Ciarán Devane: out with the old
A hypothesis for us: if we want to do more, we need to do less.
The NHS is no different from any other organisation. There is much unnecessary activity and, given today’s troubled financial climate, we need to save what money we can. But in no other organisation does the adage “time is money” ring more true. We soak up clinical and patient time with out-dated models of care.
Let’s do a quick, and very approximate, thought experiment. We all know the routine where cancer patients come back for medical checkups every six months for five years. Imagine it is 1972 and you are running follow-up services for a bowel cancer clinic with 1,000 new patients a year. The typical follow-up might be a couple of appointments a year, and a scan and colonoscopy after five years - except practically no-one makes it to five years. Back then bowel cancer patients only had a mean survival rate of 18 months. At a nominal £50 for a follow-up appointment our population cost is, crudely, around £150,000.
Today, bowel cancer patients would have a mean survival of 10 years and would have a full follow-up for the first five years at which point they would have the scan at £150 and the colonoscopy also at £150. Assume five-year survival is now 70 per cent, 700 would have the full follow-up of the 10 appointments, as well as the scan and the colonoscopy. This sets our taxpayer back £560,000.
Those who died would individually cost less to the follow-up budget. But depending on the exact shape of the survival curve, they would nevertheless cost £60,000. So a follow-up regime invented long before 1972 and which then cost £150,000, now costs £620,000. Except it is worse than that, because bowel cancer has also increased in incidence by 50 per cent, so we now have 1,500 patients, taking us to £910,000.
Which medical director ever made the conscious decision to increase the investment of time and effort in routine follow-up by an additional 500 per cent? To what benefit and on what evidence? And to bust a potential myth, face-to-face follow-up is not how recurrence of many cancers is generally picked up. A leading Northern Ireland surgeon reviewed 800 cases and found one. This increase in cost happened through casual evolution, not because anyone ever sat down and said: “This is how we should do it because it helps patients most.”
The question which should ideally have been asked is this: “If I am going to multiply my investment of time and money in after-care by a factor of six, how will I do it to maximise the benefit to my patients?”
If they could, would our medical directors not have said there must be another way?
Fortunately, today there is. The National Cancer Survivorship Initiative for England will soon be publishing its guide on how to conduct a holistic assessment and care plan for after care in a time-efficient way. The guide will show how to educate patients to self-manage and how to provide exercise programmes that promote recovery in health and wellbeing. Combine these with some clever risk stratification, remote monitoring and access back through a trusted source, and your clinical commissioning group will confidently reduce costs and improve outcomes.
However, my point is much broader than cancer or England. The recent From Vision to Action document by the Richmond Group of Charities showed how the five themes the charities espouse (co-ordinated care; patients engaged in decisions; supported self-management; prevention, early detection and intervention; and emotional, psychological and practical support) apply across all conditions, from asthma to stroke. A small number of priority service improvements applied across all conditions will have a disproportionately good impact on cost, on the time of clinicians, and on outcomes for the patient.
The cost point is critical. A piece of work for Macmillan Cancer Support showed how 9 per cent of the money spent on breast and lung cancer patients in Manchester could be reallocated to drive better quality. A piece of similar modelling we did in Midhurst showed how a flexible, multidisciplinary palliative care team intervening earlier and more actively than the previous traditional model of care, was 20 per cent cheaper. It again delivers better quality and choice.
As ever, the issue is how to get from here to there. I hope that clinical commissioning groups will grasp the nettle and work with the revamped clinical networks to get the key players - commissioners, patients and clinicians - around the table. Together, they can design the focused, co-ordinated pathways we need.
A reasonable expectation of the new commissioning world is to replace forever practices that seemed sensible in the 1970s, but which we would never dream of commissioning today.
Ciarán Devane is chief executive, Macmillan Cancer Support.