

bull What is the problem ndash cancer hospital deaths chemotherapy‐

related deaths

ndashunplanned admissions lsquoAcute Oncologyrsquo

ndashpalliative chemotherapy treating too late

What is the Remedy

NCEPODAcute Oncology Remedies 1 Clinical risk management

incident (IR1) reporting

bull Deaths by final chemotherapy dosendash how many deaths occurred within one month

within three months and within six months of the final chemotherapy treatment

ndash how many had an IR1 raised

bull Unplanned admissionsndash in the last six months how many patients receiving

chemotherapy experienced an unplanned admission months

ndash what was their length of stayndash how many had an IR1rsquos were raised

NCEPODAcute Oncology Remedies 2 ISO 9000

bull Run the Chemo Unit as a proper business ISO 9000

bull Intelligence = better ITbull Web‐based records

bull Define operational Multi disciplinary team

bull Demand Managementndash Community‐based symptom‐control for advanced

metastatic cancer

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

Business Intelligence Definitions

bull Capacityndash all the resources available on the chemotherapy

lsquoproduction linersquo

to deliver drugs to individual patients

bull Activityndash all the work done each day

bull Demandndash all the referrals received each day

Productivity

= ActivityCapacity

C‐PORT Predictive modelling of Integrated Care Pathways ‐

measures currentpredicted activity and matches it to

existing resources

39

CapacityRe

sources

Predicted

demandCurrent

activity

WCC arbitration on the tariff ‐

are these Reference Costs reasonable

‐

is this level of profit reasonable

40

Blood Pharmacy IV NurseOncologist

pound20 pound50 pound30 pound30Fixed Costs

Other Costs + pound20 Utilities Secretaries etc

Total pound150IncomeDay-case pound600Attendance

Profit per attendancepound450

( assuming drug procurement costs are funded separately)

Productivity streamlining the integrated care pathway

Rate limiting steps

Wait10m Process

sample 30m

Wait 35mSample

4m

Con15m Pharmacy 30m

Chemo prep20m Admin

6m

Blood testDoctor

consultationPharmacy preparation

C‐PORT uses the algorithm of the Integrated Care Pathway to lsquoflight‐simulatersquo

a series of options

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Service Level AgreementsService Line BudgetingCapacity Activity Demand

ProductivityBusiness Cases

Costing AampE admissions

Operational SOPS Protocols Medical Records

Workforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical

Incidents Professional performace issues

NCEPODAcute Oncology

Why should I write a business‐case and how do I do it

Chaptersbull Executive Summary Introduction bull Current Situationbull Strategic Context National International Drivers bull Current Practice Case for Change Projected benefits

realization time‐scales Understanding of Commissioning Perspective

bull Data Analysis Capacity Planning Implications of Data for the Future

bull Options and Options Appraisal Preferred Option Proposed Service Model

bull Proposed Implementation of Projectbull Post‐Project Report bull Referencesbull Appendices

Cetuximab for 1st

line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million

Costs for 48 patients in KMCNKRAS testing (only wild‐type

(unmutated) KRAS)pound9500 - pound20500 (testing 68 patients)

(applicable from 2010)

Procurement Cetuximab (14 weeks)

pound550000 (pound462000 with Merck Serono rebate scheme)

Delivery (14 weeks treatment ndash 7 additional day-case chemo costs)Based on day case chemotherapy tariffs of pound536 (Medway) pound720-810 (MTW)

pound180000 - pound272000

Liver resections (10 additional resections at pound8744)

pound87500

Total pound827000 - pound930000

pound739000 - pound842000 (with drug rebate)(the costs of second line chemotherapy will be offset in those patients whose liver metastases are resected successfully)

Cetuximab 1st

line Metastatic Colorectal

When can we start prescribingWCC Commissioning answer when you have in place

1

the machinery for policing the NICE commissioning recommendation

ndash ie KRAS positive Liver only Primary resected

2

the Business Case for KRAS testing setting out

ndash which patients are we paying for

ndash all newly diagnosed or all metastatic

ndash which organisations initiates amp carry out the testing process

3

the Business Cases for implementing delivery costs (oncologist pharmacist nurse job‐plans)

All of this will delay treatment and cause lsquopost‐codersquo variations

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Structures devolvedoutreach

Service Line BudgetingCapacity Activity Demand

Productivity Business Cases

Costing AampE admissionsExplicit non‐elective acute

oncology contracting

Operational Audited Standard Operational Procedures

Protocols Medical RecordsWorkforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical Incidents

Professional performace issues

NCEPODAcute Oncology

47

Acute Oncology amp End‐stage (palliative)

