In February 2010 a QIPP initiative to deliver Herceptin at home, saving £700k recurrently, was at risk of failing. Despite local CQUIN incentive for Trusts, there were barriers,(organisational, financial, emotional and safety) to working with a private sector organisation, Health Care at Home, through a Strategic Partnership with the West Midlands Specialised Commissioning Group. There was also a risk to other cancer services if the QIPP savings were not achieved through this initiative.
The Cancer Network and its Service Improvement Team were asked to support this work stream as a key priority. By focusing on improving the patient’s experience of care, the Service Improvement Facilitator was able to bring together local teams to agree the appropriate care pathway, supported by IT and effective communication in accordance with Information Governance requirements.
This pilot demonstrated the feasibility of delivering home chemotherapy through effective partnership working between NHS and private sector providers.
In November 2009, as part of the plans for 2010/11 contract negotiations, the West Midlands Specialised Commissioning Group (SCG) identified delivering Herceptin at Home as a major QIPP project across three large provider units in Birmingham, Sandwell and Solihull. The intention was to add ‘chemotherapy at home’ to a range of ‘out of hospital’ initiatives being delivered through an established partnership between Birmingham East and North PCT and Health Care at Home.
As part of the contracting round, SCG agreed a CQUIN with the Trusts. The intention was to improve the patient’s experience by offering choice and convenience, increase efficiency in day case units, struggling for capacity and generate savings for commissioners.
Healthcare at Home were selected to become the SCG’s Strategic Partner to deliver this scheme and Herceptin was selected as the first regimen to be delivered in the home environment. This scheme was initially intended to run from April 2010 to March 2012 and the QIPP savings were built into the annual commissioning assumptions ie, PCT high-cost cancer drugs budgets were fixed on the assumption that £700k of recurrent QIPP savings would be achieved from this initiative.
The project experienced significant delays as objections were raised by the clinical and nursing teams in relation to the proposed patient pathway. These included the need for clarity around the responsibilities of acute provider and health care at home, governance, patient safety, additional work involved in patient selection, counselling and support.
Failure of the Herceptin at Home scheme would present a significant cost pressure to commissioners. The contract with Healthcare at Home was already in place, financial assumptions had been built around the savings being realised and there was a firm belief that providing patients with the option of care outside of hospital would be a significant quality improvement for patients and driver to modernise chemotherapy delivery.
Pan Birmingham Cancer Network and it’s Service Improvement Team were asked to help ensure the project succeeded by working with Trusts to overcome the obstacles to delivering the proposed new care pathway.
The aim of this pilot was to test the concept, acceptability and effectiveness of a service that delivered Herceptin to women with breast cancer in their home environment, when historically patients would be treated in a hospital day case unit.
The objectives were to:
The Network Board supported the involvement of the Service Improvement Team.
A project steering group with representatives from NHS providers, Health Care at Home, Specialised Commissioners and the Network was set up.
A Service Improvement Facilitator was assigned to the project full time. Three working groups were established at Heart of England FT, Sandwell &West Birmingham FT and University Hospitals Birmingham FT. It was these groups that led the change programme across five chemotherapy units.
Leadership from the Network and Trust Cancer Managers was important to raise the profile of the project and the importance of success within each organisation. Trusts identified a local lead for each pilot site, while Healthcare At Home provided link nurses to each site and a clinical champion (Consultant Medical Oncologist) was identified for the Network.
A number of presentations regarding the aims and objectives of the pilot were made to the Breast NSSG, Chemotherapy Group, Patient and User Partnership Group and Trust Lead Managers. These were important to set the pilot in the context of a ‘joint’ service redesign initiative between the Network and Commissioners.
The clinical champion (an oncologist), along with the Network Pharmacist was key to ensuring that governance and safety associated with prescribing, compounding, and delivering chemotherapy, (Herceptin in particular) outside of a hospital environment were addressed for all organisations.
The principle of ‘do once and share’ was adopted throughout. In this way, where possible, processes and documentation developed in one organisation could be rapidly shared across all Trusts to achieve rapid adoption. The Steering Group was responsible for resolving local issues as and when they arose, and if necessary outside the formal meetings.
The groups quickly identified that a ‘shared care’ approach was required in order to ensure a seamless transition from hospital initiation of Herceptin (in conjunction with chemotherapy for adjuvant patients), to home delivery with planned cardiac monitoring at appropriate intervals.
Although the patients were to receive their Herceptin at home, the responsibility for offering choice, prescribing, dosing and routine cardiac monitoring remained the responsibility of the Trusts. Therefore it was essential that the Healthcare at Home Nurses were fully integrated into the multidisciplinary team and effective two-way communication be established.
Winning the hearts and minds of the clinicians, pharmacists and nurses was essential to ensure that local teams were engaged in finding local solutions to obstacles. It was important that the Trust staff had confidence in the home care team and that there was support for teams delivering care in patients home.
Throughout the project, the local teams met weekly. A ‘team approach’ was engendered to enable honest and open communication around areas where there were potential conflicts of interest, mistrust or barriers to the process. Although the Service Improvement Facilitator (and chemotherapy nurses) was aware of the CQUIN target and financial pressure to deliver the project, they were not directly involved in the contracting of Trust financial issues and therefore the SIF was able to provide an external, objective, facilitatory approach that focused on improvements for patients.
