Nid yw’r dudalen ar gael yn y Gymraeg
National Assembly for Wales
Health and Social Services Committee
Review of Cancer Services for the People of Wales
| Name of respondent:Sian Evans |
| Are you responding on behalf of an organisation?Yes |
| If so please give the name The Royal Pharmaceutical Society of Great Britain |
| Address: Gloucester House 14 Mount Stuart Square Cardiff CF10 5DP |
| Telephone number: 029 20412800 |
| Would you be willing to give oral evidence to the Committee? |
| If the evidence you give below is your personal view, rather then that of an organisation, please state whether or not you are willing for your evidence to be published by putting a X in the appropriate box below: |
| I am content for my evidence to be published |
| I am not content for my evidence to be published |
| 1 | How can information technology be used more effectively to track and facilitate the patient’s journey? |
| Response | All professionals involved in the care of a patient need access to and the ability to contribute to the patient’s medical record. This is best achieved by a single patient record. Community pharmacists are often forgotten when planning for integration of information technology for healthcare. They can often provide useful information on for example a patient’s medication history and it would benefit the patient if, with the patient’s permission, they could receive information on medication changes.Electronic prescribing is further advanced in chemotherapy than in most other specialties. In addition to providing decision support and a means of ensuring prescribing complies with agreed protocols, it can also provide good information for patient management, clinical audit and service planning. Funding is being provided centrally in England to establish electronic prescribing systems for chemotherapy at Cancer network level. An All-Wales system would provide the benefits described above. Two of the three Cancer Centres in Wales have already installed the "ChemoCare" system but progress is hampered both by the lack of a strategy and access to funding to join the current systems together and further develop them. |
| 2 | How effectively is research and good practice being integrated with service delivery? What can be done and by whom to improve this? |
| Response | Dissemination of information on good practice has improved and hopefully this is incorporated into practice. Opportunities for research are available but the heavy workload faced by most healthcare practitioners including pharmacists discourages many from undertaking practice research. Resources are also problematic and whilst there may be long term gains, the extra short-term costs and lack of flexibility between budgets, can delay introduction of new technologies into practice. For example the use of erythropoietin can save blood supplies but the costs of the drug would have to be borne by individual Trusts. As blood transfusion is funded centrally in Wales, there is no gain to the Trusts in introducing such a technology.Setting up and running non- sponsored clinical trials is becoming very difficult due to the associated service costs and sometimes the drug costs not being met. Clinical trials are very heavy on resources for pharmacy, both in the time needed in setting them up and the preparation of sometimes complex chemotherapy. Current levels of support for service costs associated with clinical trials often do not provide enough support for departments such as Pharmacy and Radiology. |
| 3 | What are your views on the complexity of commissioning services? Is the process hampered by the involvement of the local health boards, cancer networks and Health Commission Wales? How could it simplified? |
| Response | Commissioning of cancer services in Wales appears overly complex. Trusts providing cancer services negotiating with all 22 LHBs and HCW is time consuming and wasteful for both sides. LHBs have to ensure that services provided by Trusts are clinically and cost effective but often do not have the expertise to evaluate specialist services. Regional consortia or for highly specialised services, all Wales commissioning would appear a better solution.Ease of access to palliative care medicines in the community is variable in Wales, especially in relation to out of hours. WHC (02)86 directed LHBs to make provision for accessing palliative care medicines in relation to the All Wales Collaborative Pathway for the last days of life. Very few LHBs appear to have complied fully with this. The 5 LHBs in the former Gwent Health Authority area have by commissioning a number of community pharmacists to provide an on call arrangement as an enhanced service. The service is fully integrated with the Gwent Healthcare Out of Hours GP service. |
| 4 | What evidence is there of the value of screening and immunisation? |
| Response | |
| 5 | What are the barriers to the NHS in Wales keeping abreast of, and responding to, developing technologies and therapies? How might these barriers be overcome? |
| Response | Recent advances in the diagnosis and treatment of cancer have often been costly in terms of acquisition costs and the manpower needed to deliver the service. NICE and AWMSG have often taken a long time to appraise new technologies which has led to frustration for patients and clinicians. If clinicians know that a thorough appraisal of a product is to take place within a reasonable timescale, there will be less pressure to rush the introduction of a product. The NHS does not have an open-ended budget and must be assured of value for money but faster appraisals with a clear timetable are needed. These appraisals also often ignore the workforce and capacity issues of providing the new technology which can delay introduction of a proven treatment into practice. Recent NICE technology appraisals on Docetaxel for prostate cancer, Trastuzumab for early breast cancer and Oxaliplatin as adjuvant treatment for colo-rectal cancer all have considerable workload implication for Pharmacy. The two first drugs are new additional treatments, whilst the latter is a complex treatment replacing a simple bolus injection. |