Chemotherapy

bull What is the problem ndash cancer hospital deaths chemotherapy‐

related deaths

ndashunplanned admissions lsquoAcute Oncologyrsquo

ndashpalliative chemotherapy treating too late

What is the Remedy

NCEPODAcute Oncology Remedies 1 Clinical risk management

incident (IR1) reporting

bull Deaths by final chemotherapy dosendash how many deaths occurred within one month

within three months and within six months of the final chemotherapy treatment

ndash how many had an IR1 raised

bull Unplanned admissionsndash in the last six months how many patients receiving

chemotherapy experienced an unplanned admission months

ndash what was their length of stayndash how many had an IR1rsquos were raised

NCEPODAcute Oncology Remedies 2 ISO 9000

bull Run the Chemo Unit as a proper business ISO 9000

bull Intelligence = better ITbull Web‐based records

bull Define operational Multi disciplinary team

bull Demand Managementndash Community‐based symptom‐control for advanced

metastatic cancer

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

C‐PORT Predictive modelling of Integrated Care Pathways ‐

measures currentpredicted activity and matches it to

existing resources

39

CapacityRe

sources

Predicted

demandCurrent

activity

WCC arbitration on the tariff ‐

are these Reference Costs reasonable

‐

is this level of profit reasonable

40

Blood Pharmacy IV NurseOncologist

pound20 pound50 pound30 pound30Fixed Costs

Other Costs + pound20 Utilities Secretaries etc

Total pound150IncomeDay-case pound600Attendance

Profit per attendancepound450

( assuming drug procurement costs are funded separately)

Productivity streamlining the integrated care pathway

Rate limiting steps

Wait10m Process

sample 30m

Wait 35mSample

4m

Con15m Pharmacy 30m

Chemo prep20m Admin

6m

Blood testDoctor

consultationPharmacy preparation

C‐PORT uses the algorithm of the Integrated Care Pathway to lsquoflight‐simulatersquo

a series of options

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Service Level AgreementsService Line BudgetingCapacity Activity Demand

ProductivityBusiness Cases

Costing AampE admissions

Operational SOPS Protocols Medical Records

Workforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical

Incidents Professional performace issues

NCEPODAcute Oncology

Why should I write a business‐case and how do I do it

Chaptersbull Executive Summary Introduction bull Current Situationbull Strategic Context National International Drivers bull Current Practice Case for Change Projected benefits

realization time‐scales Understanding of Commissioning Perspective

bull Data Analysis Capacity Planning Implications of Data for the Future

bull Options and Options Appraisal Preferred Option Proposed Service Model

bull Proposed Implementation of Projectbull Post‐Project Report bull Referencesbull Appendices

Cetuximab for 1st

line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million

Costs for 48 patients in KMCNKRAS testing (only wild‐type

(unmutated) KRAS)pound9500 - pound20500 (testing 68 patients)

(applicable from 2010)

Procurement Cetuximab (14 weeks)

pound550000 (pound462000 with Merck Serono rebate scheme)

Delivery (14 weeks treatment ndash 7 additional day-case chemo costs)Based on day case chemotherapy tariffs of pound536 (Medway) pound720-810 (MTW)

pound180000 - pound272000

Liver resections (10 additional resections at pound8744)

pound87500

Total pound827000 - pound930000

pound739000 - pound842000 (with drug rebate)(the costs of second line chemotherapy will be offset in those patients whose liver metastases are resected successfully)

Cetuximab 1st

line Metastatic Colorectal

When can we start prescribingWCC Commissioning answer when you have in place

1

the machinery for policing the NICE commissioning recommendation

ndash ie KRAS positive Liver only Primary resected

2

the Business Case for KRAS testing setting out

ndash which patients are we paying for

ndash all newly diagnosed or all metastatic

ndash which organisations initiates amp carry out the testing process

3

the Business Cases for implementing delivery costs (oncologist pharmacist nurse job‐plans)

All of this will delay treatment and cause lsquopost‐codersquo variations

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Structures devolvedoutreach

Service Line BudgetingCapacity Activity Demand

Productivity Business Cases

Costing AampE admissionsExplicit non‐elective acute

oncology contracting

Operational Audited Standard Operational Procedures

Protocols Medical RecordsWorkforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical Incidents

Professional performace issues

NCEPODAcute Oncology

47

Acute Oncology amp End‐stage (palliative)

