HC 1048-III Health CommitteeWritten evidence from Roche Products Ltd (PH 176)

1. About Roche

Roche is a leading manufacturer of innovative medicines, including in oncology, rheumatology and virology. We closely with organisations to improve the quality and efficiency of NHS services, including the Department of Health, NICE, patient and professional organisations, NHS commissioners and providers of care.

Roche aims to improve people’s health and quality of life with innovative products and services for the early detection, prevention, diagnosis and treatment of disease. Part of one of the world’s leading healthcare groups, Roche in the UK employs nearly 2,000 people in pharmaceuticals and diagnostics. Globally Roche is the leader in diagnostics, and a major supplier of medicines for the treatment of cancer, transplantation, virology, bone and rheumatology, obesity and renal anaemia.

Roche has a heritage in working with NHS organisations to translate information about health service delivery into intelligence on how services can be improved, and on into action to improve the quality of care provided to patients.

2. The Creation of Public Health England within the Department of Health

2.1 Roche supports the establishment of Public Health England within the Department of Health. This national body should ensure that there is sufficient oversight of public health issues and a means to ensure joint working across the NHS, public health and social care services.

2.2 Public Health England should play a role in ensuring that a proportion of the public health budget is spent by local authorities on information campaigns such as those on bowel, breast and lung cancer which are currently being piloted. It should also provide advice on the type of awareness campaigns that could be undertaken in areas of high prevalence of a condition such as hepatitis C.

2.3 Public Health England will also be responsible for screening programmes. It should take a lead in improving participation in existing programmes and ensure that screening hubs are able to implement new programmes as soon as evidence supports it. This should include technologies such as flexible sigmoidoscopy for bowel cancer for which the evidence exists and lung cancer screening if the pilot shows that this system is proven to work.

2.4 Roche welcomes the proposal to publish data on public health outcomes by Public Health England— this will allow benchmarking between providers and a mechanism to drive up performance. Roche has a history of collecting and analysing data on areas relevant to our markets and we would welcome the opportunity to share this data to encourage public health providers to improve their performance and target areas where people are being disadvantaged with poorer public health outcomes.

3. The Abolition of the Health Protection Agency and the National Treatment Agency for Substance Misuse

3.1 Roche is concerned that the abolition of the Health Protection Agency may impact negatively on the collection and analysis of data on key public health areas such as pandemic influenza and hepatitis C. Measures should be taken to ensure the transfer of data and responsibilities is smooth and that no expertise is lost.

4. The Public Health Role of the Secretary of State

4.1 It is welcome that the Secretary of State has a specific role to protect the health of the nation. His specific responsibilities should include:

4.1.1Ensuring that the ring-fenced public health budget is used on measures that are linked to clear health improvements such as awareness campaigns for bowel cancer, hepatitis C and rheumatoid arthritis and targeted screening programmes for cancer and hepatitis C.

4.1.2Ensuring that the activities of Public Health England, the NHS and social care are effectively coordinated so that services that span the three services such as cancer, hepatitis C and rheumatoid arthritis are streamlined and deliver the best outcomes for patients

4.1.3Ensuring that measures in the Public Health Outcomes Framework are coordinated with the NHS and social care outcomes frameworks and focused on real health outcomes such as the proportion of patients diagnosed at Stage 1 or Stage 2 cancer and a reduction in mortality from liver disease

5. The Future Role of Local Government in Public Health (including Arrangements for the Appointment of Directors of Public Health; and the Role of Health and Wellbeing Boards, Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies)

5.1 Alignment across Public Health, adult social care and the NHS is vital if we are to improve outcomes across the health service. Directors of Public Health should take a lead in ensuring that local government focuses on measures that have a tangible public health impact.

5.2 Health and wellbeing boards will be very important to ensuring that services are joined up. These boards should include input from experts in the delivery of services such as cancer networks, the voluntary sector and patients.

5.3 Where necessary, there should be joint performance measurement across the NHS, public health and social care as some of these interventions will require high quality commissioning from more than one commissioner. For example, early diagnosis may involve awareness (public health), screening (public health), primary care diagnostics (NHS) and secondary care investigation (NHS). Therefore it will be important to develop joint commissioning outcome indicators which can be shared at a local level.

