A Tariff for Innovation

It’s one thing to innovate. It’s another to spread that innovation across the NHS and that’s exactly what a new tariff system could do, says Tara Donnelly

A new tariff came into play in April this year and for the first time we have a payment scheme to encourage the spread of innovation within the NHS. This is significant, laudable and we need to do everything in our power to ensure that we make the most of the opportunity. Even better, the focus of the tariff in its first year is innovations that make hospital care safer.

Most of the devices that are eligible for the tariff have been developed by innovative clinicians who saw opportunities to improve care – making it safer and more effective.

Dharmesh Kapoor, a consultant obstetrician at Bournemouth Hospital invented scissors that make childbirth safer; Maryanne Mariyaselvam, a doctor in training working in research in Addenbrookes, came up with a device that prevents tragic accidents with blood lines; Peter Young, a consultant anaesthetist at King’s Lynn Hospital created a ventilation tube that prevents the most serious complication of ITU care; Simon Bourne, a consultant respiratory physician at Portsmouth Hospital devised myCOPD an online platform that helps patients self-manage with dramatic results; Robert Porter, a consultant microbiologist at Queen Alexandra Hospital has developed a treatment that cures Clostridium difficile through faecal transplantation.

Accelerating the uptake of innovation

We should be proud that as a country we are not only inventing these superb devices, we are also designing systems to help accelerate their uptake. NHS England’s Innovation and Technology Tariff (ITT) enables NHS Trusts in England to use these patient safety innovations either for free, or to claim a charge per use.

The 15 AHSNs have lobbied for a tariff to support innovation for some time, and it was the NHS Innovation Accelerator – a national programme supported by all 15 AHSNs – which was a key influencer in its development. The AHSNs therefore are delighted with this development, and are working to support uptake of these innovations within their geographies.

Obstetric Anal Sphincter Injuries (known as OASIS) during childbirth is the leading cause of faecal incontinence in women in the UK. It is a devastating injury, requiring surgical repair, with 30% of women having some level of symptoms a year later. OASIS costs the NHS approximately £57 million annually in repair and litigation costs and is on the rise. Dharmesh developed guided mediolateral episiotomy scissors, known as EPISCISSORS-60 that minimise the risk of obstetric injury, they are set to 60 degrees, the optimal angle to avoid serious injury. A number of studies have proven their efficacy.

Maryanne’s non-injectable arterial connector (the NIC) enables conventional arterial line sampling for patients in theatre or intensive care with the huge bonus that it is not possible to accidently inject medicine into it. This prevents wrong route drug administration, which, while rare can have terrible consequences including in the most extreme circumstances, amputation.

Peter’s PneuX invention has also been proven in studies to reduce the rate of ventilator acquired pneumonia (VAP). In its guidance, NICE quotes a plethora of studies including a recent UK randomised control trial which found that PneuX tube halved the rates of VAP after cardiac surgery from 21% to 10.8% patients. Bearing in mind VAP has a 30% mortality rate this is very good news, and would mean many more ITU beds available across the NHS.

Chronic Obstructive Pulmonary Disorder or COPD is the second most common reason for hospital admissions in the country costing the NHS over £800m in direct healthcare costs. Studies have also found that 90% people with COPD are unable to take their medication correctly. Simon’s support system known as myCOPD, has educational, self-management, symptom reporting and pulmonary rehabilitation aspects, all delivered online.

Robert’s innovation helps people with Clostridium difficile, a serious bacterial infection affecting the digestive system, who have a one in six chance of dying within 30 days. Antibiotics are the first treatment and cure the condition in many cases. But for a proportion – about 20 per cent – antibiotics do not work. A frozen microbiota transplantation will cure 90% per cent of these patients.

UroLift is an alternative surgical procedure for the treatment of the common condition of benign prostatic hyperplasia, where the enlarged prostate makes it difficult for men to pass urine, leading to urinary tract infections, urinary retention, and in some cases renal failure. It is considerably less traumatic than existing surgical treatments.

Guidance on the new tariff

Guidance came out from NHS England recently, circulated to Finance Directors. However it will be important to others such as CEOs, COOs, Medical, Nursing, Midwifery and Clinical Directors, Operational Managers and Patient Safety leads are aware so that high rates of uptake can be achieved quickly.

We have in the past bemoaned that the NHS doesn’t support clinical entrepreneurs, and that the period between discovery of an innovation and its widespread uptake at the often quoted time of 17 years is too long.

Here we have a handful of fantastic inventions that improve safety and reduce cost, devised by UK clinicians who have been hugely supported by the NHS to date. Increasing uptake is now down to all of us. What about getting over 50% uptake in 17 months instead of 17 years? Are you up for ITT?