Chemotherapy

bull What is the problem ndash cancer hospital deaths chemotherapy‐

related deaths

ndashunplanned admissions lsquoAcute Oncologyrsquo

ndashpalliative chemotherapy treating too late

What is the Remedy

NCEPODAcute Oncology Remedies 1 Clinical risk management

incident (IR1) reporting

bull Deaths by final chemotherapy dosendash how many deaths occurred within one month

within three months and within six months of the final chemotherapy treatment

ndash how many had an IR1 raised

bull Unplanned admissionsndash in the last six months how many patients receiving

chemotherapy experienced an unplanned admission months

ndash what was their length of stayndash how many had an IR1rsquos were raised

NCEPODAcute Oncology Remedies 2 ISO 9000

bull Run the Chemo Unit as a proper business ISO 9000

bull Intelligence = better ITbull Web‐based records

bull Define operational Multi disciplinary team

bull Demand Managementndash Community‐based symptom‐control for advanced

metastatic cancer

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

WCC arbitration on the tariff ‐

are these Reference Costs reasonable

‐

is this level of profit reasonable

40

Blood Pharmacy IV NurseOncologist

pound20 pound50 pound30 pound30Fixed Costs

Other Costs + pound20 Utilities Secretaries etc

Total pound150IncomeDay-case pound600Attendance

Profit per attendancepound450

( assuming drug procurement costs are funded separately)

Productivity streamlining the integrated care pathway

Rate limiting steps

Wait10m Process

sample 30m

Wait 35mSample

4m

Con15m Pharmacy 30m

Chemo prep20m Admin

6m

Blood testDoctor

consultationPharmacy preparation

C‐PORT uses the algorithm of the Integrated Care Pathway to lsquoflight‐simulatersquo

a series of options

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Service Level AgreementsService Line BudgetingCapacity Activity Demand

ProductivityBusiness Cases

Costing AampE admissions

Operational SOPS Protocols Medical Records

Workforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical

Incidents Professional performace issues

NCEPODAcute Oncology

Why should I write a business‐case and how do I do it

Chaptersbull Executive Summary Introduction bull Current Situationbull Strategic Context National International Drivers bull Current Practice Case for Change Projected benefits

realization time‐scales Understanding of Commissioning Perspective

bull Data Analysis Capacity Planning Implications of Data for the Future

bull Options and Options Appraisal Preferred Option Proposed Service Model

bull Proposed Implementation of Projectbull Post‐Project Report bull Referencesbull Appendices

Cetuximab for 1st

line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million

Costs for 48 patients in KMCNKRAS testing (only wild‐type

(unmutated) KRAS)pound9500 - pound20500 (testing 68 patients)

(applicable from 2010)

Procurement Cetuximab (14 weeks)

pound550000 (pound462000 with Merck Serono rebate scheme)

Delivery (14 weeks treatment ndash 7 additional day-case chemo costs)Based on day case chemotherapy tariffs of pound536 (Medway) pound720-810 (MTW)

pound180000 - pound272000

Liver resections (10 additional resections at pound8744)

pound87500

Total pound827000 - pound930000

pound739000 - pound842000 (with drug rebate)(the costs of second line chemotherapy will be offset in those patients whose liver metastases are resected successfully)

Cetuximab 1st

line Metastatic Colorectal

When can we start prescribingWCC Commissioning answer when you have in place

1

the machinery for policing the NICE commissioning recommendation

ndash ie KRAS positive Liver only Primary resected

2

the Business Case for KRAS testing setting out

ndash which patients are we paying for

ndash all newly diagnosed or all metastatic

ndash which organisations initiates amp carry out the testing process

3

the Business Cases for implementing delivery costs (oncologist pharmacist nurse job‐plans)

All of this will delay treatment and cause lsquopost‐codersquo variations

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Structures devolvedoutreach

Service Line BudgetingCapacity Activity Demand

Productivity Business Cases

Costing AampE admissionsExplicit non‐elective acute

oncology contracting

Operational Audited Standard Operational Procedures

Protocols Medical RecordsWorkforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical Incidents

Professional performace issues

NCEPODAcute Oncology

47

Acute Oncology amp End‐stage (palliative)

Chemotherapy

bull What is the problem ndash cancer hospital deaths chemotherapy‐

related deaths

ndashunplanned admissions lsquoAcute Oncologyrsquo

ndashpalliative chemotherapy treating too late

What is the Remedy

NCEPODAcute Oncology Remedies 1 Clinical risk management

incident (IR1) reporting

bull Deaths by final chemotherapy dosendash how many deaths occurred within one month

within three months and within six months of the final chemotherapy treatment

ndash how many had an IR1 raised

bull Unplanned admissionsndash in the last six months how many patients receiving

