Medicine in the Time of Covid
Published: August 2020
NHS England/Improvement has placed the restoration of all cancer services at the heart of the third phase of the NHS’ response to the COVID-19 pandemic, and last week published changes in recommendations for cancer medicines in the form of interim treatment recommendations, which can be found here. This development is both an indication of the urgency behind the intention of the NHS to recover the ground lost during the COVID-19 pandemic, and of the national commissioner’s ability to set aside established processes to determine treatment guidelines.
The new recommendations were published on 3 August 2020. They were formulated by the Chemotherapy Clinical Reference Group, which develops national service specifications for adult and child chemotherapy, commissioning policies that set out access to therapies for patient groups, and statements to inform service contracts. Commissioning policies automatically incorporate NICE technology appraisal guidance and draw on relevant recommendations in NICE clinical guidelines.
We have summarised the recommendations for the most prevalent cancers below:
The treatment guidelines include recommendations for therapeutic areas in addition to the ones highlighted in the above diagram. It is worth noting 3 immunotherapies are recommended as first line treatment across 4 therapeutic areas. Some of these are transformative and could be potentially curative, breaking the mould of high cost late stage drugs that have limited impact on life expectancy.
The new interim treatment recommendations are designed to reduce the risk to patients with cancer of contracting COVID-19, either by selecting treatment options that are less immunosuppressing, such as chemotherapy regimens for colorectal cancer that contain cetuximab or panitumumab, or that can be administered at home or in other settings where the risk of coronavirus transmission is lower than it currently is in hospital. The recommendations also aim to maximise the use of available capacity by using treatments that can be administered more easily or for shorter periods in hospital, such as switching intravenous rituximab to subcutaneous rituximab in follicular lymphoma patients receiving rituximab with lenalidomide.
It is essential to explore everything that can be done to recover the ground that has been lost in improving outcomes for people. These new recommendations are carefully worded to ensure that patient access to new treatments recommended by NICE is protected, and that where NICE recommends against the routine use of a new therapy, a desire to throw everything at the task of restoring cancer services avoids compromising the effective use of NHS resources.
The differences in the processes that NICE and the Chemotherapy Commissioning Group take to determining treatment recommendations reflect their respective roles and the traditions from which they come. The history of commissioning policies has its roots in local PCT collaborations that predate the creation of NHS England and that rely on the expertise and opinion of policy group members rapidly interpreting the evidence available to them. NICE’s approach is made possible by a mandate that both requires and supports an extensive review of the evidence, for both clinical cost-effectiveness and extensive consultation. The NHS needs both these mechanisms. In the exceptional times we are currently experiencing it is important that the one that is selected achieves an appropriate balance between the need to do the right thing for patients, the importance of making the best use of NHS resources, and the value of holding true to what should be an enduring commitment by the NHS to an evidence-based approach to deciding what treatments to provide.
Carnall Farrar (CF) is a management consultancy and analytics company dedicated to improving health and care. We inspire and support our clients to innovate and sustain change, stretching the bounds of possibility. We work across health and care, including the NHS, life sciences, and analytics.
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Sir Andrew Dillon has held a number of senior management positions in the NHS. He was appointed as the Founding Chief Executive of NICE, the National Institute for Health and Care Excellence in 1999, a post he held until he stepped down in 2020. He now works as an independent healthcare advisor.
Laurent Abuaf is a senior executive with more than 16 years experience in pharma leading local and regional businesses across Europe and Asia. Laurent spent 4 years at BCG Paris and worked on a wide diversity of industries. He was the Country President for AstraZeneca in the UK for 2 years until stepping down in 2020 to become an independent advisor.
Ben Richardson is a co-founder and Managing Partner at CF where he leads CF’s work in Life Sciences and Data Science & Analytics. Prior to joining CF Ben was a Partner at McKinsey & Company. He has worked across all aspects of health and care systems and for life sciences companies in the UK and around the world.
Scott Bentley is a Senior Manager at CF in Life Sciences. He has worked extensively with the health and care systems of the UK and Life Sciences companies. Prior to joining CF Scott worked at ZS Associates.
We would like to thank and acknowledge the support of Elizabeth Hubbard in the drafting of this article.