Calm from chaos

It’s been a turbulent month in the NHS. If you have somehow escaped the madness, NHS England has been abolished, with its functions to be absorbed into the DHSC.

Integrated care boards, once seen as the future of the NHS, have had their workforces shredded – and some commentators, including many at my own publication HSJ, are predicting their imminent demise – or at least transformation into merged super-ICBs, NHS Regions, Lead Provider Models, or something we haven’t seen yet.

So, we’ve seen a fair amount of panic, chaos and questions, many of which remain unanswerable: about budgets; accountability; structure; staffing arrangements and where this leaves the stated aims of the NHS. We still have the 10-year plan to come in late spring, and hopefully that will at least begin to answer some of these.

In the meantime, there are many unknown unknowns. But the health service will still continue business as usual: GPs will still see patients; therapists will still counsel mental health patients; surgeons will operate; pharmacists will dispense.

This article focuses on these known knowns. What remains, behind the façade of NHS management, is demand. Demand and supply, and the capacity to address them, is still the most salient challenge of the NHS – and the most important thing for pharma to engage on.

While the DHSC will now cover a lot of things NHS England and some ICBs used to do, it will still need to look at variation in supply and demand and capacity, which is largely driven by population health.

At HSJ Market Intelligence we argue that the need has never been greater to present solutions to these issues, based on the most accurate, current, granular and broad data.

We believe there has never been a better time to interrogate NHS pathways.  Regardless of who is nominally running it, what are the optimal interventions the health service can make to open up access, streamline process, speed up throughput, enhance patient experience and, most importantly, improve clinical outcomes?

In this example, we’ve taken the cancer pathway to explore what can be highlighted to your NHS partners to create a solid case for change.

1. Variation in cancer provision
Variation is critical to understanding service improvement, and the more types of variation you can point out, the richer the pool of solutions can be. My business has recently developed a new tool, Quantis 2.0 Cancer Pathways, that shows significant variation in provision of cancer care, offering the insight into cancer care variation that is desperately needed by industry.

We can now interrogate a wider range of data, and carry out more detailed analysis.
We can look specifically at variation in screening, diagnosis, initial referrals, treatment pathways after referral, the stage of disease patients present at, the use of biopsies, use of treatment – for example variation in use of chemo, surgery and radiotherapy – and the use of biopsies and endoscopies: especially important for companies developing more targeted therapies, where molecular biomarkers are important.

2. Interrogating cancer diagnostics
Diagnostic variation is very noticeable in the NHS. For example, regions such as the East of England have 31 per cent of patients waiting above six weeks for an MRI scan – the North West has only 17.

The variation is almost always linked to the number of patients coming through in the first place; so it’s not the commissioning that drives variation, nor the possibility that an oncologist in one part of the country knows less than another.

While efforts might be made to reduce it by local commissioners, regional demand for diagnostic services and capacity will continue to drive local decisions.

The need for a joined-up approach across contractors and providers is still there, and perhaps for the NHS to treat patient groups as a population unbound by artificially constructed geographical management areas. Better prioritisation and stratification is needed for this kind of demand management. Pharma, with the right data and analysis, can help.

3. Variation in treatment length, number of cycles and dosage
Across all cancers, there is variation in cycle number and length of treatment, with the same drug, for patients with the same cancer.

This issue came up in the recent HSJ Cancer Forum: Chatham House rules applied but this was a senior clinical oncologist with a role in a Cancer Alliance, questioning why patients in some areas were receiving six, and in others four cycles of the same therapy.

It is connected of course with individual clinicians’ decisions – but is this compliant with manufacturers’ recommendations? Is it doing what NICE says it should? What impact is it having on outcomes? And perhaps most importantly, why is it happening?

At least some of the answer comes back to variable demand and available supply to meet it. In industry, do you know why some patients are on more cycles of a drug and if that reason is clinical or to do with demand management?

4. Elective wait time for surgery across all cancers
Wait times affect surgery success and long-term survival, so getting these down is in the interests of the entire cancer community.

Waiting times for first appointments are getting longer: we can see that this is the case across all three principal referral routes. Between 2019/20 and 2023/24, average waiting times for routine, urgent and suspected cancer referrals increased 57.0%, 64.8% and 77.1%, respectively.

While this can be explained by the significant capacity issue facing the NHS since the backlog increased post-COVID, further action will be needed to improve the standard of care across all three referral routes.

What can be done about such bottlenecks, and how are patients being managed while they wait?

5. Variation in severity of cancer
Stage 4 cancer presentation rates are higher in areas with higher-than-average deprivation.

ICBs with higher levels of deprivation were associated with higher rates of stage 4 cancer: this includes deprived ICBs such as Nottingham & Nottinghamshire ICB, North East & North Cumbria ICB, Black Country ICB and South Yorkshire ICB.

Conversely, localities associated with low levels of deprivation – South West London, Buckinghamshire, Oxfordshire & Berkshire West ICB, Surrey ICB and Frimley ICB – were also associated with lower levels of stage 4 cancer.

There is therefore a clear correlation between deprivation and aggregate outcomes in oncology care – but why? Is it to do with poorer access, or lack of information, leading to late diagnosis, and then patients presenting too late?

The high number of stage 4 cases recorded leaves questions about how many of those could have been prevented from progression earlier – and remember a stage 4 is a huge cost effort for the NHS as well as a mighty clinical challenge.

It’s worth exploring the burden in your area to see if some joint work on access and patient identification is possible.

Cancer, in particular perhaps, gives us an extremely rich data picture of what is going on with the NHS across the entire pathway: the demographics, the inequalities, the variation; what’s happening with screening, diagnosis, stage at presentation, biopsies, hospital referrals, treatment types, cycles, length of stay, survival, mortality, morbidity, co-morbidities and outcomes, to name just a few.

But the data is there, if you know where to find it, in other therapy areas. Add in data for spend, or prescribing, and all kinds of analyses can be done about the value of pathways in different iterations – including demonstrating the difference therapies can make – and their role in easing capacity burdens and addressing variation in treatment and outcomes.

Whoever is in charge at the NHS, they will need data insight, demand management solutions and a cool head. Pharma is more than capable of providing them with all three.

Oli Hudson is content director at HSJ. Go to hsjmarketintelligence.co.uk