Written evidence submitted by Sanofi (CBP0065)

 

Sanofi is dedicated to supporting people through their health challenges. We are a global biopharmaceutical company focused on human health. We help prevent illness with vaccines, provide innovative treatments to fight pain and ease suffering. We stand by the few who suffer from rare diseases and the millions with long-term chronic conditions.

With more than 100,000 people in 100 countries, Sanofi is transforming scientific innovation into healthcare solutions around the globe.

  1. What positive lessons can be learnt from how healthcare services have been redesigned during the pandemic?  How could this support the future work of the NHS and care services?

 

Homecare and improved access to care

 

Although COVID-19 has posed significant challenges to the health system and to those seeking access to healthcare, certain service changes implemented during this period could produce material benefits beyond the pandemic, if retained.

Homecare

While some people had benefitted from access to biologic treatment at home prior to the pandemic, for many patients the increased use of homecare represented a significant shift.  For severe asthma patients, NICE’s COVID-19 rapid guideline: severe asthma[i], enabled them to self-administer their biologic treatments rather than travel to hospital.

Should patients be empowered to self-care via home care beyond COVID-19, it holds the potential to improve patients’ quality of life through reducing the amount of time patients have to take off work and education.  Indeed, research from the think tank Demos published in February 2021 found a £2 billion per year loss to the economy incurred from people taking time off work for treatment as well as lower pay for those with inadequately controlled asthma[ii]. Supporting homecare may also reduce the resource burden on the small number of specialist severe asthma centres in England[iii].

New models of care

The pandemic has accelerated the redesign of services – notably in primary and community care, to help meet the demands of patients with long-term health conditions such as CVD, diabetes, and asthma. Catching up on routine checks, is proving to be one of the most challenging barriers to overcome.

This need is evident with diabetes for example, with Diabetes UK reporting a significant reduction in people with type 1 diabetes (-37.5%) and type 2 diabetes (-40.8%) receiving all eight care processes in 2020 compared to 2019[iv]. In addition, the number of people undertaking an NHS Health Check, a programme aimed at detecting many chronic conditions including cardiovascular disease saw a 97% drop in the second quarter of 2020 compared to the same period in 2019[v].

The NICE COVID-19 rapid guideline for severe asthma[vi] recommends that clinicians start patients on biologic treatment even if a multidisciplinary team discussion is not possible, instead recommending that two senior clinicians in the commissioned service, or delegated by the commissioned service, may make the decision to start biologic treatment.  Indeed, with Asthma UK’s recent analysis finding that as few as 18% of those who should be referred to specialist centres are referred, while three in four people eligible for biologic treatment are still not accessing it[vii]; retaining this new model of care could improve capacity within specialist services.  It could also improve patient access to specialist care by expanding the breadth of the service away from the small number of hub specialist centres and into the ‘spoke’ centres.

It is widely acknowledged that the redesign of care services will help meet this significant backlog. To play its part in meeting this challenge, Sanofi is looking at how it can support the system beyond the medicines that it manufactures to engage in programmes aimed at training the wider health workforce, for example providing education and support for care home staff to manage an ageing population of people with diabetes.

Improved management of patients using digital

There is a perception among some dermatologists that biologic medicines for atopic dermatitis may be lower risk and require less ongoing monitoring by the clinical team than standard immunosuppressive therapies, thus freeing-up clinical time. Such benefits were perceived to be particularly important during the pandemic, especially in reducing the need for patients to attend clinical settings[viii], which was one of the priorities in dermatology care during the pandemic[ix].

Recently introduced treatments such as biologic medicines have the potential to support the redesign of services in atopic dermatitis; for example, supporting the greater use of remote consultations and follow-ups and reducing the need for patients to visit hospitals. One consultant dermatologist described the introduction of biologic medicines for the treatment of atopic dermatitis as a “major step forward”[x]. It is worth pointing out that the level of monitoring required will vary between individual biologic medicines and would need to be assessed on a case-by-case basis. 

While a reduction in face-to-face consultations between clinicians and patients may have some positive effects in terms of resources, there may be opposition within the patient community in several therapeutic areas. The Patients’ Association survey of patients’ experience during the pandemic for example saw 48% of respondents reported that utilising remote telephone consultations resulted in a negative experience of care[xi].

