Summary

This project was designed to simplify the considerable task of costing cancer into an achievable process by focusing on costing two high-volume cancer pathways – breast and lung. The key objective was to facilitate the delivery of high-quality cancer care by understanding the costs of the clinically effective pathways in order to inform future commissioning, ensuring services are appropriately funded. This would give a good guide to commissioners on their total funding requirements for cancer and allow them to have an informed discussion with their providers on how they could improve quality and value-for-money cancer care.

The project will give commissioners greater clarity on which HRGs align with the national pathways for lung and breast cancer, and enable consistent coding of activity across London. Commissioners will have a better understanding of current patient pathway flows across London Trusts, and the impact that has on costs. In turn this should inform commissioning of secondary care activity related to best practice care. Roche have benefited from costed pathways being developed to include NICE approved treatments and cancer care being appropriately funded across London.

The project has managed to bring providers and commissioners closer together to help them better understand the true cost of delivering cancer care. A population-based predictive cost model has been developed to cost out the best practice breast cancer care pathway. This has enabled greater clarity on current service specification against the best practice pathway and informed negotiations between commissioners and providers on quality improvements.  The output from the costed pathways project is also being used as part of a pilot to develop best practice tariffs for selected tumours in shadow form from 2012/13 across London.

Objectives

The objectives of the team were to:

• understand, through patient level detail, the cost of cancer treatment thereby leading to greater transparency between actual provider costs and the national tariff
• develop a population-based predictive funding flow model at local or pan-London level that could be used to model prices of future populations based on forecast incidence and mortality rates for different tumour sites
• develop an agreed process for the commissioning of cancer services, across the entire clinically effective pathway with built-in service specifications for quality monitoring purposes.

Solution

Phase 1 - Mapping and validating the clinical pathway 

The first task was to translate the breast cancer pathway detailed on the map of medicine into simple flowcharts highlighting the key stages of activity. 

The initial mapping and modelling was undertaken with the support of the London School of Economics. The result was a multi-layer spreadsheet that systematically mapped the patient journey across three distinct pathways: 

• triple assessment diagnostics 
• early or locally advanced disease 
• advanced disease.

Once the proposed pathways had been drawn up a series of workshops was organised to introduce the model and its purpose to relevant health professionals including: oncologists, breast cancer nurse specialists, surgeons, coders and finance staff. This multi-disciplinary validation was critical to the development process as it helped ensure clinical engagement with the project and provided assurance that the pathways depicted by the model were both realistic and based on best practice medicine. Once all the necessary adjustments proposed at the workshops had been made to the model, the final step of Phase 1 was to cross check the model against NICE guidelines.

Phase 2 – Review each step of the breast cancer pathway and match it to the national tariff, where a tariff exists

Once the three pathways had been validated by clinicians the project team turned their attention to identifying the cost of each element of the pathway. The first task was to incorporate the national tariffs relating to breast cancer – outpatient clinic attendance and surgical breast procedures – into the appropriate step of the model. 

The cost of outpatient attendances proved relatively straightforward to calculate. The project team worked with clinicians to estimate the percentage of patients entering each stage of the pathway and the number of clinics that each patient would be required to attend. We then used the national tariff for 1st and 2nd outpatient attendance to give total overall cost. Working with clinicians, the team reviewed each procedure performed locally and then mapped it to the most relevant Healthcare Resource Group (HRG) and related national tariff. 