5.4 National outcomes strategies such as the Liver Strategy, which is currently in development, provide a real opportunity to ensure joint working as they will set out how the different parts of the health service should work together. This has already been demonstrated in Improving outcomes: a strategy for cancer which underlined the importance of joint- working between the NHS, public health and social care services in improving outcomes. The Department of Health should also prioritise the development of an outcomes strategy for musculoskeletal conditions to ensure seamless delivery of these services.

5.5 Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies should take into account the needs of the local population in order that services can be directed in an appropriate manner. Some areas of the country have a higher prevalence of hepatitis C for example. In these instances, there should be some kind of measurement available that will ensure that these strategies focus on measures that will offer real public health benefit such as targeted awareness and screening campaigns. It is vital that resources are appropriately directed and not spent on more general areas of local authority funding streams.

6. Arrangements for Public Health Involvement in the Commissioning of NHS Services

6.1 Health and wellbeing boards should work to ensure that specific public health expertise within a local area are consulted on. On issues relevant to bowel cancer, the cancer networks should be included in discussions around commissioning. The voluntary sector should also be consulted as they have a wealth of information about the needs of the people that they represent.

6.2 Health and wellbeing boards should also consult people in the local area that run services relevant to public health. This could include pharmacies that have the capability of supporting testing for hepatitis C and signposting patients to their GP if they display symptoms of more serious conditions. It could also include drug treatment programme managers that may have expertise in identifying patients at risk of contracting blood borne viruses such as hepatitis C.

7. Arrangements for Commissioning Public Health Services

7.1 Coordination will be key to commissioning effective public health services. Some public health interventions will require high quality commissioning from more than one commissioner. For example, early diagnosis may involve awareness (public health), screening (public health), primary care diagnostics (NHS) and secondary care investigation (NHS).

7.2 Early diagnosis is vital across all disease areas and should be the aim of every provider and commissioner. This includes cancer where Cancer Director Professor Sir Mike Richards has pointed to England’s poor diagnosis rates for cancer as one of the reasons that England lags behind its European counterparts on cancer survival. For conditions such as hepatitis C, diagnosing the condition not only allows patients to be offered effective remedial treatment but it also means that these patients can be given advice on how to avoid the spread of the virus.

7.3 Joint working is vital to ensure that capacity planning is accurate—there is no point undertaking an awareness campaign for hepatitis C if there is no capacity in the NHS to undertake testing and to instigate treatment.

7.4 Cancer networks should play a key role in coordinating the commissioning of cancer services to ensure seamless care for the patient. This will also ensure that appropriate expertise is available to inform commissioning. It is welcome that future funding for cancer networks has been secured to support the implementation of the reforms to the NHS and public health service. Other clinical networks should be introduced in areas where they will help to ensure that services are integrated and coordinated across public health, NHS and social care—this could include cardiovascular disease and musculoskeletal conditions.

7.5 Where necessary, guidance should be given by Public Health England on the commissioning of public health services. This should help to ensure that local authorities commission services which have a tangible public health benefit. In times when budgets are tight, there is a danger that local authorities will commission initiatives that can be broadly defined as “public health” measures but which will not necessarily lead to improvements in the health of the local population.

8. The Future of the Public Health Observatories

8.1 Public Health England and local authorities will be responsible for the functions of Public Health Observatories and cancer registries. This change in responsibility should allow time for reflection in the timeliness of data collection around cancer.

8.2 Roche has a strong heritage in using data to drive improvements in outcomes—Public Health England should introduce measures that will speed up the publication of data on public health issues. This will support healthcare providers and commissioners to make informed choices about where to target resources and improve outcomes accordingly. In some instances, it may be necessary to develop proxies for outcomes to drive improvements in areas where the public health benefit may not immediately be seen. For example, it may be advisable to record and report on the percentage of patients diagnosed with hepatitis C being offered treatment. These early interventions will ensure that more complex and expensive treatments for chronic disease will be avoided.

8.3 Data on cancer survival, mortality and incidence is reported with a time lag of around four years—this kind of gap should not be acceptable in the age of the Information Revolution. Data collection systems should be streamlined to ensure that data are collected, verified and published as quickly as possible. Local authorities and the local NHS providers, with the support of Public Health England, in conjunction with local authorities, should take a lead in making this happen.

