NHS0025

Written evidence submitted by AbbVie

 

Introduction

Thank you for the opportunity to contribute to the Public Accounts Committee Inquiry into the NHS Recovery. AbbVie is a global research-based biopharmaceutical company formed in 2013 following separation from Abbott Laboratories. The company’s mission is to use its expertise, dedicated people and unique approach to innovation to develop market advanced therapies that address some of the world’s most complex and serious diseases. For further information on the company, its people, portfolio and commitments, please visit www.abbvie.co.uk.

Our submission highlights the priority needed to implement new ways of working to create capacity within the system and accelerate the backlog recovery including:

  1. Prioritising long term conditions in the NHS recovery plan would alleviate pressure across the entire NHS system in primary and secondary care.
  2. Implementing national pathway transformation and referral optimisation guidance across the system – for example implementing virtual urgent skin cancer two week wait (2WW) pathway comprehensively across NHS England could alone create capacity equivalent to 48,000 hours of specialist consultant time.
  3. Adopting capacity extending innovation, where choice of treatment can free up resource and patient demand for hospital services and outpatient appointments.

1. Prioritising long term conditions in elective recovery planning

The pandemic has placed a huge pressure on health and care services across the country.  Rightly the Government and successive health secretaries have recognised the importance of prioritising NHS recovery.

While the recovery plan, Delivery Plan for tackling COVID-19 backlog of elective care”, sets out ambitious and challenging targets for the NHS by focusing on increasing activity to reduce waiting lists, there is a risk that this approach to recovery is not sustainable.  AbbVie believes that adopting new ways of working and investing in service transformation are fundamental to supporting the exhausted workforce and ensuring the long-term stability and sustainability of the NHS. 

Long-term conditions as a group are not considered or prioritised within the NHS’s recovery plan to the same degree as surgical elective care or cancer care. Yet there are an estimated 15 million people in England living with at least one long term condition.

Managing long-term conditions makes up a significant portion of the NHS’s day-to-day workload. Of every £10 spent on health and care in England, £7 goes towards the diagnosis, treatment and management of long-term conditions, with long-term conditions comprising 50% of all GP appointments.

AbbVie commissioned research by healthcare analytics company Carnall Farrar to understand the impact of the pandemic on patients and health services and to explore potential solutions to manage the backlog of care. The research found huge disruption across the system.

The research concluded that in light of continued delays to diagnosis and treatment of long-term conditions, the health system needs to think differently about how it can improve access to care. The elective recovery plan is a welcome start, but new models of care must be rapidly deployed, assessed and expanded to drive down the backlog and meet the ambition to reduce waiting lists by March 2024.

The Carnall Farrar research modelling offers an insight into how this can be achieved:

Addressing the lack of capacity in hospital care

The most significant impact on reducing the backlog across the six long-term health conditions would be to address the pressures on secondary care first.

Opportunities for transformation

The NHS needs to think and operate differently across the whole system, which will require collaboration across the health community. Based on the modelling, AbbVie’s recommendations include:

Whilst each recommendation may not be directly applicable across all long-term conditions, these innovative approaches can be tailored across services to reform care for patients.

2. Prioritising National Pathway Transformation: In Focus - Potential impact of Teledermatology to create workforce capacity and reduce NHS dermatology backlog

Dermatology services are currently facing unprecedented demand in the aftermath of COVID. There are currently over 380,000 people waiting longer than 18 weeks and thousands waiting longer than a year to see a dermatologist[ii]. From the available data during the period from March 2020 to October 2021, there is evidence to suggest a possible backlog of almost 1 million dermatology outpatient appointments missing from the system[iii]. Without creating significant increase in service capacity this backlog could take over 8 years to clear – approximately three times longer than comparable long term condition service such as rheumatology[iv]

To help tackle this challenge, NHS England is proposing new policies that embrace innovative digital solutions to improve capacity in the dermatology pathway. One specific policy is the Teledermatology virtual urgent skin cancer two week wait (2WW) pathway, released in April this year, which uses high quality images to help ensure face-to-face hospital attendance only when necessary[v].

Each year, approximately 460,000 patients are referred through the 2WW face-to-face referral pathway for GP-suspected skin cancers. However, only around 6% of referrals lead to a diagnosis of melanoma and squamous cell carcinoma cancers[vi]. A report commissioned by AbbVie, conducted by Carnall Farrar, shows that if adopted as the standard form of assessment for 100% of urgent cancer referral patients instead of a traditional face-to-face 2WW model:

         48,000 hours of specialist consultant time could be saved and potentially redeployed to other dermatological conditions, e.g. inflammatory skin conditions

         This would create 5% extra capacity to begin reducing the backlog of unseen patients. For context, a 15% capacity increase would reduce the time taken to clear the backlog to 27 months.

         The time saved is the equivalent to almost 15% of the unfilled Whole Time Equivalent (WTE) posts dermatology consultant posts[vii].

Of course, there are challenges to be overcome before full implementation could be achieved not least the need to ensure systems have the equipment and people needed to take and send the required good quality images. Systems are not currently equipped for full adoption - in response to a questionnaire by GIRFT to 117 NHS Trusts published in 2021, 30% reported their local Teledermatology services as adequately and safely integrated with their services; 52% replied they were not; and 18% had no local Teledermatology service at all[viii].

