Supplement case studies: The ways and means of new care pathways

Smarter working in Southampton

Patients in Southampton with inflammatory bowel disease (IBD) are benefiting from a better service as a result of smarter working across the local healthcare economy.

Commissioners and providers have worked together to draw up a new pathway that aims to make better use of existing resources to enable patients to get access to greater support and effective new treatments.

Fraser Cummings, a consultant gastroenterologist at University Hospital Southampton Foundation Trust, who has a special interest in IBD, says it is important that commissioners and primary and secondary care are all involved, and that they all benefit from the new arrangements.

‘New biologic therapies are making a real difference’

He explains that the outlook for people with Crohn’s disease and ulcerative colitis has been changing, with the advent of new treatments, and new National Institute for Health and Care Excellence guidance.

“New biologic therapies are making a real difference to patients and we want to prescribe them,” he says. “But they are expensive, costing £10,000 to £15,000 per year per patient. That’s obviously a huge cost to the clinical commissioning group budget.

“What we have done is to look at where we can save money in existing services so that we can invest in new treatments where we think they are appropriate. The aim is to achieve higher quality care along with cost savings, with the benefits that accrue being shared between stakeholders.”

In Southampton, clinicians worked with commissioners to take a detailed look at the service pathway to identify ways of doing things differently. A key point has been the licensing of biosimilars – like previously licensed biological agents (due to how these drugs are produced they cannot be exactly the same) – for infliximab (marketed as Remicade), a treatment for both Crohn’s disease and ulcerative colitis.

‘By investing in the management of biologics as a whole, we can generate savings’

“Prescribing biosimilars can mean drug acquisition cost savings of up to 50 per cent,” says Dr Cummings, adding that last year, the budget for infliximab in IBD in Southampton was £1.6m.

Simply switching patients to the cheaper drug with no discussion was not considered a reasonable option, however, as there are perceived risks and potential reluctance from patients who might be managing perfectly well on the more expensive treatment.

“What we have done in Southampton is to set up a managed switching programme with a dedicated specialist IBD nurse to support patients through this process, which helps to manage any of the theoretical risks,” he says.

“By investing in the management of biologics as a whole, we can generate savings, but it requires investment in an IBD biologics management system which included specialist nurse, IT to collect outcome/audit data, and clerical support.”

Specialist nursing

The specialist nursing support is vital, he says, because patients need support. “Some patients have been using Remicade for a long time. It’s had a transformational effect on people’s lives.

“It’s understandable that there’s some anxiety about changing to something different. But the feedback from patients has been good, and there’s a sense that we’re generating a win for patients because they know the savings are being invested in making services better.”

It is a rolling process and so far almost 50 patients have changed onto the different drugs. They are monitored very closely and every time they come to receive the drugs, which are delivered via an infusion, they are asked to fill in a questionnaire.

‘The feedback from patients has been good’

But the savings do not stop there. Clinicians have agreed to review patients to make sure that they are on the right treatment regime for their condition, and to stop drugs in line with NICE guidance where appropriate.

They are also making every effort to enrol patients into clinical trials, which again can lead to drug acquisition cost savings. He believes that a gain share agreement between hospital and commissioners has been crucial to getting buy-in and ensuring that everyone has an interest in making it work.

Information technology is also vital. “One of the key things is uploading data at the point of care. The UK IBD registry has developed a number of tools to facilitate this. We need to use this information and data to manage our patients better and to measure the impact and outcomes.”

New patient pathway in south east London

Hearing first hand about patients’ experiences of IBD services had a transformative effect on commissioners in south east London. Insights not only informed development of a new pathway of care, but were central to changing the way commissioners and clinicians thought about the condition and the services people want.

The result is a new pathway that is attracting national interest, and is – at just a few months in – showing positive results.

“We were interested in looking at biologics use in IBD,” explains Vanessa Burgess, chief pharmacist and assistant director commissioning for Lambeth CCG, which hosts the south east London area prescribing committee (covering six CCGs, three acute trusts and two mental health trusts). “We were aware that nobody had done this work locally, and we decided to take a different approach to engaging patients,” she explains.

‘We heard directly from patients’

“Working with local clinicians, we held an event where we spent the afternoon with expert patients mapping out their feelings about how their treatment had been managed. We heard directly from patients about how much impact the disease had on their lives, how long it took to get diagnosed, how long it took to get to the right specialist. We realised there was lots of waste in the pathway – and that some people really hadn’t had the best experience.”

New drugs were part of this, she explains, but although they were the “high cost” element, the whole system was not geared up to getting the best value.

“Biologics were working well, but it took time for patients to get to that point under the right specialist. We needed to look at the whole system to make sure that we were getting the best value, and patients were getting the right treatment, first time,” Ms Burgess says.

This was music to the ears of consultant gastroenterologists Bu’Hussain Hayee and Peter Irving, who had initially approached commissioners to bid for changes in the IBD service. “When we started to look at this we were just tinkering round the edges,” says Dr Hayee of King’s College Hospital in south London.

“We had various bits of information, such as details of a shared care arrangement with GPs, and an updated formulary, and we went to the CCG to submit all this. They responded that there was no problem with any of that, but wanted to talk about high cost drugs.

“We said that’s an interest of ours: we want to prescribe the drugs we believe our patients should have.

“So, in effect, it was the commissioners who asked us to look at the whole pathway, from the point that the patient arrives in the system.”

‘We wanted to invest in things like antibody testing, and choice of biologics’

Dr Hayee says that the support of local commissioners was vital in helping the clinicians to develop the new pathway, which aimed to eliminate waste and give patients a more streamlined experience. It also aimed to ensure that patients had access to new biologics drugs where appropriate, without having to go through the often time consuming and frustrating individual funding request process.

“Some of it was about spreading good practice,” says Ms Burgess. “What we were aiming for was cost neutrality, but we wanted to invest in things like antibody testing, and choice of biologics.

“We are aiming for the investment to be paid for by making the whole pathway more efficient and getting more value out of the money we were spending.”

Locally, clinicians have embraced the new pathway, and practice will be monitored to ensure that it is followed and that the expected savings flow.

“The work is still continuing – we’ve no illusion that the job’s done,” she says. “We’re just organising another patient engagement event and we will ask them to comment on how it’s going, and we’ll also be monitoring things like their quality of life under the new pathway.”

Ms Burgess recommends meaningful patient engagement. “The expert patient input was incredibly valuable and really made us change our focus; it wasn’t a token gesture,” she says.

From a commissioner’s point of view, she has been watching as NICE has been updating its advice to widen access to new biologics for ulcerative colitis. “NICE is catching up with us,” she smiles. “It feels like we have forward planned.”