Phase 3 – Ascertain costs for areas without tariff or reference cost 
The next phase of the project was to ascertain costs for the steps on the pathway that are not yet covered by tariff. The cost of outpatient attendances and surgical procedures was incorporated into the model in phase 2 so the challenge in phase 3 was to try to identify and incorporate clinical costs such as Hormone Receptor and HER2 testing, blood tests, bone scans, CT scans and chest x-rays into the model. The funding for tests such as these is bundled in the national outpatient tariff so the cost was calculated based on activity data relating to each hospital clinic.
The two main cost drivers on this pathway - radiotherapy which accounts for 22% of the total cost, and chemotherapy and biologics which accounts for 38% of total cost – were considered separately in phases 4 and 5 of the project.
Phase 4 – Use the Chemotherapy Planning Online Resource Tool (C-PORT) costing module to estimate the costs of chemotherapy taking account of National Chemotherapy Advisory Group (NCAG) recommendations.
At this stage of the project North West London Cancer Network (NWLCN) provided support by providing C-PORT data (an online chemotherapy modelling and planning tool), to try to gain a better understanding of the costs relating to chemotherapy. Two local NHS trusts were also asked to collect and to cost chemotherapy activity data relating to a sample of patients and this information was then used for sensitivity analysis on the data provided by NWLCN.
Phase 5 – Use provider data to estimate the costs of radiotherapy, taking account of National Radiotherapy Advisory Group (NRAG).
Radiotherapy is the other main cost driver in breast cancer care but, as with chemotherapy, there is no nationally agreed tariff; the cost is hidden in block contracts or incorporated into cost and volume contracts. An organisation located in NEL had, however, calculated the actual cost of radiotherapy services for a Department of Health led project on the development of a national tariff so it was agreed to use these costs throughout the model.
Phase 6 – Review the patient flow through the pathway – utilising local sources of data including Hospital Episode Statistics (HES) and Thames Cancer Registry (TCR) – to understand how current practice compared with clinically informed best practice.
With the unit cost of each step of the clinical pathway agreed and activity data for radiotherapy and chemotherapy incorporated into the model the project team turned their attention to sourcing the remaining activity data. We began by collecting easily accessible, centrally collated data: the number of direct referrals from the NHS Breast Screening Programme as recorded by the Quality Assurance Reference Centre (QARC), for example, and the incidence rates of breast cancer from Thames Cancer Registry.
Once the model was fully populated with referral, activity and price data, we were able to calculate the estimated cost of commissioning breast cancer care in North East London. The process was then followed through for lung cancer.

Results

The success criteria based on key project milestones have been achieved – A Population-based predictive funding models for breast and lung cancer have successfully been developed and reflect the overarching objectives of the project. 

Evaluation

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Throughout the project, monthly review meetings were used to monitor and evaluate project progress, with agreement of deliverables and key project milestones. These included:

• Mapping the national clinical national standard pathway to tariff, where a tariff exists
• Bottom up costing for areas without tariff or reference cost 
• Detailed approach to filling costing gaps agreed by project team
• Utilising the Chemotherapy Planning Oncology Resource Tool (CPORT) costing module to estimate cost of the chemotherapy part of pathway, including NICE approved drugs
• Sensitivity analysis (range of cost for each key component x number of times cost component is used at population level to estimate the size of impact if assumptions incorrect) for cost accuracy of each part of the pathway to understand and validate high risk procedures / assumptions 
• Patient flow through the pathway – utilising HES data to understand current pattern and clinically informed best practice. With consideration given on how to estimate the unplanned patient activity through A&E etc
• Building pathway cost model to estimate population cost of delivering pathway at PCT, network and London level. Pathway funding will have the ability to model cost of future population based on forecast changes in incidence and case mix for tumour sites.
• The mapped-out best practice care pathways were expanded in detail through workshops attended by clinical teams, clinical coders, and finance personnel. The expanded detail was necessary to ensure accurate cross matching of pathway activity to tariff.

Innovation

The Government paper on Delivering the Cancer Strategy Reform highlighted how many commissioners did not do enough to understand costs and value for money in their delivery of cancer services; few commissioners make best use of the information available and most do not know whether their commissioning is cost-effective.

This project has been a proof of concept to proove that by using tariff and dervied costs it is possible to map the spend across a care pathway. This work has been pivotal in moving away from block contract to investing in whole care pathways.

Over the past two years the project has managed to bring providers and commissioners closer together to help them better understand the true cost of delivering cancer pathways. There has been greater clarity on current service specification against the national clinical care pathway which has provided a platform for negotiation between commissioners and providers on how services can be improved to close the gap. And most importantly there is now a predictive cost model that can be used to cost out the pathway and therefore make informed decisions to aid service redesign.

The approach has pioneered further costed pathways across other major tumour sites and there is also consideration to applying this methodology across other high spend areas such mental health and cardiovascular disease.

Impact

The model has provided a route map to help: 

• engage all stakeholders in service delivery 
• encourage an interdisciplinary approach towards change 
• identify gaps in existing service delivery 
• focus attention on areas where performance is below standard 
• manage variations in treatment and costs 
• support more efficient and effective resource allocation 
• encourage innovative service provision 
• instigate process improvement 
• hold providers to account 
• provide a formal framework for review