| 6 | How can the NHS and the voluntary sector work together more effectively to deliver services? |
| Response | The voluntary sector provides a valuable service to patients and healthcare professionals looking after people with cancer. |
| 7 | How can the collection and use of data on where the terminally ill spend their last weeks or months be improved better to inform service provision for those people? |
| Response | It is important to ascertain from terminally ill patients where they wish to die and to be able to provide the support necessary for patients who wish to be at home. There are difficulties faced by patients and carers despite improvements in palliative care services. Access to controlled drugs and other palliative care medicines is often difficult, especially out of hours. We need to ask patients and carers of their experiences in this and other areas of difficulty and use their answers to inform future service provision. |
| 8 | There are a number of issues around prescribing and the cost of drugs: |
| 8(i) | What should be done and by who to reduce continued prescribing of inappropriate drugs? |
| Response | The CSCG Cancer standards and All Wales guidelines e.g. All Wales guidelines on the use of hormonal therapies in breast cancer will, along with NICE guidelines, ensure that appropriate treatments are prescribed. Pharmacists in Cancer Networks are in an ideal position to audit these and other local guidelines but as there is only one of the three networks which has a funded Network Pharmacist post, it is unlikely to take place under the current arrangements. Wastage of drugs can occur following transfers of care. Highlighting to patients being admitted into secondary care that they should bring their medicines into hospital with them and systems designed to assess and reuse these medicines has reduced wastage.Medication reviews by pharmacists in primary and secondary care can highlight problems with medication including compliance issues and unnecessary drugs being prescribed. Pharmaceutical advisors in primary care are now providing GPs with advice on prescribing to individuals and groups of patients which have been available in secondary care for some time. |
| 8(ii) | Should people who are prepared to pay privately for drugs not available to them on the NHS, be able to do so without having to become private patients and having to pay for all their treatment? |
| Response | We feel that cancer drugs cannot be taken in isolation when considering this question. If a drug is not available on the NHS, it may be for a number of reasons. The drug may be very new and not yet appraised by NICE or AWMSG or for a rare indication which is unlikely to be appraised. It may however have been rejected by NICE on cost or clinical effectiveness grounds.If NHS patients were allowed to pay for non-approved treatments there could be pressure put on prescribers to provide a treatment which is unproven or not cost-effective. The world wide web is a powerful tool and most clinicians have several patients who have learned of new drugs on the internet and demand treatment. That in it would not be a problem provided the drug was known to be safe. However there are additional costs involved in providing the treatment over and above the acquisition costs of the drugProviding a drug treatment to a patient involves prescribing, dispensing and usually administration. If a patient were to pay for a drug which was not available on the NHS who would provide the associated costs? These could include extra laboratory test, extra out-patient attendances, preparation and dispensing costs and finally administration costs which could involve an in-patient stay. The administration of a system of charging patients for drugs also incurs costs.The NHS has always provided treatment free at the point of care. Whilst it is recognised that the cost of new treatments may be more than the NHS can sustain, equity of care is still important. If NHS Wales were to allow patients to pay for expensive new drugs whilst remaining NHS patients, it will not be long before the first patient who cannot afford such a treatment becomes headline news.It is therefore the view of pharmacists in Wales that the disadvantages to NHS Wales in allowing patients to pay for drug whilst remaining NHS patients, outweighs any advantages. |
| 8(iii) | Do doctors, pharmacists and other health professionals have adequate access to independent advice and guidance on the prescribing of drugs? |
| Response | The expansion of health evidence sites on HOWIS and the Access to Knowledge initiative has improved information available to health professionals. However the availability of HOWIS within and beyond secondary care may need improvement. |
| 9 | Are services centred on the patient, with service users consulted? If not what are the reasons for this and how can patient involvement be improved? |
| Response | Patient- centred services have improved but we must not be complacent and continue to listen to patient views. However, it is sometimes difficult to obtain objective views from patients, who either provide over-enthusiastic praise or have had an unfortunate experience on a single occasion which has coloured their views on their whole service. Patients may need educating on how to give constructive criticism and sharing of good practice in this area would be welcomed. |
