The NHS is developing a new contracting strategy to increase the capacity of radiotherapy services. Thoreya Swage looks at what this new approach means for the medtech industry, both within cancer treatment and beyond.
The opening up of the UK healthcare market to providers other than the NHS has been much heralded and discussed over the past few years. The threat of competition from independent sector healthcare organisations from abroad and at home, with their slicker and more innovative ways of working, should in theory have shaken up the NHS. However, with the exception of a few cases, it has been difficult to budge NHS commissioners from their comfort zone of dealing with the providers they know to having a dialogue with organisations that have a different background or pedigree.
The Government tried to increase the market share of independent sector organisations in the English healthcare market with the Independent Sector Treatment Programme, set up over four years ago. However, as the DH had to pay a premium to stimulate this market, there were criticisms that it was centrally driven, unwanted and expensive compared to local NHS provision. As a consequence, with the contracts for the first wave of ISTCs coming to an end next year, the companies have little appetite for continuing to provide the services at a lower cost – while the NHS has scant enthusiasm to pay for healthcare that seems to be surplus to requirements.
The cancer challenge
What is needed is another approach to enable the private sector to access the healthcare market. An opening emerged with the publication of the Cancer Reform Strategy in 2007, which identified the need for a dramatic increase in capacity for radiotherapy services. This was quantified as an increase in radiotherapy treatment for cancer patients from the current average of 30,000 fractions per million population to 54,000 fractions per million population by 2016. The Strategy recognised that this meant a requirement for more skilled staff and linacs or linear accelerators (radiotherapy machines) to deliver the service, with investment to support this development across England. It quickly become apparent that current NHS facilities could not meet this future demand, and so the scene was set for a different way of looking at how care could be provided – and in particular, how to enable potential providers from the independent sector to help fill this gap.
In response to this challenge, the National Cancer Action Team (in conjunction with the Commercial Directorate at the Department of Health) has developed a new methodology for commissioning and contracting for radiotherapy services. At its heart are the following principles:
• Radiotherapy is defined as a discrete service (whether part of a current facility or a separate organisation) comprising radiographers, medical physicists and supporting staff, together with linacs. The service is separate from the multidisciplinary cancer team (which is based in a different organisation), but has clear accountability to it in providing the radiotherapy section of the whole cancer pathway for the patient.
• The methodology allows for the development of different models of service that providers can come up with, as long as these are within defined outputs.
• The methodology is reliant on the principles of the ‘safe patient pathway’ as developed by the Commercial Directorate.
Roads to recovery
The cancer pathway is complex, with a number of sub-pathways (radiotherapy, chemotherapy, surgery etc) that could be followed by a patient. It is made more complex if the different sub-pathways are provided by different providers, with a risk of discontinuity of care as the patient moves from one pathway to another. Figure 1 illustrates the four layers within the safe patient pathway:
• Commissioning (procuring the radiotherapy service and managing the contract).
• Clinical case direction (management of an individual patient by the multidisciplinary cancer team).
• Provision of the radiotherapy service or process (the treatment received by a patient).
• The organisational platform on which the service or process sits (systems to manage and audit clinical care, competencies of the staff providing the radiotherapy service, managing change and innovation, working with partners).
It is essential that at each level there are clear governance arrangements to ensure sound and safe systems of delivery of patient care, with clear lines of accountability between the different levels.
A new landscape
This work resulted in the following tools:
• A high-level radiotherapy pathway to describe the interventions (administrative, technical and clinical) that occur during the patient’s journey for this section of their cancer care.
• A contracting framework toolkit to set out the standards and outputs required of a radiotherapy service.
• A template service specification that can be modified by local commissioners to meet the needs of their local populations. This sits within the NHS standard contract for acute services.
Cancer networks across the country need to get a grip on increasing radiotherapy capacity, and the Cancer Action Team is planning a rollout of the new strategy to support networks in this task.
This situation presents a number of new opportunities, both for radiotherapy services and for the medtech industry.
Defining the radiotherapy service from first principles makes it possible for different models of care to be provided by different organisations. These models could range from providing the whole radiotherapy service (i.e. radiographers, medical physicists and linacs) to working in partnership by providing only staffing or linacs and facilities.
Purchasing the linacs requires major capital investment up front. Here, organisations wishing to provide a radiotherapy service may decide to enter into different agreements with medtech companies over the provision of the linac: buying the machinery outright; leasing the linac and providing maintenance, either in-house or externally; or with another provider responsible for provision and maintenance of the linac within the service.
Access to treatment is another key issue. Cancer networks are in the very early stages of working out how to increase radiotherapy capacity in their localities. A key element of the expansion in radiotherapy services will be ensuring that patients do not have to travel far to receive treatment. The access target is a journey no longer than 45 minutes from the patient’s home.
The cancer networks will have identified gaps in the delivery of radiotherapy services within their localities, and will be looking to develop more locally accessible care. This may mean the establishment of ‘satellite’ services, which could be either an extension of a current wider cancer service into another geographical locality or an independently-run service that has clear sub-contracting and governance arrangements with the local multidisciplinary cancer team.
NHS cancer networks need to expand their radiotherapy services to meet the future demand for cancer care. NHS providers will not be able to fulfill this requirement by themselves, and so the door is open for dialogue with the independent sector.
What medtech can do
The medtech industry has an opportunity to be proactive. Now is the time to think differently and consider developing radiotherapy services in partnership with NHS providers, or even with other independent sector providers (who might, for example, provide staff), as described by the high-level pathway and contracting framework.
Look up the tools that have been developed on the NHS cancer website (see below) and consider how these can help to shape and define radiotherapy services.
|For more information on the tools developed, visit: www.cancer.nhs.uk |
Dr Thoreya Swage has several years’ experience in the NHS, both as a clinician (psychiatry) and as a senior manager, including Executive Director for a Health Authority, in various NHS organisations covering acute and primary care. She has expertise in commissioning health services, most recently working with the independent sector as part of the Independent Sector Treatment Programme at the DH. She is currently working for a number of NHS organisations, including DH agencies, to develop a more commercial approach to the commissioning of healthcare.
It is worth establishing contact with local cancer networks to find out what their specific issues and gaps in radiotherapy services are. It will also be helpful to understand the patterns of service that are planned for the future in a network locality.
Cancer networks may also welcome discussions with potential providers about the different models of radiotherapy care that could be offered.
Identify potential partners, approach them and start discussions about the shape and form of the radiotherapy service to be provided, and the various business or sub-contracting relationships with respect to provision of staff and equipment, using the contracting framework as a guide.
Look on the NHS procurement portal Supply2health (see below), which allows potential providers to search for clinical service opportunities announced by NHS commissioners.
This is a very real opportunity for the medtech industry. NHS cancer networks need to expand their radiotherapy services to meet the future demand for cancer care. NHS providers will not be able to fulfill this requirement by themselves, and so the door is open for dialogue with the independent sector.
The new commissioning methodology has potential applications in other therapy areas. For example, the approach could be applied to all aspects of diabetes care, from prevention, initial diagnosis and management to continuing care of inpatients and outpatients, services for complications of diabetes (renal, vascular, ophthalmic etc), obstetrics, paediatrics and end of life care. Thus a whole range of services can potentially be brought into play.
This points to a significant shift in the relationship between the NHS and the medtech industry, as the NHS extends its horizons to commissioning healthcare from a wider range of providers.