In a survey by Allergy UK of their members during July 2021, the importance of face-to-face appointments for ensuring appropriate care was made clear by the responders, citing for example the difficulty of consulting on a very visual condition over the phone or via photographs taken by patients themselves[xii]. While trying to realise the benefits of greater use of digital technology, all must be mindful of the preferences and needs of patients. The NHS Long Term plan highlighted a drive for some specialist referrals for dermatology to take place with pictures and questionaries. While this may offer support for some people, in person support should be retained where appropriate[xiii]

The increasing digitisation of the NHS has changed the way in which Sanofi engages with the healthcare system. For example we have looked at how we can bring together healthcare professionals from different backgrounds to help share best practice and education around running a successful virtual consultation across CV and Diabetes care.

As a result of this increasing trend towards digitisation, Sanofi is also increasingly engaging beyond the medicines it manufactures through virtual healthcare. Through engagement with the healthcare sector, we have recognised the need for additional mental health and wellbeing support for people with chronic conditions such as diabetes. Approaches to providing support through technology could ease pressure on the existing resources to ensure that those people who needed it could access the support quickly. It is however important as the system recognises the potential for increased use of digital services - the approval, access and reimbursement processes for digital technologies in the UK are as agile as possible to help meet this need.

  1. How might the organisation and work of the NHS and care services be reformed in order to effectively deal with the backlog, in the short-term, medium-term, and long-term

In the short term, it is important to recognise that companies who provide medicines to the NHS require proactive engagement from health authorities such as DHSC and NHS England around the anticipated demand for goods. Where Brexit and COVID-19 have added to the complexity of supply chains and increased the system’s awareness around market resilience, as healthcare activity increases authorities need early engagement with manufacturers to help quantify the increased demand for goods such as medicines. This will be increasingly important for ensuring that the elective and non-elective surgical backlog is met.

The bulk of NHS reform to tackle the backlog should be focussed on supporting people with chronic conditions who have been adversely affected by missed appointments, delays to diagnosis and reduced access to clinical support. A clear example of this has been for people living with respiratory conditions.

The criteria used by NHS Digital to identify clinically extremely vulnerable people during COVID-19[xiv] led to a number of people without a formal diagnosis being informed that they may have severe asthma[xv].  According to evidence submitted to the Respiratory APPG, this could be because no one single definition of severe asthma exists[xvi].  Indeed, as no guidelines on referral exist, there is also significant variation in individual clinicians’ thresholds for referral[xvii]

To ensure that those who have been identified by the NHS as clinically extremely vulnerable – but are not under the care of a respiratory consultant or have not been referred to specialist care for investigations – are able to access a timely diagnosis and appropriate treatment, a consistent definition of severe asthma should be enshrined in the upcoming NICE/BTS/SIGN guidance.  This guidance should also define criteria for referral to specialist care, in line with recommendations from the National Review of Asthma Deaths[xviii] which are consistent with the criteria adopted by NHS Digital during COVID-19.  In the medium-to-long-term, this would help ensure that patients with severe asthma are appropriately managed as early as possible following the identification of symptoms, thereby reducing avoidable presentations and admissions[xix] [xx].

 

Inquiry questions

There is analysis that shows that total dermatology appointments reduced to 58% of pre-pandemic levels during the first lockdown, and that by October 2020 they were still at only 75% of pre-lockdown levels. In total in 2020, there were 484,415 fewer appointments between April and October, as compared to the same period in 2019[xxi].

There is also some evidence that anxiety around the use of immunosuppressant and biologic medicines did lead to some patients stopping using their medicines[xxii], and that there was a delay on some patients starting to use immunosuppressant and biologic medicines as a result of concern about access to regular blood tests and injections; this was particularly prevalent during the first wave[xxiii].

NICE guidelines on the treatment of atopic dermatitis have not been updated for more than a decade, and there is a lack of standardised guidelines for atopic dermatitis across the UK, despite the recent advances in treatment. As more and more biologic medicines become available in atopic dermatitis, this will become more of an issue as clinicians have to decide which ones are most suitable for most patients[xxiv]. We recommend that NICE looks to accelerate its intention to develop these guidelines, in partnership with patient organisations, healthcare professionals and the industry.

