Organisation implements a standardised approach to dose banding for efficient chemotherapy usage, enabling pharmacy services to deliver safe, timely chemotherapy for appropriate patients

Standardisation of Chemotherapy drug doses across England through the implementation of a standardised approach to dose banding*.

The project is improving value at a national scale by reducing drug wastage, enabling the bulk purchasing and or manufacture of chemotherapy drugs and free up pharmacist time for more patient facing activity rather than time consuming bespoke pharmacy production. The project has already developed and agreed standardised dosing tables for 19 different chemotherapy drugs and agreed implementation of this through a national CQUIN scheme which has been agreed with 88 Hospital Trusts.

The next phase of the project is now expanding this approach to a much broader range of Chemotherapy with the aim of standardisation of >90% of all chemotherapy doses in England. A CQUIN has been agreed for 2017-19 to support delivery of this. In addition, the project is also developing a consistent approach to chemotherapy product specification (rather than each and every Hospital Trust purchasing similar but not identical products from NHS and commercial compounding units).

*Dose Banding is a system whereby doses of intravenous cytotoxic drugs are calculated on an individualised basis that are within defined ranges, or bands, are rounded up or down to predetermined standard doses’

Challenges

-Chemotherapy is the single biggest service area within the Specialised Commissioning portfolio which is commissioned directly by NHS England. There are high rates of annual growth (8%+ per year) and an annual spend of approximately £1.5 Billion across England. Therefore it is crucial that opportunities for improving value in this service area are identified and implemented at scale.

- While chemotherapy is generally prescribed on the basis of a patient weight or surface area, across England significant variation existed in the actual doses prescribed due to an inconsistent approach to dose rounding / banding.

- It is both logical and safe to dose band chemotherapy, so that for any particular drug only a limited number of preparations can be used.

- Attempts had been made to standardise chemotherapy prescribing in England on at least 2 previous occasions and these have previously failed.

- There was variance of opinion as to what was the best method of dose-banding to adopt.

Actions

- using the power of NHS England as the single commissioner of Specialised services to drive through change.

- using strong clinical leadership and advice from the medicines optimisation clinical Reference group and Chemotherapy clinical Reference Group.

- using a National CQUIN as a contractual lever to fast track change

- to back up the contractual lever with National and local education events to inform people of the changes

- to create National groups to manage and sustain change and imprvoement

Results

- adoption of the national CQUIN for dose banding by the majority of trusts involved in chemotherapy administration

- Agreement of improvement targets to achieving standardisation between individual Trusts and local commissioning teams.

- 150 delegates attending a meeting in Manchester where the national dose bands were launched

- a further CQUIN developed for 2017/18 and 18/19 to further embed change

- Regional tenders being undertaken on the basis of the national dose banding tables

Value

The project has identified a potential £27 million saving nationally through waste reduction which it aims to deliver by 2019. The benefits of dose banding are still being realised, and will continue to be realised over the coming years. Through the introduction of dose banding it is inevitable that wastage of chemotherapy will be reduced. . As dosages which had previously been wasted will now be used safely for other patients. With far more chemotherapy available in ‘ready to use’ forms hospitals can now hold stock of these dosages significantly reducing patient waiting times for treatment.

The best data available at the moment is the impact dose banding has had on recent regional tenders for chemotherapy. In the recent North West tender for pre-prepared doses of chemotherapy - where dose standardisation has led to far fewer doses being required a 25% reduction in price has been seen on a number of product lines. For some lines even greater price reductions are being seen.

In detail

INTRODUCTION

Chemotherapy remains the most common intervention in the treatment of cancer. While the NHS and Trusts are limited in what they can do to impact upon the actual cost of chemotherapeutic drugs, there is a great deal which can be done to minimise wastage and ensure that we use chemotherapy as efficiently as we can.

Chemotherapy is the single biggest service area within NHS England’s specialised commissioning spend. It is estimated that NHS England spends approximately £1.5 billion on the routine commissioning of chemotherapy, with drug costs (which are paid by NHS England as pass through payments) being 80% of this. There is a very high rate of annual cost growth of approximately 8%. Dose banding can be described as a “system whereby doses of intravenous cytotoxic drugs are calculated on an individualised basis that are within defined ranges, or bands, and are rounded up or down to pre-determined standard doses’.

AMBITION

To make the use of chemotherapy in England as efficient as it possibly can be. To eliminate avoidable waste and minimise costs. Traditionally, chemotherapy doses have been unique to individual patients based on either their surface area or weight. Such specific dosing does not provide additional clinical or patient benefit and significantly increases time and costs of preparation and costs of drug wastage.

Additionally, standardised dosing will allow standardisation of the chemotherapy products available by diluent, volume and labelling which will allow access to ready to administer chemotherapy from generic and NHS manufacturers. Dose Standardisation is achieved through a standardised approach to dose banding across England. The approach is in line with the Efficiency and Productivity review undertaken by Lord Carter, which recommends the elimination of waste through a consistent approach to patient care.

OUTCOME

Dose standardisation has improved the ability of pharmacy services to deliver safe, timely chemotherapy for appropriate patients. Dose standardisation has been adopted throughout England. All stakeholders are now in agreement as to the dose banding methodologies to be used, and clear outcomes are now being observed in prices charged for dose-banded products.

SPREAD

The dose standardisation initiative has been rolled out across every chemotherapy provider in England. Within the next two years nearly every dose of chemotherapy administered will be dosed in accordance with the national dose banding tables developed through the medicines optimisation CRG. Early indications are that the pharmaceutical industry now appreciates the importance of dose banding and will adopting the principles of dose banding in trial design and in new product development.

Members of the medicines optimisation CRG working group on dose banding have been invited to speak at conferences across Europe on this project and indications are that dose banding will be rolled out across Europe. It is also planned to harmonise the approach to dose banding with Scotland.

VALUE

The value of dose standardisation can already be measured in the significant reductions seen in the most recent tender processes for dose banded products. In the North West region price reductions of over 25% have been seen in a number of product lines. Involvement. This project could not have been possible without the engagement and support of a wide number of stakeholders.

The medicines optimisation CRG led on the initiative; Pharmacists from the major UK cancer centres supported the development of national dose banded tables; NHS England commissioners supported the roll out of the project through the development of national CQUINS; The Chemotherapy CRG, UKONS, the National chemotherapy Board all endorsed the initiative, with the national dose banding tables hosted on the chemotherapy CRG webpage; Every haematology / oncology pharmacist in England has championed dose banding at their local trusts - and gained local approval to adopt the national tables.

This is probably the best example ever of clinicians, commissioners, and cancer professionals coming together to deliver a national initiative in a very short period of time. The outcomes of which will generate significant savings over many years and improve the patient experience.