Written evidence submitted by the British Oncology Pharmacy Association (ECS0031)

 

The purpose of the British Oncology Pharmacy Association (BOPA), which is a registered charity, is to promote excellence in the pharmaceutical care of patients with cancer through education, communication, research and innovation by an alliance of hospital, community and academic pharmacists, pharmacy technicians, those in the pharmaceutical industry and other healthcare professionals.

 

  1. Workforce

The Cancer Workforce Plan committed to the expansion of capacity and skills by 2021

 

Community pharmacy:

The community pharmacy workforce is suffering from a significant lack of pharmacists, many of whom have left the community pharmacy sector to take up the 1,500 new PCN posts working with GP surgeries.  We recognise the direct patient benefit that these PCN pharmacist posts have had within the healthcare but   there seems to have been limited workforce planning undertaken by Government to mitigate the loss of such a significant proportion of the community pharmacy sector’s trained professional workforce.     Community pharmacies are having to close regularly leaving them in breach of NHS contract, and many more pharmacists are unable to take allocated leave, at the detriment of their mental health and wellbeing.   Community pharmacists play a key role in identifying patients with ‘red flag symptoms’ and referring patients to their GPs for a potential early diagnosis of cancer as well as supporting patients through all stages of their cancer journey.  Jackie Lewis of Lewis Pharmacy, Exmouth says ‘I estimate my workload of queries from customers regarding suspected red flag cancer symptoms has tripled during covid.’  This represents an opportunity to utilise community pharmacy services to support wider NHS strategic objectives and inform improvements in patient care.

In general, the community pharmacy workforce is underutilised despite a huge potential role in promoting healthy lifestyles to reduce cancer risk, encouraging participation in cancer screening programmes, early diagnosis of cancer as well as supporting patients living with and beyond cancer.  

Funding to upskill community pharmacists in this role and a commitment to embed this into the community pharmacy contract would help to realise this potential along with funding and commitment to expand cancer medicines into the New Medicine Service long term.  There is currently no facility for community pharmacists to directly refer patients into rapid diagnostic services which would very effectively speed up the pathway to diagnosis.

For further information on the role of community pharmacists in the prevention and early detection of cancer, please see the following articles:

Lewis, J ‘How to support cancer patients in community pharmacies’ The Pharmaceutical Journal, March 2017, Vol 298, No 7899;298(7899) access vial: https://pharmaceutical-journal.com/article/ld/how-to-support-cancer-patients-in-community-pharmacies

Lewis, J ‘Identifying patients with suspected cancer: red flags and referral’ The Pharmaceutical Journal, 2018; Vol 298, No 7899 access via: https://pharmaceutical-journal.com/article/ld/identifying-patients-with-suspected-cancer-red-flags-and-referral

The Royal Pharmaceutical Society, 2020 ‘Utilising community pharmacists to support people with cancer’ access via: 00207 001a 2001 Cancer Paper WEB.pdf (rpharms.com)

BOPA have produced an e-learning programme aimed at upskilling and empowering community pharmacy staff which can be found on our website:

Showreel: Let's Communicate Cancer

 

Hospital Pharmacy:

 

For further information please refer to:

Cancer Research UK 2017, ‘FULL TEAM AHEAD: UNDERSTANDING THE UK NON-SURGICAL CANCER TREATMENTS WORKFORCE’

Workforce retention is also an issue in the hospital pharmacy sector with specialist cancer pharmacists are senior cancer pharmacists leaving. Workforce retention needs to be addressed. Tied into this, there is also little evidence of some of the commitments in the NHS Long Term Plan, one such example being: "We will also do more to nurture the next generation of leaders by more systematically identifying, developing and supporting those with the capability and ambition to reach the most senior levels of the service".

Recent workforce reports have revealed a 17% shortage of oncologist posts across England. These shortages are in the context of increasing patient numbers and increases in patients surviving further into their journey with cancer. The cumulative effect of these advances in treatment mean that cancer is increasingly becoming a chronic condition, with patients requiring long term support from oncology services.

Pharmacists are well positioned to reduce the impact of the documented shortages in oncologists. Oncology pharmacists were among the early adopters of the role of the pharmacist independent prescriber role. (PIP). Utilising professional expertise in medicines, many pharmacists are transitioning into advanced practice roles where they assume responsibility for treatment and provide holistic care for patients with great success, as advocated in the NHS 5 years forward view report. There has been a proliferation in consultant oncology pharmacists’ posts across England within the past 5 years, with a range of well documented benefits to patient care and workflow within organisations where these posts are funded. Expansion of advanced practice and consultant pharmacist roles would increase capacity within the cancer multi-disciplinary team and help alleviate many of the current challenges facing cancer services. However, the number of such posts are still limited across NHS England and funding arrangements vary significantly across the NHS. Job planning of these roles in a similar fashion to medical staffing would improve the sustainability of these roles.

To support cancer pharmacists to transition into these roles, and realise the benefits that they can provide, it is important to identify and implement suitable training pathways at local, regional and national levels. Current training pathways should be optimised to increase provision of formal academic training at postgraduate level, such as MSc courses in oncology, to enhance capability of pharmacists and provide assurance of competence to support enhanced patient care. These changes should be initiated in conjunction with increased access to advanced practice qualifications to enhance the clinical skillset of pharmacists to allow them to assume greater responsibility for patient care and help address many of the challenges facing cancer services.