MAT-GB-2103979 (v1.0)              September 2021


[i] NICE, Covid-19 Rapid Guideline Severe Asthma (2020) Available from: https://www.nice.org.uk/guidance/ng166/resources/covid19-rapid-guideline-severe-asthma-pdf-66141904108741

[ii] Potential Limited, Demos 2020. Available from: https://demos.co.uk/wp-content/uploads/2021/02/Potential-Limited-Report.pdf 

[iii] Respiratory Health APPG report, Improving asthma outcomes in the UK (2020). Available from: https://www.ed.ac.uk/files/atoms/files/appg-asthma-report-2020.pdf

[iv] Diabetes UK, ‘Diabetes Can’t Wait’ (2021), pg. 12 Available from: https://diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/public/2021-07/Diabetes%20is%20Serious%20Report%20Final_0.pdf

[v] British Heart Foundation, ‘The Untold Heartbreak’ (2021), pg.16 https://www.bhf.org.uk/what-we-do/news-from-the-bhf/news-archive/2021/august/pandemic-backlog-heart-care-five-years-recover

[vi] https://www.nice.org.uk/guidance/ng166/resources/covid19-rapid-guideline-severe-asthma-pdf-66141904108741

[vii] Asthma UK, Asthma UK, Do no harm – Safer and better treatment options for people with asthma (2020) Available from: https://www.asthma.org.uk/418cbc36/globalassets/campaigns/publications/severe-asthma_report_final.pdf

[viii] McPherson, T; Wali, G; Laws, P; The Treatment Landscape of Atopic Dermatitis:

Interviews with Three Consultant Dermatologists. EMJ. 2021;6[1]:23-32.

[ix] COVID-19 rapid guideline: dermatological conditions treated with drugs affecting the immune response - NICE guideline Published: 9 April 2020 https://www.nice.org.uk/guidance/ng169/resources/covid19-rapid-guideline-dermatological-conditions-treated-with-drugs-affecting-the-immune-response-pdf-66141909147589

[x] McPherson, T; Wali, G; Laws, P; The Treatment Landscape of Atopic Dermatitis:

Interviews with Three Consultant Dermatologists. EMJ. 2021;6[1]:23-32.

[xi] The Patients’ Association, ‘Pandemic Patient Experience II – From lockdown to vaccine rollout’, pg. 9, https://www.patients-association.org.uk/Handlers/Download.ashx?IDMF=835c8fb6-71f2-41e3-8e44-489216762cf6

[xii] From data collected by Allergy UK as part of a joint project with Sanofi (not yet published). These responses relate to a survey distributed by Allergy UK to their membership of patients, and to healthcare professionals.  Over the course of the 3 weeks that the survey was open in July 2021, 268 patients and 30 healthcare professionals responded.

[xiii] The NHS Long Term Plan (2019) p98. Available from: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-term-plan-june-2019.pdf

[xiv] NHS Digital, Coronavirus Shielded Patients List. (2020). Available from: https://digital.nhs.uk/coronavirus/shielded-patient-list

[xv] Asthma UK. Confused about whether you have severe asthma or not? You’re not alone. Available from: https://www.asthma.org.uk/support-us/campaigns/campaigns-blog/confused-about-whether-you-have-severe-asthma-or-not-youre-not-alone/

[xvi] Respiratory Health APPG report, Improving asthma outcomes in the UK (2020). Available from: https://www.ed.ac.uk/files/atoms/files/appg-asthma-report-2020.pdf

[xvii] https://www.asthma.org.uk/globalassets/get-involved/external-affairs-campaigns/publications/severe-asthma-report/auk-severe-asthma-gh-final.pdf

[xviii] National Review of Asthma Deaths. Why Asthma Still Kills. (2015). Available from: https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills

[xix] Department of Health, Respiratory Team (2011) An outcomes strategy for chronic obstructive pulmonary disease (COPD) and asthma in England (DH, London) Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216139/dh_128428.pdf

[xx] British Thoracic Society, Scottish Intercollegiate Guidelines Network (2014) British guideline on the management of asthma (SIGN, SIGN 141. Edinburgh) http://www.sign.ac.uk/pdf/SIGN141.pdf

[xxi] Ibrahim, LS; Venables, ZC; Levell, NJ. The impact of COVID-19 on dermatology outpatient services in England in 2020. Clinical and Experimental Dermatology, 25/12/2020 found at https://onlinelibrary.wiley.com/doi/10.1111/ced.14547

[xxii] McPherson, T; Wali, G; Laws, P; The Treatment Landscape of Atopic Dermatitis:

Interviews with Three Consultant Dermatologists. EMJ. 2021;6[1]:23-32.

[xxiii] McPherson, T; Wali, G; Laws, P; The Treatment Landscape of Atopic Dermatitis:

Interviews with Three Consultant Dermatologists. EMJ. 2021;6[1]:23-32.

[xxiv] McPherson, T; Wali, G; Laws, P; The Treatment Landscape of Atopic Dermatitis:

Interviews with Three Consultant Dermatologists. EMJ. 2021;6[1]:23-32.

 

Sept 2021