However, as Carnal Farrer report recommends, with more national leadership and accountability to ensure Integrated Care Systems (ICSs) are monitored and supported to implement these pathways, this single policy shift could begin to impact on the backlog in the way the Elective Recovery plan envisaged. At the moment, this is not happening, and Dermatology services continue to struggle to cope with demand.  This can be evidenced by the national referral to treatment times (RTT), which in February 2022, just after the Elective Recovery Plan was introduced, stated that only 63% of patients waiting to start treatment were waiting up to (i.e. under) 18 weeks, thus not meeting the established 92% standard. In September 2022 (latest available data in November 2022) this figure remains low at 62% and has therefore not improved[ix].

The use of Teledermatology also has wider dermatology pathway applications which can be found in recent NHSE Referral Optimisation for People with Skin Conditions guidance, issued in September[x]. This guidance contains reflect the conclusions of the Carnall Farrar report and the increased use of Teledermatology to optimise treatment pathways in dermatology. The document provides guidance to support primary care practices to help avoid hospital referrals where appropriate and ensure patient care can be delivered closer to home.

In summary the policies to help create system capacity are there, however, more governmental leadership is needed to provide support to the system to adopt them at pace.

3. Adopting capacity extending innovation: In Focus - creating capacity in cancer services

The following model of capacity extending innovation provides an example on how the innovative use of innovative medicines and delivery outside of secondary care can help to create capacity and alleviate pressure on services:

During the pandemic, the NHS recognised the value of using medicines differently, as NHS England issuing temporary guidance on ‘COVID-friendly’ cancer treatments[xi]. With focus on recovery from the pandemic, there is an opportunity for the NHS to consider what more can be done to harness the potential of innovation. Doing so can help extend capacity and achieve the greatest value from limited NHS resources. Examples of capacity extending innovation includes:

Treat to remission therapies: Allowing patients to be treated to the point where their cancer is in remission and their treatment can stop. Patients in remission may require less ongoing clinical management and support in the long term; removing patients from the system frees up clinic time and capacity. Time off treatment limits a patient’s exposure to ongoing side effects, which may require further healthcare resource utilisation and offers immunocompromised cancer patients the opportunity to regain their natural immunity.

Fixed duration therapies allow services to sustainably plan their healthcare resource utilisation from a clinical capacity perspective (knowing when patients will complete treatment); as well as budgetary impact (through fixed costs compared to continuous treatment costs). The number of patients accessing services could be more consistently managed, enabling improved budgetary planning as healthcare providers and commissioners know patients will come off treatment and be discharged from outpatient services. This will reduce the patient population and free up capacity, resource and utility[xii].

Conclusion

As this submission notes, approximately a quarter of the nation could be suffering with a long-term condition and they are frequent and repeated users of NHS services. The backlogs in care for these patients are among the largest of any NHS service. However, current broad backlog recovery and capacity creation planning, and policy does not prioritise them in the same way it does more acute conditions. This submission provides just two examples of how the NHS recovery could be delivered more effectively and capacity can be created within the system if fully and quickly implemented. However, policy formulation alone is not enough, it requires political focus and leadership commitment to allow upfront resource commitment and reconfiguration to happen.

The definition of innovation also needs broader consideration. Innovation is widely regarded as part of the solution to the challenges of rising demand for limited NHS capacity, yet innovation can take many forms; use of digital tools and tele-health technology or recognising the capabilities of good medicines management – innovative technology that exists and is available within the healthcare system.

AbbVie, and the wider pharmaceutical industry, is a partner in the delivery of healthcare solutions it is important that the incredible partnership between industry and the NHS that supported agile working and emerged during the peak of the pandemic is sustained in a way that can support the NHS recovery.


[i] Carnall Farrar analysis, Recovery in Long Term Conditions, 2022, https://www.carnallfarrar.com/case-studies/recovery-in-long-term-conditions/ (Accessed November 2022)

[ii] NHS Referral to Treatment Time data, August 2022, https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2022/10/Aug22-RTT-SPN-publication-version.pdf (Accessed November 2022)

[iii] Carnall Farrar analysis, Creating Capacity Transforming the dermatology service, https://www.carnallfarrar.com/wp-content/uploads/2022/11/Potential-impact-of-Teledermatology-on-NHS-backlogs-%E2%80%93-The-case-for-adoption-Report-Nov-22-2.pdf (Accessed November 2022), November 2022

[iv] Carnall Farrar analysis, Creating Capacity Transforming the dermatology service, November 2022

[v] NHSE and BAD, 2WW skin cancer pathway, April 2022, https://www.england.nhs.uk/wp-content/uploads/2022/04/B0829-suspected-skin-cancer-two-week-wait-pathway-optimisation-guidance.pdf  (Accessed August 2022)

[vi] 3. NHSE and British Association of Dermatologists, The two-week wait skin cancer pathway, April 2022

[vii] Carnall Farrar analysis, Creating Capacity Transforming the dermatology service, November 2022

[viii] GIRFT Dermatology, Programme National Special Report, August 2021, https://www.gettingitrightfirsttime.co.uk/wp-content/uploads/2021/11/Dermatology-overview.pdf (Accessed August 2022)

[ix] NHS Referral to Treatment Time data, August 2022, https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2022/10/Aug22-RTT-SPN-publication-version.pdf (Accessed November 2022)

[x] NHSE Referral optimisation for people with skin conditions, September 2022, https://www.england.nhs.uk/wp-content/uploads/2022/09/B1149-referral-optimisation-for-people-with-skin-conditions.pdf (Accessed September 2022)

[xi] NHS England, NHS rolls out ‘COVID-friendly’ cancer treatments, 2020, https://tinyurl.com/yuxyfawe, (Accessed November 2022)

[xii] AbbVie, The currency of capacity in cancer: alleviating pressure on NHS cancer services through capacity extending innovations, roundtable discussion, 2022 [DATA ON FILE]

 

November 2022