9. The Structure and Purpose of the Public Health Outcomes Framework

9.1 Roche is broadly supportive of the Public Health Outcomes Framework. Measures within the framework should be directly linked to health improvement. Local authority budgets are being reduced and there is a risk that many activities that may be cut could be covered by a public health budget. This will ensure that the Outcomes Framework, Local Authority Public Health allocation, and the health premium contribute fully to health inequality reduction and advancing equality.

9.2 The Outcomes Framework should also encourage partnership working across the NHS and public health. The inclusion of measures that span across both the NHS and public health should support these—these measures include that in Domain 4 patients diagnosed at stage 1 or 2 as a proportion of cancers diagnosed and those in Domain 5 on mortality rate from cancer and mortality rate from chronic liver disease.

9.3 For a condition like hepatitis C, measures that span across the NHS and public health are important as screening and awareness may be the responsibility of the public health service but the treatment and testing will take place in the NHS—coordination will ensure that patients that are identified by the public health service are given the support they need in the NHS to be successfully treated.

9.3.1The Liver Strategy is currently in development and it is important that the measures within the Public Health Outcomes Framework, including the data collected, reflect the aims of the strategy. This trend has already been seen in Improving outcomes: a strategy for cancer.

9.4 The inclusion of a measure on work sickness absence rate in domain 4 of the Public Health Outcomes Framework is welcome. This should ensure that local authorities take into account the wider implications on the economy of measures such as awareness campaigns for RA.

9.5 It is important that the lack of data is not used as an excuse not to focus on an important issue. In these instances, it may be necessary to collect data that have not been previously gathered. This is particularly relevant to hepatitis C where reporting and collection of data is poor.

9.6 Data should be collected at GP consortia level so that it supports local decision making and the NHS Outcomes Framework. In the development of data parameters, it should be borne in mind that all data is potentially comparable and they should be collected in a way that allows this. All information should be disaggregated according to age, gender, at-risk group so that it is possible to focus on specific population levels.

9.7 It is important that the time lag before the long-term benefits of public health measures are seen is considered in relation to indicators within the Framework. For example, for those investing in hepatitis C testing, the benefits on liver mortality may not be seen for a number of years. In the interim period, local authorities may decide to redirect spending in the search for fast results, thus there should be a clear focus on screening or diagnosis rates for hepatitis C within domain 4 as set out above to make sure that the longer-term benefits are achieved.

10. Arrangements for Funding Public Health Services (including the Health Premium)

10.1 Local authority budgets are being cut and there is a chance that activities under threat could be covered by a public health budget. It is important that the funding for public health services is directed at evidence-based interventions that are directly linked to health improvement such as hepatitis C testing among at-risk groups, national bowel cancer screening and awareness programmes for conditions such as cancer, hepatitis C and rheumatoid arthritis.

10.2 In order to maintain a focus on reducing inequalities, there should be measures focused on at-risk groups—for example those with an increased chance of contracting hepatitis C or developing bowel cancer.

11. The Future of the Public Health Workforce (including the Regulation of Public Health Professionals

11.1The public health workforce should be encouraged to be flexible and spread across wide areas of the community including the use of health in the workplace schemes, forging new partnerships across primary care and supporting the implementation of national awareness programmes.

12. How the Government is Responding to the Marmot Review on Health Inequalities

12.1 A greater emphasis should be placed on addressing inequalities – within the public health white paper, there was patchy information on the equality impact assessment for the measures set out in the plans. This suggests that steps to take on board the recommendations from the Marmot Review on health inequalities had not been properly taken on board.

12.2 Initiatives such as the National Cancer Equalities Portal should be encouraged for other disease areas as means to assess data that can identify inequalities in health outcomes. This information should be used to identify areas that require improvement. This portal is an early example of how the principle of the Information Revolution can be applied to a specific disease area. For example, the commitment in Improving outcomes: a strategy for cancer to examine survival, mortality and incidence data by geographical area and to publish one-year survival data is welcome as it will support identification of groups that are more likely to present late.

12.3 Equalities data should be used to support the public health service in introducing targeted campaigns aimed at particular equality groups within their area.

June 2011

Prepared 28th November 2011