chemotherapy experienced an unplanned admission months

ndash what was their length of stayndash how many had an IR1rsquos were raised

NCEPODAcute Oncology Remedies 2 ISO 9000

bull Run the Chemo Unit as a proper business ISO 9000

bull Intelligence = better ITbull Web‐based records

bull Define operational Multi disciplinary team

bull Demand Managementndash Community‐based symptom‐control for advanced

metastatic cancer

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

Productivity streamlining the integrated care pathway

Rate limiting steps

Wait10m Process

sample 30m

Wait 35mSample

4m

Con15m Pharmacy 30m

Chemo prep20m Admin

6m

Blood testDoctor

consultationPharmacy preparation

C‐PORT uses the algorithm of the Integrated Care Pathway to lsquoflight‐simulatersquo

a series of options

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Service Level AgreementsService Line BudgetingCapacity Activity Demand

ProductivityBusiness Cases

Costing AampE admissions

Operational SOPS Protocols Medical Records

Workforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical

Incidents Professional performace issues

NCEPODAcute Oncology

Why should I write a business‐case and how do I do it

Chaptersbull Executive Summary Introduction bull Current Situationbull Strategic Context National International Drivers bull Current Practice Case for Change Projected benefits

realization time‐scales Understanding of Commissioning Perspective

bull Data Analysis Capacity Planning Implications of Data for the Future

bull Options and Options Appraisal Preferred Option Proposed Service Model

bull Proposed Implementation of Projectbull Post‐Project Report bull Referencesbull Appendices

Cetuximab for 1st

line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million

Costs for 48 patients in KMCNKRAS testing (only wild‐type

(unmutated) KRAS)pound9500 - pound20500 (testing 68 patients)

(applicable from 2010)

Procurement Cetuximab (14 weeks)

pound550000 (pound462000 with Merck Serono rebate scheme)

Delivery (14 weeks treatment ndash 7 additional day-case chemo costs)Based on day case chemotherapy tariffs of pound536 (Medway) pound720-810 (MTW)

pound180000 - pound272000

Liver resections (10 additional resections at pound8744)

pound87500

Total pound827000 - pound930000

pound739000 - pound842000 (with drug rebate)(the costs of second line chemotherapy will be offset in those patients whose liver metastases are resected successfully)

Cetuximab 1st

line Metastatic Colorectal

When can we start prescribingWCC Commissioning answer when you have in place

1

the machinery for policing the NICE commissioning recommendation

ndash ie KRAS positive Liver only Primary resected

2

the Business Case for KRAS testing setting out

ndash which patients are we paying for

ndash all newly diagnosed or all metastatic

ndash which organisations initiates amp carry out the testing process

3

the Business Cases for implementing delivery costs (oncologist pharmacist nurse job‐plans)

All of this will delay treatment and cause lsquopost‐codersquo variations

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Structures devolvedoutreach

Service Line BudgetingCapacity Activity Demand

Productivity Business Cases

Costing AampE admissionsExplicit non‐elective acute

oncology contracting

Operational Audited Standard Operational Procedures

Protocols Medical RecordsWorkforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical Incidents

Professional performace issues

NCEPODAcute Oncology

47

Acute Oncology amp End‐stage (palliative)

Chemotherapy

bull What is the problem ndash cancer hospital deaths chemotherapy‐

related deaths

ndashunplanned admissions lsquoAcute Oncologyrsquo

ndashpalliative chemotherapy treating too late

What is the Remedy

NCEPODAcute Oncology Remedies 1 Clinical risk management

incident (IR1) reporting

bull Deaths by final chemotherapy dosendash how many deaths occurred within one month

within three months and within six months of the final chemotherapy treatment

ndash how many had an IR1 raised

bull Unplanned admissionsndash in the last six months how many patients receiving

chemotherapy experienced an unplanned admission months

ndash what was their length of stayndash how many had an IR1rsquos were raised

NCEPODAcute Oncology Remedies 2 ISO 9000

bull Run the Chemo Unit as a proper business ISO 9000

bull Intelligence = better ITbull Web‐based records

bull Define operational Multi disciplinary team

bull Demand Managementndash Community‐based symptom‐control for advanced

metastatic cancer

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Service Level AgreementsService Line BudgetingCapacity Activity Demand

ProductivityBusiness Cases

Costing AampE admissions

Operational SOPS Protocols Medical Records

Workforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical

Incidents Professional performace issues

NCEPODAcute Oncology

Why should I write a business‐case and how do I do it

Chaptersbull Executive Summary Introduction bull Current Situationbull Strategic Context National International Drivers bull Current Practice Case for Change Projected benefits

realization time‐scales Understanding of Commissioning Perspective

bull Data Analysis Capacity Planning Implications of Data for the Future

bull Options and Options Appraisal Preferred Option Proposed Service Model

bull Proposed Implementation of Projectbull Post‐Project Report bull Referencesbull Appendices