The oncology pharmacy workforce also includes other groups, such as pharmacy technicians and non-registrant staff, all of whom have provide services which have a significant impact on the care of cancer patients.  In particular, the role of pharmacy technician has widened and the demand for increased numbers of technicians is outstripping the pipeline of student technicians currently in training. This staff group has the potential to reduce elements of the workload of nursing staff through deployment to chemotherapy day units. In this setting pharmacy technicians are able to provide counselling to patients regarding prescribed treatments and supportive therapies to optimise effective use of medications, facilitate clerking of patients other prescribed medications to identify and resolve drug interactions and improve patient safety and coordinate chemotherapy treatments with pharmacy production facilities, thereby reducing waste.

Overall, the pharmacy workforce in all sectors is facing significant workforce pressures due to increase demand, COVID impact, staff health and wellbeing as well as the decline the numbers of students in the pipeline. In response to this in March 2021 the role of the pharmacist was added to the Home Office’s Shortage Occupation List. The lack of workforce planning and the implementation of strategies to alleviate the workforce pressures has meant the oncology pharmacy workforce in the frustrating position of being ideally placed to improve the care of cancer patients but without the resources to fulfil these aspirations to the fullest benefit of the cancer patient.

 

Oncology Pharmacy Workforce: A workforce with untapped potential to improve cancer services but one that is under-resourced to deliver whilst coping with and increasing demand.

 

To address these factors, and establish baseline service provision across the NHS, we would call for a consultation across stakeholder groups to identify where pharmacy services can provide patient benefit and identify areas of excellence across treatment centres to share these lessons across the network.

 

See also:

Building Back Cancer Services in England. Institute for Public Policy research. 2021, September. https://www.ippr.org/files/2021-09/building-back-cancer-services.pdf

NHS Five Year Forward View. NHS England. 2014. https://www.england.nhs.uk/five-year-forward-view/

Five Year Forward View: A Briefing for Members. The Royal Pharmaceutical Society. 2016, March

Consultant Pharmacist Guidance: Consultant Pharmacist Short life Working Group. 2020, January. https://www.hee.nhs.uk/sites/default/files/documents/Consultant%20Pharmacist%20Guidance%20Final%20Jan2020.pdf

  1. Diagnostics

2020 to ensure most patients receive a definitive diagnosis or ruling out of cancer within 28 days of referral from GP or from screening.  By 2028 the proportion of cancers diagnosed at stages 1 and 2 will rise from around 50% now to 75% of cancer patients

Community pharmacy services are well positioned to play a greater role in patients’ journey to diagnosis and support identification of cancers at an earlier stage of disease. Published evidence demonstrates that 90% of the population of England live with a 20-minute walk of a community pharmacy, making them one of the most readily accessible healthcare resources to the public. Community pharmacies are currently actively involved in public health campaigns which promote lifestyle interventions which reduce patients risk of developing cancers, alongside several other serious healthcare conditions. Community pharmacy services also have an established role in supporting smoking cessation services within portfolio of primary care services and has a demonstrated history of success in delivering this intervention.

The role of the established network of community pharmacies in England could be expanded to support earlier identification of cancers and help the NHS realise its ambitions of increasing the proportion of cancers diagnosed at stages 1 and 2. A number of published studies suggest that patients with symptoms of possible cancers, but who have not yet received a formal diagnosis, present to community pharmacies for treatment and advice regarding these “red flag” symptoms. To improve the rates at which such patients are identified and appropriately referred to diagnostic services BOPA have begun work to drive the changes which are required within the profession. The Lets Communicate Cancer programme is a dedicated training platform aimed to provide community pharmacy staff with a basic set of skills to facilitate increased ability to identify patients with such symptoms and provide them with the tools hold effective consultations.

The potential scope of community pharmacy as a venue to support these ambitions has been recognised by Health Education England, who are currently supporting a study in conjunction with BOPA around London and the Southeast to identify the impact that the Lets Communicate Cancer programme delivers regarding patient care. While further development of this service is required, there is clear scope for community pharmacy services to take a more active part in this process.

Direct referral to rapid diagnostic services by either community or PCN pharmacists would help meet the 28-day target for definitive diagnosis of cancer, save time and reduce GP workload.

 

 

  1. Living well with and Beyond Cancer

By 2021 where appropriate every person diagnosed with cancer will have access to personalised care, including needs assessment, a care plan and health and wellbeing information and support

 

The commitment gives a deadline of 2021 which is clear, but it doesn’t provide clear metrics of how to determine whether the commitment has been met or notStaffing resource is a particular issue with regards to achieving this commitment. For example, the personalised care discussions within secondary care are often undertaken by cancer clinical nurse specialists (CNSs). This is in addition to their regular to clinical work, which has to be prioritised, leaving limited time to ensure holistic needs assessments (HNAs), care plans and health and wellbeing information are provided to patients.

