CLINICAL MANAGEMENT

Published: 16/06/2005, Volume II5, No. 5960 Page 36 37 38

The complex, inter-departmental nature of cancer services presents diverse challenges. At the Christie Hospital trust, a joint venture with a pharmaceutical company to supply chemotherapy drugs has helped improve services

Cancer services encompass some of the most complex treatments provided by the NHS, with extensive multidisciplinary working and the involvement of several hospital departments in the care of patients.

This could suggest it is a difficult area in which to involve the independent sector, but some trusts are forging relationships with private companies to provide vital components of care, partnerships that are being encouraged by the government.

One of the longest-running relationships is between Christie Hospital trust in Manchester and Baxter Healthcare, which prepares chemotherapy drugs for the trust. The two have worked together for 13 years and the trust has recently signed a 10-year repeat contract with Baxter. Baxter also has joint ventures with Oxford Radcliffe Hospitals trust and Hillingdon Hospital trust, at the Mount Vernon Hospital site.

Other companies also prepare chemotherapy drugs for the NHS, but the three joint ventures with Baxter are unusual as they involve close working between the trust and the comapny's pharmacists.

At the Christie, 90 per cent of chemotherapy drugs given are prepared by Baxter - 70,000 a year. Until now the company has operated on-site, but currently staff are moving off-site to enable room for expansion as demand increases.

Chemotherapy is a time-sensitive process, where the wrong dosage or mix could have disastrous consequences. Quality management is vital and the trust and Baxter are now working on allowing electronic transmission of prescriptions to minimise misreadings and errors.

A vital issue from the hospital's perspective is getting the right drug to the right patient at an appropriate time. Turnaround time - the time between the drugs being ordered and delivered for administration - needs to be minimised to keep clinics moving.

But some chemotherapy may be dependent on blood tests performed that day, leaving little time for preparation. Some have a limited shelf life and need to be administered within hours - and noone wants to throw out what may be thousands of pounds' worth of drugs because they arrived late.

Baxter pharmacy services manager Clive Richards says a complex system of preparing drugs is in place. The service has been designed so chemotherapy is available for the patient as soon as trust staff are ready to administer the dose.

This minimises patients' waiting times and maximises the number that can be treated. Some drugs are batch-produced - generally those with a long shelf-life - so they can be stored ready for use in the hospital. Altogether, more than 80 per cent of the Christie's drugs are now pre-ordered, thought to be one of the highest proportions in the country.

Some drugs, however, will have to be made to order and be available within two hours of the prescription arriving at the unit.

The preparation of some pre-planned drugs can be switched between the company's units to help it cope with fluctuations in demand - something that would be impossible if everything was made to order.

The firm operates to agreed key performance indicators, such as turnaround time for drug requests. But the Christie also has to keep to agreed parameters such as the percentage of preordered drugs, which are discussed at quarterly meetings between the company and senior hospital managers. An annual financial review looks at workload over the course of the contract - accurately predicting demand over 10 years is difficult, and flexibility is needed. There is also contact between Baxter and the Christie's pharmacy department on an almost daily basis.

Risks are shared; Baxter takes responsibility for producing the ordered drugs within a specified time span and for the quality of production, as well as complying with regulations. The Christie has to make sure the right drugs are ordered for patients. If drugs are ordered but not used, the cost falls on the trust.

Baxter business unit director Andy Goldney - who worked at the Christie as a pre-registration pharmacist before moving to Baxter - sees the relationship as a true partnership, albeit one that has gone through stressful moments.

Five to six years ago, the demand for chemotherapy was increasing so rapidly that the company's unit found it difficult to cope. The move to new, larger premises has been partly prompted by this experience.

This rocky time led to greater co-ordination between the partners, especially around forecasting future demand. Mr Goldney insists that, although it was a stressful time, it was one from which both partners have learned: 'Once you have been through an experience like that, you ask what mechanisms you put in to make sure it does not happen again.' The new contract allows for a variation of plus or minus 5 per cent on forecast capacity, which the Baxter unit will meet. However, bigger variations will need further discussion - but with close monitoring of volumes and trends, any significant change should be picked up quickly.

Horizon-scanning for changes in procedure or new drugs coming to market is important in forecasting capacity; the new unit should allow Baxter to meet forecast increases at the Christie over the next 10 years and also provide some services to other trusts.

Mr Goldney says the introduction of key performance indicators has been crucial. 'We know the turnaround time, what the wastage is, how much is pre-ordered. We can sit down and have a conversation about how both sides are performing. What we do and what the NHS does has to be very clearly defined.' He believes the trust and the company have a true partnership, rather than Baxter simply being seen as a commercial operator out to make money. The company obviously makes a satisfactory profit from the work. But what are the benefits from the Christie's perspective?

A major effect is that pharmacists employed by the trust can spend more time with patients and clinicians, developing this part of their role rather than spending time on the relatively mechanical task of making up compounds.

'What we wanted to do was focus the internal pharmacy service on added value - working with clinicians and patients, ' says trust chief executive Joanna Wallace.

Christie chief pharmacist June So points out that Baxter is not bound by NHS pay regulations - it can pay more for hard-to-fill positions. The jobs on offer may also attract a different sort of pharmacist, one committed to the painstaking, technical work of compounding. And Baxter can offer different career paths for NHS staff.

The company can also invest in research that the NHS would find hard to do, such as improving the chemical stability of drugs, allowing them to be batched and held for weeks.

This work helps its units run more efficiently and can reduce patient waits for chemotherapy, as the drugs are instantly available.

Mr Goldney sees better use of chemotherapy nurses as one of the benefits for the hospital.