Cetuximab for 1st

line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million

Costs for 48 patients in KMCNKRAS testing (only wild‐type

(unmutated) KRAS)pound9500 - pound20500 (testing 68 patients)

(applicable from 2010)

Procurement Cetuximab (14 weeks)

pound550000 (pound462000 with Merck Serono rebate scheme)

Delivery (14 weeks treatment ndash 7 additional day-case chemo costs)Based on day case chemotherapy tariffs of pound536 (Medway) pound720-810 (MTW)

pound180000 - pound272000

Liver resections (10 additional resections at pound8744)

pound87500

Total pound827000 - pound930000

pound739000 - pound842000 (with drug rebate)(the costs of second line chemotherapy will be offset in those patients whose liver metastases are resected successfully)

Cetuximab 1st

line Metastatic Colorectal

When can we start prescribingWCC Commissioning answer when you have in place

1

the machinery for policing the NICE commissioning recommendation

ndash ie KRAS positive Liver only Primary resected

2

the Business Case for KRAS testing setting out

ndash which patients are we paying for

ndash all newly diagnosed or all metastatic

ndash which organisations initiates amp carry out the testing process

3

the Business Cases for implementing delivery costs (oncologist pharmacist nurse job‐plans)

All of this will delay treatment and cause lsquopost‐codersquo variations

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Structures devolvedoutreach

Service Line BudgetingCapacity Activity Demand

Productivity Business Cases

Costing AampE admissionsExplicit non‐elective acute

oncology contracting

Operational Audited Standard Operational Procedures

Protocols Medical RecordsWorkforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical Incidents

Professional performace issues

NCEPODAcute Oncology

47

Acute Oncology amp End‐stage (palliative)

Chemotherapy

bull What is the problem ndash cancer hospital deaths chemotherapy‐

related deaths

ndashunplanned admissions lsquoAcute Oncologyrsquo

ndashpalliative chemotherapy treating too late

What is the Remedy

NCEPODAcute Oncology Remedies 1 Clinical risk management

incident (IR1) reporting

bull Deaths by final chemotherapy dosendash how many deaths occurred within one month

within three months and within six months of the final chemotherapy treatment

ndash how many had an IR1 raised

bull Unplanned admissionsndash in the last six months how many patients receiving

chemotherapy experienced an unplanned admission months

ndash what was their length of stayndash how many had an IR1rsquos were raised

NCEPODAcute Oncology Remedies 2 ISO 9000

bull Run the Chemo Unit as a proper business ISO 9000

bull Intelligence = better ITbull Web‐based records

bull Define operational Multi disciplinary team

bull Demand Managementndash Community‐based symptom‐control for advanced

metastatic cancer

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

Why should I write a business‐case and how do I do it

Chaptersbull Executive Summary Introduction bull Current Situationbull Strategic Context National International Drivers bull Current Practice Case for Change Projected benefits

realization time‐scales Understanding of Commissioning Perspective

bull Data Analysis Capacity Planning Implications of Data for the Future

bull Options and Options Appraisal Preferred Option Proposed Service Model

bull Proposed Implementation of Projectbull Post‐Project Report bull Referencesbull Appendices

Cetuximab for 1st

line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million

Costs for 48 patients in KMCNKRAS testing (only wild‐type

(unmutated) KRAS)pound9500 - pound20500 (testing 68 patients)

(applicable from 2010)

Procurement Cetuximab (14 weeks)

pound550000 (pound462000 with Merck Serono rebate scheme)

Delivery (14 weeks treatment ndash 7 additional day-case chemo costs)Based on day case chemotherapy tariffs of pound536 (Medway) pound720-810 (MTW)

pound180000 - pound272000

Liver resections (10 additional resections at pound8744)

pound87500

Total pound827000 - pound930000

pound739000 - pound842000 (with drug rebate)(the costs of second line chemotherapy will be offset in those patients whose liver metastases are resected successfully)

Cetuximab 1st

line Metastatic Colorectal

When can we start prescribingWCC Commissioning answer when you have in place

1

the machinery for policing the NICE commissioning recommendation

ndash ie KRAS positive Liver only Primary resected

2

the Business Case for KRAS testing setting out

ndash which patients are we paying for

ndash all newly diagnosed or all metastatic

ndash which organisations initiates amp carry out the testing process

3

the Business Cases for implementing delivery costs (oncologist pharmacist nurse job‐plans)

