Health CommitteeWritten evidence from Baxter Healthcare (LTC 41)

Baxter Healthcare welcomes the opportunity to respond to The Health Committee’s examination of the way in which the NHS and social care system in England supports people with long-term conditions.

Baxter is a worldwide, diversified healthcare company that is known for applying innovative science and technology to develop specialty therapeutics, medical products and services that save and sustain patients’ lives. Our core purpose is to improve the quality of life of patients with rare and chronic diseases. From hospital to home, we strive to deliver better and more affordable healthcare for people worldwide.

The committee has asked following questions and our responses are below.

The Scope for Varying the Current Mix of Service Responsibilities so that more people are Treated Outside Hospital and the Consequences of such Service Re-Design for Costs and Effectiveness

There is huge scope for enabling more people with long term conditions to be treated outside of the hospital environment. Despite a wealth of evidence to support both clinical and cost effectiveness of home based therapies, uptake for many diseases is poor and is in fact declining in certain parts of the UK. In particular, the use of Peritoneal Dialysis (PD) and home Haemodialysis for the treatment of chronic kidney failure is at an all time low, despite a plethora of guidelines, evidence and quality standards supporting its use.1 2 3

In addition to the treatment of chronic kidney failure, there are many other conditions that lend themselves to home or self-care treatment. These include parentral nutrition for patients who have intestinal failure, outpatient parenteral anti-microbial therapy (OPAT) and immunoglobulin therapies (IG) for people suffering from immunological disorders.

One of the reasons for the decline in the uptake of home dialysis is thought to be the overestimation of the need to increase in-centre haemodialysis capacity4 which has resulted in a proliferation of centre based dialysis facilities throughout the UK. Once a centre has been commissioned, it is incumbent upon clinicians and managers to keep the facility working at capacity to ensure cost effectiveness. However, decommissioning of such services and re-allocating staff to support home dialysis patients would greatly improve the ability for more people to be treated at home.

As well as the many quality of life benefits and improved outcomes that patients report by being on a home based treatment it also generates cost savings.5 With the current focus by the NHS on QIPP, to improve patient outcomes and generate cost savings these forms of treatment need to be fast tracked and implemented on a more substantial scale so that the full benefits can be realised by patients and the NHS alike.

Another strategy that will aid the uptake of self care or home treatments is patient education, training and empowerment. Raising awareness of the availability and success of home based therapies amongst patients and the public can promote their use. This requires the commitment of all those involved in the design and delivery of services, including the physicians and nurses who discuss treatment options with their patients. High quality training and education of patients and their families before commencing and during their time on home based treatments will also improve patients’ adherence to treatment regimes and thus promote clinical and cost effectiveness of treatments.

The Readiness of Local NHS and Social Care Services to Treat Patients with Long-Term Conditions (Including Multiple Conditions) within the Community

Uptake of home or community based treatments varies considerably across the UK. Our experience shows that in areas where there is a belief and culture in home therapies from both clinicians and commissioners, uptake is higher. In areas where there is a lower level of belief, barriers from social care services tend to become more difficult to overcome.

The IT infrastructure that can support the treatment of patients in the community is still weak. Anecdotally, there is resistance to the uptake of remote monitoring systems due to potential liability issues on the part of the clinician. If the appropriate IT capabilities were available to enable clinicians to have remote oversight of the patients’ clinical condition, reassurance (that the patient can be managed as well outside the acute setting as within hospital) could be provided to all parties.

The Practical Assistance Offered to Commissioners to Support the Design of Services which Promote Community-Based Care and Provide for the Integration of Health and Social Care in the Management of Long-Term Conditions

To our knowledge there is very little available for commissioners to promote or support the design of services for home based therapies or to further integrate health and social care services.

We believe that should such support be made available, the uptake of home treatments for long term conditions could see an increase. The recent changes to the NHS in England, and in particular the commissioning of specialist services, has led to a relatively small number of commissioners being given responsibility for a much wider scope of specialist services. Their task of being fully informed on all available treatment options for the full range of diseases within their remit is therefore made even more erroneous. Many of these rare diseases frequently co-exist with a range of other long term conditions and patients would benefit enormously from self care and home care being offered.