With drugs being batched or pre-ordered, nurses can start administering them at the start of the day rather than having to wait for them to be prepared. This means a scarce resource - nurses trained in chemotherapy are in short supply and can limit the number of patients treated - is used to the maximum benefit of patients.

At Oxford Radcliffe Hospitals trust, Baxter already compounds at one site and delivers to two more - one in Banbury, 25 miles away. Trust directorate manager for pharmacy and therapy services Raj Gokani says the three-year relationship is working well. 'We needed to change some of our procedures to make the unit more efficient, which in turn means they can respond more flexibly to our requests.' Maintaining the relationship takes work on both sides, at different levels within the organisations.

Ms Wallace points out the importance of maintaining a good relationship with Baxter staff, especially as they move off-site. Some of this is done through regular meetings, but 'the softer stuff' is also important - making certain they get an invitation to the Christmas party, for example.

Mr Goldney is keen that Baxter staff see the benefits of their work first hand: 'Our staff need to - and many of them do - sit in the clinics and see the implications of what they do.' Finding a partner for this kind of work is difficult as there are relatively few players. The Christie went to competitive tendering for its 10year contract, but Ms Wallace says there were 'few viable alternative providers'.

Contenders for such contracts need to reassure trusts that they can cope with current demand, as well as increasing demand in the future; this may act as a barrier to new firms entering as trusts tend to ask for examples of how services have been provided elsewhere. However, some other pharmaceutical companies are understood to be positioning themselves to break into this market.

Baxter argues that contracts also need to be relatively lengthy - eight to 10 years - to allow the company to invest in facilities, equipment and staff. Shorter contracts are likely to have increased management costs.

But what happens if the worst happens and the firm is suddenly unable to meet the Christie's requirements?

The Christie still retains some in-house compounding facilities, which are primarily used for research trials, and in an emergency some production might be switched to other Baxter units. Baxter also does some emergency and planned work for other trusts at its sites - for example, taking on compounding while a trust's own unit is closed for maintenance or building work. It is hoping to extend this work and, like many other private sector firms, is trying to assess whether to invest in more facilities in the hope of acquiring a stream of NHS work.

As Mr Richards points out, NHS cancer czar Professor Mike Richards - who opened the new£1.5m unit at the Christie earlier this year - has made positive comments about private sector involvement. .

ON THE EVIDENCE: ANTIDEPRESSANTS

The issue One objective in treating people with antidepressants is to reduce suicide and self-harm.

But it has been suggested that some antidepressants, in particular the selective serotonin reuptake inhibitors (SSRIs), may lead to the emergence or worsening of suicidal ideas in some patients.

The link between antidepressant therapies and suicide was examined in two papers in the BMJ earlier this year. They were both secondary analyses of existing trials.

The research The first study, by Gunnell et al, was a metaanalysis of data from 477 randomised controlled trials of SSRIs compared with placebo. All had been undertaken in adults and submitted to the safety review of the Medicines and Healthcare products Regulatory Agency.

Sixteen suicides and 172 episodes of non-fatal self-harm were reported.

Compared to placebo there was no significant statistical evidence that SSRIs increased the risk of suicide or increased self-harm.

The second study, by Fergusson et al, was an analysis of the data from a review of randomised controlled trials comparing SSRI with an active non-SSRI control.

The information was obtained by undertaking a rigorous trawl of the Medline clinical database, accessing the Cochrane collaboration's collection of randomised controlled trials and checking bibliographies of previous reviews.

This trial also found no significant increase in chances of suicide attempts (fatal and nonfatal) for patients receiving SSRIs compared to tricyclic antidepressants.

In practice One of the difficulties of using data from previously conducted trials is the way the information was gathered. In the case of the meta-analysis by Gunnell et al, the work depended on pharmaceutical company submissions to the regulators. While this has the advantage of enabling consideration of published and unpublished information, there is a risk that submissions were selective and that work by independent researchers was not considered. So it is reassuring to also have Fergussan et al's review.

A further problem of linking 'second hand' data is that there is inevitably a degree of dissimilarity between trials. There could be differences in drug intervention, population studied and outcomes assessed.

It is a matter of judgement as to whether it is reasonable to lump studies together, and it is important to be aware that the two analyses included trials for indications aside from depression (eg obsessive compulsive disorder and anxiety). But as the distinction between anxiety and depression in a primary care population may not be clear-cut, the breadth of these studies is reassuring.

The bottom line is that these studies offer some initial reassurance that SSRIs are no more likely to lead to suicide in adults than other antidepressants.

BMJ 2005; 330: 285-8 and 396-9.

www. bmj. com

PRIVATE COMPANIES

OPPORTUNITY KNOCKS

Some private companies are said to be interested in taking on cancer work in the NHS - but what is available?

Scanning and diagnostics is one obvious area in which there has been independent sector involvement that is likely to increase.

It might also have a role in providing positron emission tomography (PET) scanning or more linear accelerators. The investment needed for this is considerable and firms are likely to want a guaranteed income stream over a number of years before they invest.

Providing various components of treatment is another area; Healthcare at Home treats over 3,000 cancer patients each year and is a major employer of specialist cancer nurses. Nurses will administer chemotherapy at the patient's home, collecting the drugs from the hospital and liaising with hospital staff. They also provide an on-call service.

Key points

Baxter Healthcare has a successful and long-running contract to supply chemotherapy drugs to Christie Hospital trust in Manchester.

More than 80 per cent of the Ch r ist ie's chemotherapy drugs are now pre-ordered - one of the highest proportions in the country.

A big benef it of the partnership is that Baxter staff do a lot of the compounding work, leaving trust pharmacists with more time to spend with patients and clinicians.