All of this will delay treatment and cause lsquopost‐codersquo variations

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Structures devolvedoutreach

Service Line BudgetingCapacity Activity Demand

Productivity Business Cases

Costing AampE admissionsExplicit non‐elective acute

oncology contracting

Operational Audited Standard Operational Procedures

Protocols Medical RecordsWorkforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical Incidents

Professional performace issues

NCEPODAcute Oncology

47

Acute Oncology amp End‐stage (palliative)

Chemotherapy

bull What is the problem ndash cancer hospital deaths chemotherapy‐

related deaths

ndashunplanned admissions lsquoAcute Oncologyrsquo

ndashpalliative chemotherapy treating too late

What is the Remedy

NCEPODAcute Oncology Remedies 1 Clinical risk management

incident (IR1) reporting

bull Deaths by final chemotherapy dosendash how many deaths occurred within one month

within three months and within six months of the final chemotherapy treatment

ndash how many had an IR1 raised

bull Unplanned admissionsndash in the last six months how many patients receiving

chemotherapy experienced an unplanned admission months

ndash what was their length of stayndash how many had an IR1rsquos were raised

NCEPODAcute Oncology Remedies 2 ISO 9000

bull Run the Chemo Unit as a proper business ISO 9000

bull Intelligence = better ITbull Web‐based records

bull Define operational Multi disciplinary team

bull Demand Managementndash Community‐based symptom‐control for advanced

metastatic cancer

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

Cetuximab for 1st

line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million

Costs for 48 patients in KMCNKRAS testing (only wild‐type

(unmutated) KRAS)pound9500 - pound20500 (testing 68 patients)

(applicable from 2010)

Procurement Cetuximab (14 weeks)

pound550000 (pound462000 with Merck Serono rebate scheme)

Delivery (14 weeks treatment ndash 7 additional day-case chemo costs)Based on day case chemotherapy tariffs of pound536 (Medway) pound720-810 (MTW)

pound180000 - pound272000

Liver resections (10 additional resections at pound8744)

pound87500

Total pound827000 - pound930000

pound739000 - pound842000 (with drug rebate)(the costs of second line chemotherapy will be offset in those patients whose liver metastases are resected successfully)

Cetuximab 1st

line Metastatic Colorectal

When can we start prescribingWCC Commissioning answer when you have in place

1

the machinery for policing the NICE commissioning recommendation

ndash ie KRAS positive Liver only Primary resected

2

the Business Case for KRAS testing setting out

ndash which patients are we paying for

ndash all newly diagnosed or all metastatic

ndash which organisations initiates amp carry out the testing process

3

the Business Cases for implementing delivery costs (oncologist pharmacist nurse job‐plans)

All of this will delay treatment and cause lsquopost‐codersquo variations

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Structures devolvedoutreach

Service Line BudgetingCapacity Activity Demand

Productivity Business Cases

Costing AampE admissionsExplicit non‐elective acute

oncology contracting

Operational Audited Standard Operational Procedures

Protocols Medical RecordsWorkforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical Incidents

Professional performace issues

NCEPODAcute Oncology

47

Acute Oncology amp End‐stage (palliative)

Chemotherapy

bull What is the problem ndash cancer hospital deaths chemotherapy‐

related deaths

ndashunplanned admissions lsquoAcute Oncologyrsquo

ndashpalliative chemotherapy treating too late

What is the Remedy

NCEPODAcute Oncology Remedies 1 Clinical risk management

incident (IR1) reporting

bull Deaths by final chemotherapy dosendash how many deaths occurred within one month

within three months and within six months of the final chemotherapy treatment

ndash how many had an IR1 raised

bull Unplanned admissionsndash in the last six months how many patients receiving

chemotherapy experienced an unplanned admission months

ndash what was their length of stayndash how many had an IR1rsquos were raised

NCEPODAcute Oncology Remedies 2 ISO 9000

bull Run the Chemo Unit as a proper business ISO 9000

bull Intelligence = better ITbull Web‐based records

bull Define operational Multi disciplinary team

bull Demand Managementndash Community‐based symptom‐control for advanced

metastatic cancer

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

Cetuximab 1st

line Metastatic Colorectal

When can we start prescribingWCC Commissioning answer when you have in place

1

the machinery for policing the NICE commissioning recommendation

ndash ie KRAS positive Liver only Primary resected

2

the Business Case for KRAS testing setting out

ndash which patients are we paying for

ndash all newly diagnosed or all metastatic

ndash which organisations initiates amp carry out the testing process

3

the Business Cases for implementing delivery costs (oncologist pharmacist nurse job‐plans)