The recent production of specialist commissioning service specifications should help with this, however the quality of these is variable and work needs to be done to ensure that they are consistent in approach.

The development of CQuINS should also help commissions to drive innovation and develop services for patients at home. However uptake of specific home therapy based CQuINs varies and is not yet mandatory.

It is essential that commissioners become fully engaged with Health and Wellbeing Boards to ensure a full understanding of the social care barriers that need to be addressed.

The Ability of NHS and Social Care Providers to Treat Multi-Morbidities and the Patient as a Person rather than Focusing on Individual Conditions

Baxter is not in a position to comment on this question however we would encourage the development of a simple mechanism for regular feedback from patients groups, individual patients and others to monitor this closely.

Obesity as a Contributory Factor to Conditions Including Diabetes, Heart Failure and Coronary Heart Disease and how it might be Addressed

Baxter is not in a position to comment on this question.

Current Examples of Effective Integration of Services Across Health, Social Care and other Services which Treat and Manage Long-Term Conditions

Baxter has a number of examples of good practice with effective integration of services to treat and manage long-term conditions. The concept of shared fields of practice, of which home dialysis is one example, requires collaboration and equity among health care professionals to ensure that the impact of change is for the benefit of the patient.

Automated Peritoneal Dialysis (APD) is a home-based therapy usually carried out by patients themselves. Training takes place in a renal unit or specialist training centre in all aspects of care. The parent unit regularly follows up patients either in clinic or in the community. However, many patients with end-stage renal disease are unable to undertake peritoneal dialysis (PD) on their own, yet would prefer treatment in their own homes. In particular, the majority of elderly patients are on the hospital based treatment, haemodialysis (HD) despite the problems and costs of transport, achieving vascular access and, often, poor tolerance of the HD process. To address this problem, assisted PD using community Healthcare Assistants has been developed. Healthcare assistants visit the patient’s home once a day to check the previous day’s treatment, check the patient’s wellbeing and set up the dialysis for the next treatment. The healthcare assistant is trained to observe for a range of sign and symptoms and to call the patient’s parent renal unit should they have concerns.

This system has been operating in the UK for almost six years and seen great success. Over 250 patients are currently using the service which represents almost 10% of the PD population, all of whom would not be able to have a home based treatment if the service was not available. The system required collaboration and team work between the NHS renal unit, the home care provider and the nursing support organisation to enable seamless high quality care.

The Implications of an Ageing Population for the Prevalence and type of Long Term Conditions, together with Evidence about the Extent to which Existing Services will have the Capacity to meet Future Demand

The implications of an ever increasing elderly population will inevitably impact on the prevalence and type of long term conditions experienced. In many long term disease areas, as treatments improve, patients live for longer and thus are susceptible to a greater number of co-morbidities. For example people with the bleeding disorder haemophilia, would have an average survival of 15 years if born in 1960, whereas today they have a normal life expectancy as techniques such as prophylaxis are now used to better manage their condition. In addition, treatments for long term diseases are now offered to older patients than previously. Thus, more patients are being treated for more diseases with more treatments than before.

Capacity planning therefore needs to be much more holistic than in the past, and consider all available locations for care. Integration between primary, secondary, community and social care needs to be factored into capacity planning and the use of home care considered for a greater proportion of patients.

Remote monitoring systems and electronic health records should be considered as integral to the support of patients and these must be accessible to patients as well as clinicians in both primary and secondary care.

Currently there are many perverse financial incentives that exist, preventing the uptake of home treatments. Frequently the acute hospital is financially penalised for moving care out of the hospital setting, despite home treatments being clinically effective and more cost effective and than in-centre alternatives. One example of this is the use of outpatient anti-microbial therapy (OPAT) for the treatment of multi-resistant TB.

The Interaction between Mental Health Conditions and Long-Term Physical Health Conditions

Baxter is not in a position to comment on this question.

The Extent to which Patients are being offered Personalised Services (Including Evidence of their Contribution to Better Outcomes)

Baxter is not in a position to comment on this question however we would encourage the development of a simple mechanism for regular feedback from patients groups, individual patients and others to monitor this closely. The regular use of patient reported outcome and experience measures should become routine practice.

9 May 2013