The SIF liaised with pharmacy representatives from Healthcare At Home to agree a common approach to prescribing, dispensing and administration protocols including handling spillage, etc. This was important to ensure patient safety and quality in line with national standards for peer review.
IT and information governance protocols were agreed and signed off by Trusts to ensure access to patient records was in accordance with Trust Information Governance requirements. Shared folders were established at each Trust to enable information to be accessible to both unit and Health Care at Home staff.
Honorary contracts were set up for Health Care at Home staff involved in the pilot to improve local engagement and training.
The patient information leaflet initially developed by Healthcare At Home needed to be revised to satisfy NHS standards for patient information. This leaflet was taken through the Network Governance process to enable rapid adoption by Trusts and to avoid local information governance committees.
Referral forms – both paper and electronic – prescriptions for Herceptin, anaphylaxis and pre-meds were developed along with a patient consent form for Health Care at Home to provide treatment.
A patient satisfaction survey was developed.
Once the clinical pathway for home delivery of Herceptin had been agreed it was piloted in one Trust first so that any issues could be resolved. For example:
In order to provide equity and make selection process easier, the commissioners agreed that the eligibility criteria could include these patients.
Communication was essential to ensure all stakeholders were aware of the pilot and the benefits to patients. This included letters to all GPs whose patients were receiving home care, briefings to Network site-specific and user partnership groups and a launch event to ensure that there was clarity around roles and responsibilities for each step on the pathway.
Because of the work involved in setting up the pilot, the start of the pilot was delayed from March 2010 to June 2010. However, the pilot continued beyond the end of the 2010/11 financial years.
At the end of the pilot phase 100 per cent of eligible patients were being offered the choice of Herceptin at home. By February 2011, 61 per cent of eligible patients in the Pan Birmingham Cancer Network opted onto the Herceptin home care pathway. Uptake varied between trusts ranging from 58- 65 per cent.
The patient satisfaction survey indicated that 100 per cent of patients on the home care pathway were more than satisfied with the care they received.
Uptake of the home care option steadily increased as Trusts became confident with the pathway and trust grew between NHS and Health Care at Home.
All Trusts achieved their CQUIN target
Commissioners saved £660k by the end of 2010/11 financial years.
The pilot continued to be delivered by Health Care at Home through the contract during 2011 after which Trusts were required to develop their own home care solutions.
The pilot proved that home care delivery of Herceptin was feasible and acceptable to patients and was used as proof of concept for home chemotherapy.
The pilot demonstrated that it is possible for NHS and Private Sector providers to work in partnership to deliver care to patients.
IT access between NHS and private sector providers can be achieved both physically through N3 connectivity, and legally through information and clinical governance checks and adherence to set organisational and national standards. These solutions rely on willingness of IT departments and Information Governance leads to work together with the private sector.
This pilot has demonstrated the feasibility of safely delivering chemotherapy outside hospitals and in patients’ own homes. The pilot also demonstrates that it is possible to work in partnership between NHS and private sector providers to deliver a seamless care pathway for patients.
The pilot highlights the fact that the contracting process, even if supported by financial incentives (CQUIN), is not the only lever for change. Clinical Teams needed active support through meaningful stakeholder engagement and team work (involving commissioners, clinicians and patients) to deliver rapid and sustainable change.
After a difficult start, within six months, five chemotherapy units in three acute Trusts were delivering Herceptin at home to 61 per cent of eligible patients.
The biggest impact of this pilot was on the quality of care for patients. Patients were given a real choice of location and convenience in terms of time of treatment. Patients could opt for home care in the knowledge that their care was being delivered by a team who were fully integrated with the hospital team and that they could return to hospital treatment if unhappy with the home care option. Patients also benefitted from 1:1 nursing care.
The next biggest impact was on NHS staff. Despite the added work involved in offering and supporting patients onto the home care pathway, chemotherapy nursing staff and pharmacists were happy to work in partnership with the Health Care at Home staff. A culture of mutual respect and trust grew out of the local team working to deliver the pilot. As a result of the pilot, all three Trusts established a range of materials, protocols, IT solutions, governance frameworks on which to base future home care services. Capacity pressures within chemotherapy units were relieved.
Finally there was a significant financial advantage to Trusts in achieving the CQUIN targets and to commissioners in realising the £660k QIPP target.
The partnership with Health Care at Home continued through to 2012 when Trusts were able to develop local home care services or put the service out to tender.
The project steering group received a monthly report which identified the number of patients that were clinically suitable to receive Herceptin at home; the number expressed as a percentage that opted for home care. This was segmented by Trust.
REASONS FOR NOT CHOOSING HOME CARE
The monthly report also included an analysis of the reasons given for not choosing the home care option – to identify trends and address concerns to encourage uptake if appropriate.
A survey of all home care patients was undertaken to ensure patients were satisfied with the home care option. The level of satisfaction was extremely high and patients who opted for home care found it the most convenient.
Although a lot more work was required on the part of NHS Staff to identify and support patients on the home care pathway, there was positive feedback from NHS staff regarding the pilot and the choice this gave to women.
Although not part of the pilot evaluation, the Trusts involved in the pilot did satisfy the CQUIN requirements and receive the associated payment.
Commissioners did achieve £660k QIPP savings, which were reinvested in cancer services. The savings were developed through reduced drug wastage, reduced VAT and lower overhead costs of the homecare system.
Programme Lead for Cancer and HIV
Midlands and East Specialised Services Commissioning Team