All of this will delay treatment and cause lsquopost‐codersquo variations

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Structures devolvedoutreach

Service Line BudgetingCapacity Activity Demand

Productivity Business Cases

Costing AampE admissionsExplicit non‐elective acute

oncology contracting

Operational Audited Standard Operational Procedures

Protocols Medical RecordsWorkforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical Incidents

Professional performace issues

NCEPODAcute Oncology

47

Acute Oncology amp End‐stage (palliative)

Chemotherapy

bull What is the problem ndash cancer hospital deaths chemotherapy‐

related deaths

ndashunplanned admissions lsquoAcute Oncologyrsquo

ndashpalliative chemotherapy treating too late

What is the Remedy

NCEPODAcute Oncology Remedies 1 Clinical risk management

incident (IR1) reporting

bull Deaths by final chemotherapy dosendash how many deaths occurred within one month

within three months and within six months of the final chemotherapy treatment

ndash how many had an IR1 raised

bull Unplanned admissionsndash in the last six months how many patients receiving

chemotherapy experienced an unplanned admission months

ndash what was their length of stayndash how many had an IR1rsquos were raised

NCEPODAcute Oncology Remedies 2 ISO 9000

bull Run the Chemo Unit as a proper business ISO 9000

bull Intelligence = better ITbull Web‐based records

bull Define operational Multi disciplinary team

bull Demand Managementndash Community‐based symptom‐control for advanced

metastatic cancer

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

ISO 9000 Business Intelligence ‐

Service Line Reporting

Governance Elective Non Elective

Financial Structures devolvedoutreach

Service Line BudgetingCapacity Activity Demand

Productivity Business Cases

Costing AampE admissionsExplicit non‐elective acute

oncology contracting

Operational Audited Standard Operational Procedures

Protocols Medical RecordsWorkforce CPD

Structures for Demand Management

Clinical ComplaintsLitigation Clinical Incidents

Professional performace issues

NCEPODAcute Oncology

47

Acute Oncology amp End‐stage (palliative)

Chemotherapy

bull What is the problem ndash cancer hospital deaths chemotherapy‐

related deaths

ndashunplanned admissions lsquoAcute Oncologyrsquo

ndashpalliative chemotherapy treating too late

What is the Remedy

NCEPODAcute Oncology Remedies 1 Clinical risk management

incident (IR1) reporting

bull Deaths by final chemotherapy dosendash how many deaths occurred within one month

within three months and within six months of the final chemotherapy treatment

ndash how many had an IR1 raised

bull Unplanned admissionsndash in the last six months how many patients receiving

chemotherapy experienced an unplanned admission months

ndash what was their length of stayndash how many had an IR1rsquos were raised

NCEPODAcute Oncology Remedies 2 ISO 9000

bull Run the Chemo Unit as a proper business ISO 9000

bull Intelligence = better ITbull Web‐based records

bull Define operational Multi disciplinary team

bull Demand Managementndash Community‐based symptom‐control for advanced

metastatic cancer

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

47

Acute Oncology amp End‐stage (palliative)

Chemotherapy

bull What is the problem ndash cancer hospital deaths chemotherapy‐

related deaths

ndashunplanned admissions lsquoAcute Oncologyrsquo

ndashpalliative chemotherapy treating too late

What is the Remedy

NCEPODAcute Oncology Remedies 1 Clinical risk management

incident (IR1) reporting

bull Deaths by final chemotherapy dosendash how many deaths occurred within one month

within three months and within six months of the final chemotherapy treatment

ndash how many had an IR1 raised

bull Unplanned admissionsndash in the last six months how many patients receiving

chemotherapy experienced an unplanned admission months

ndash what was their length of stayndash how many had an IR1rsquos were raised

NCEPODAcute Oncology Remedies 2 ISO 9000

bull Run the Chemo Unit as a proper business ISO 9000

bull Intelligence = better ITbull Web‐based records

bull Define operational Multi disciplinary team

bull Demand Managementndash Community‐based symptom‐control for advanced

metastatic cancer

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

NCEPODAcute Oncology Remedies 1 Clinical risk management

incident (IR1) reporting

bull Deaths by final chemotherapy dosendash how many deaths occurred within one month

within three months and within six months of the final chemotherapy treatment

ndash how many had an IR1 raised

bull Unplanned admissionsndash in the last six months how many patients receiving