NHS Trusts were not provided with specific government funding to support this commitment. Funding is taken either from existing budgets or from charities such as Macmillan.   Charity-funded roles are often pump primed for a few years to embed services and assess output but even when clear benefits have been demonstrated, the Trust is often not able to continue to fund these roles making the commitments described unsustainable.

There is no doubt that patients have benefited from HNAs, care plans and health and wellbeing events (pre-COVID) and a supply of health and wellbeing information.  The commitment was sufficiently specific and wide enough in scope, with an appropriate level of ambition, however the measures need to clearer, and the reporting mechanism more visible.  The impact of the commitment has been limited by insufficient funding for staffing and IT resources.

Pharmacy professionals have a significant role to play in delivering services which support patients health and wellbeing throughout treatment and helping them after active treatment has finished. As described earlier, survival rates following a cancer diagnosis have improved significantly, with more patients than ever surviving longer with a cancer diagnosis. Historically, cancer services have been centralised in secondary care hospital trusts with limited provision made for delivery of more primary care and community-based services.

Utilising primary care pharmacy services to optimise elements of patients’ care, such as control of nausea and vomiting associated with chemotherapy, may help to increase capacity within acute secondary care settings and improve the patient experience by improving access to less complex interventions.

Primary care pharmacy staff are also well positioned to optimise the care that patients receive for other non-malignant, co-existing conditions which cancer treatments often adversely impact. With the increase in survival rates following a cancer diagnosis it is more important than ever to ensure healthcare services implement holistic reviews considering each patients co-morbidities and identify where interventions can improve outcomes and quality of life. In secondary care, specialist teams are not well-equipped to manage conditions outside of their remit.

In secondary care, the introduction of nurse and pharmacist-led review clinics can allow for a more holistic review of patients undergoing cancer treatment while reducing pressure on busy medical outpatient clinics.

Currently, these clinics tend to be run by nurse and pharmacist independent prescribers as an extension to their existing role.  Skill-mix planning, backed up with sufficient funding for dedicated posts would enable wider access to these services.

 

Innovation and Technology

Safer and more precise treatments including advanced radiotherapy techniques and immunotherapies will continue to support improvements in survival rates.

 

In the past 10 years there has been an exponential growth in the number of cancer medicines available leading to substantial patient benefit. However, this has come with significant capacity impact for pharmacy oncology services.

 

The additional funding to implement new cancer medicines is generally focussed on the acquisition cost of the medicines with limited consideration of service costs so despite significant increases in cancer medicines funding this does not translate into increased service funding

 

One example of the growth in cancer medicines is the increased use of immunotherapies. In 2011 the first immunotherapy Ipilimumab was approved for use in melanoma. As on 1st February 2022 there are seven immunotherapies in utilised in nine different tumour sites and over 20 different indications. The benefits from these treatments can been in direct patient outcomes but the differences in toxicities and duration of time patient remain in treatments in comparison to traditional chemotherapy has caused challenges, not least within oncology pharmacy services. This is particularly seen within aseptic service compounding capacity (which is already insufficient to meet demand) and increased role of the PIP in clinics to review immunotherapy patients. The further expansion of immunotherapy into the adjuvant setting will only increase these challenges further.

 

Advanced therapy medicinal products (ATMP’s) including CAR-T therapy pose a huge burden on NHS pharmacist resource due to the complex nature of these therapies.

 

Pharmacy departments and highly skilled specialist pharmacists and chief pharmacists are required to ensure institutional readiness for implementation of ATMPs at an organisational, governance, regulatory and clinical level.

 

The medicines brought about by new technologies have undoubtedly improved patient outcomes, however resource implications as these therapies continue to expand outside of the haemato-oncology remit is huge. There are currently 29 ATMPs and CAR-T therapies in the UK pipeline for approval (https://www.sps.nhs.uk/articles/annual-planning-advice-for-new-medicines-prescribing-outlook/), some are license extensions and some new therapies. It is recognised that additional pharmacy resource is required to ensure these highly specialist and complex therapies are implemented safely into routine clinical practice.

 

The NHS has acknowledged the importance of genomic medicine services to in diagnostic services to identify patients with high-risk conditions and inform treatment choices. Chemotherapy represents a treatment modality which carries a range of potential side effects with a growing body of evidence regarding treatment choices based upon patient genetic profiling. Recent commissioning of widespread DPYD testing to inform dosing for breast and bowel cancer patients has demonstrated the potential role for oncology pharmacists to utilise genetic assessment to ensure safe and effective use of chemotherapy agents. Extension of this principle to include extension of testing for other genetic markers which inform dosing and treatment choices would build upon this work. To allow pharmacists to play a greater role in interpretation of genetic assessment results which inform treatment options it is important to establish and implement suitable training pathways. Current training pathways should be optimised to increase provision of formal academic training at postgraduate level, such as MSc courses in genomic medicine, to enhance capability of pharmacists and provide assurance of competence to support enhanced patient care.

 

 

Currently there are 168 guidelines, technology appraisals, and quality standards in relation to cancer in the NICE workplan. Adequate resource, estates and infrastructure are required to properly implement advanced therapies and immunotherapies.

 

 

Jan 2022