chemotherapy experienced an unplanned admission months

ndash what was their length of stayndash how many had an IR1rsquos were raised

NCEPODAcute Oncology Remedies 2 ISO 9000

bull Run the Chemo Unit as a proper business ISO 9000

bull Intelligence = better ITbull Web‐based records

bull Define operational Multi disciplinary team

bull Demand Managementndash Community‐based symptom‐control for advanced

metastatic cancer

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

NCEPODAcute Oncology Remedies 2 ISO 9000

bull Run the Chemo Unit as a proper business ISO 9000

bull Intelligence = better ITbull Web‐based records

bull Define operational Multi disciplinary team

bull Demand Managementndash Community‐based symptom‐control for advanced

metastatic cancer

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

50

NCEPODAcute Oncology Remedies 3 lsquoProgrammersquo

Commissioning

InitialDiagnosisStaging

Treatment

2 4

Progression End stage disease

End of life care

30Causes

PreventionScreening

DemographicsCure

31

30SurveillanceMonitoring

Cure

How much end‐stage disease unplanned admissions amp deathscan be demand managed from the community

What does this mean for the workforce

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

Today Service in Meltdown

bull National PolicyCommissioning Perspectivendash NCAG (NCEPODAcute Oncology) vs

WCC

bull Provider Perspectivendash Business Intelligence amp Governance

bull Commonaltiesndash World Class Chemotherapy

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities

Commonalities

Provider1

Acute Oncology

2

Structures DevolvedOutreach

3

Capacity Planning amp Business Cases

4

PBRContracts5

Avoidable deaths admissions

clinical incidents

6

Web‐based data sharing

Commissioner1

Outcome Commissioning

Care amp Resource Utilisation

2

ContestabilitylsquoDarzirsquo locality services

3

Benchmarking

4

PBRContracts

5

lsquoValue for Moneyrsquo

6

Integrated Commissioning

• - Economic Challenges of Chemotherapy Delivery
• Slide Number 2
• TodayService in Meltdown
• World Class Commissioning (WCC) amp the NCAG Report
• World Class Commissioning
• Slide Number 6
• Slide Number 7
• Slide Number 8
• The RockBudget Deficits amp WCC
• Slide Number 10
• WCC Agendas
• WCC Agenda 1 Commissioning for OutcomesCorporate Value Management
• PCT legal challenges to NICE
• WCC Agenda 2 Contestability Market Management Darzi Care amp Resource Utilisation Programme CommissioningContestability amp Decommissioning
• lsquoProgrammersquo CommissioningCancer Commissioning Toolkit
• WCC Agenda 3 NationalInternational Benchmarking lsquoPost Codersquo Variation in access to chemotherapy
• Slide Number 17
• WCC Contracts agreeing lsquocoinagersquoAttendances or PBRHRG 4Hourly Rate or Job-Rate
• World Class Commissioning (WCC) amp the NCAG Report
• NCEPODAcute Oncology audit For Better Or Worse 2008
• NCEPODAcute Oncology 1044 patients died within 30 days
• NCEPODAcute Oncology 1044 patients died within 30 days verdict on care
• WCC Clinical Risk Pyramids
• End-stage (palliative) Chemotherapy
• Palliative chemotherapyfor progressivemetastatic disease
• End-stage (palliative) Chemotherapy
• lsquoAcute Oncologyrsquo unplanned admissions 1 National Picture
• lsquoAcute Oncologyrsquo unplanned admissions 2 National Oncology Bed CensusRCR Faculty of Clinical Oncology
• lsquoAcute Oncologyrsquo unplanned admissions 3 East Kent Acute DGH CensusSeptember 2005Population 06 million Beds 968
• End-stage (palliative) Chemotherapy
• Inappropriate Chemotherapy
• Inappropriate Palliative ChemotherapyUSA (Medicare) Canadian and UK Data suggests many patients receive palliative chemotherapy within one month of death
• TodayService in Meltdown
• Slide Number 34
• ISO 9000 Business Intelligence- Service Line Reporting
• Slide Number 36
• Slide Number 37
• Business Intelligence Definitions
• C-PORT Predictive modelling of Integrated Care Pathways - measures currentpredicted activity and matches it to existing resources
• WCC arbitration on the tariff- are these Reference Costs reasonable - is this level of profit reasonable
• Slide Number 41
• ISO 9000 Business Intelligence- Service Line Reporting
• Why should I write a business-case and how do I do it
• Cetuximab for 1st line Metastatic Colorectal Cancer June 2009 KMCN Pop 16 million
• Cetuximab 1st line Metastatic Colorectal
• ISO 9000 Business Intelligence- Service Line Reporting
• Acute Oncologyamp End-stage (palliative) Chemotherapy
• NCEPODAcute Oncology Remedies 1 Clinical risk managementincident (IR1) reporting
• NCEPODAcute Oncology Remedies 2 ISO 9000
• NCEPODAcute Oncology Remedies 3lsquoProgrammersquo Commissioning
• TodayService in Meltdown
• Commonalities