Accelerating Access

The NHS has huge potential to be creative and innovative yet the system as a whole is slow to adopt innovation and best practice. Academic Health Science Networks – AHSNs – exist to speed up this process, to improve patient care and reduce system inefficiencies.

We act as honest brokers within our region, mobilising expertise and knowledge across the NHS, academia and industry to help improve lives, save money and drive economic growth through innovation. Our regional partnerships are helping to deliver system transformation locally, described by the Five Year Forward View. As 15 AHSNs we work together in ways unprecedented across health and care, delivering improvement at pace and scale. This is having real impact through our collective work including the successful NHS Innovation Accelerator – now reaching 388 organisations within the NHS – Patient Safety Collaboratives and the Innovation Pathway; improving health and driving economic growth.

The latest work to recognise the unique role that AHSNs can play is the Accelerated Access Review, (AAR). This was an independently chaired review of innovative medicines and medical technologies, led by Sir Hugh Taylor and supported by the Wellcome Trust and the Office of Life Sciences, which published its final report in late October 2016.

It contains a series of recommendations to the NHS, which will need to be properly considered by NHS England and others, but encouragingly, the report contains a letter from Simon Stevens, where he commits: “We’ll support the AAR’s streamlined pathway to identify high value innovations. We’ll then help pull them through into mainstream care – building on our AHSNs, innovation testbeds, and our new Innovation and Technology Tariff. And where it makes sense, we’ll be increasingly open to agreeing innovative win/win product-specific reimbursement models …” (Taylor, 2016, p.10).

The report outlines how the UK can make far more of its Life Sciences and research expertise, speed up clinical trials and subsequent endorsement and adoption of new drugs, medical devices and digital technologies. The AAR’s approach is shown in Figure 1, below.

It also considers the lessons learnt from when we have got this right, the triumph of the speed of development and dissemination relating to Ebola is rightly highlighted as a fine example of this, with the MHRA’s Clinical Trials Unit fast tracking Ebola studies, Expert Advisory Groups and trial sponsors.

Figure 1: A summary of the Accelerated Access Review’s proposed approach (Taylor, 2016, p.14, reproduced with permission)

The report is well worth a read and is available here. From the 70 pages I’ve précised the top 10 areas for AHSNs and summarised these.

Accelerated Access Top 10 Changes for AHSNs

Key changes for us from the review include:

1	Strengthening of remit: The report calls for “A new mandate for AHSNs should support the local spread of adoption and enable as standard framework for local evaluation” (Taylor, 2016, p.50). It is described as a “new, strengthened remit for AHSNs” (Taylor, 2016, p.50) and that AHSNs – among others – will “drive and support the evaluation and diffusion of innovative products” (Taylor, 2016, p.12).
2	Clarity of role through a Charter for Innovation Support: “AHSNs, with their existing local networks that include NHS providers and commissioners, academia and industry, should play a vital role in supporting the testing and diffusion of technologies in the NHS. This role should be set put in a new charter with input from NHS England and NHS Improvement which clearly articulates what is expected from AHSNs and enables them to be held to account for local delivery” (Taylor, 2016, p.50).
3	Strengthening of our National Network of 15 AHSNs: The offer to innovators will include “access to a strengthened AHSN network which can facilitate local evidence-collection and adoption of innovation” (Taylor, 2016, p.13).
4	Better funding: AHSNs should be funded to a level that allows them to fulfil the role outlined in this report (Taylor, 2016, p.51), and there follows a recommendation to provide between £20million and £10million to AHSNs baseline budgets from 2017.
5	Providing capacity: the review proposes an additional role for AHSNs in providing capacity and capability locally to NHS organisations who require it, in order to make the most of new innovations. This new role would require funding of around £30million a year, and there is a suggestion that AHSNs that are able to generate match funding through working with charities or industry partners could access these resources (Taylor, 2016, p.52).
6	Creation of Innovation Exchanges: AHSNs should galvanise and support local innovation partners to create a network of “innovation exchanges” responsible for diffusing clinical and cost effective technologies across the system” (Taylor, 2016, p.50).
7	Supported more strongly: We also recommend that NHS Improvement plays a greater role in leading AHSNs, including supporting them to undertake these activities (Taylor, 2016, p.51).
8	Link to Test Beds: AHSNs have been supporting the national Test Bed programme where combinatorial innovation is being explored. The Test Bed we support in the London Test Bed, CareCity, which is bringing together technologies to keep people with dementia as safe as possible. “AHSNs should build on their current involvement in the Test Beds programme by using this learning for their own evaluation role and seeking to collaborate to promote mutual recognition of local evaluations using the national framework” (Taylor, 2016, p.51).
9	Testing and dissemination: AHSNs are noted to be “ideally placed to play a role in post-CE mark testing and dissemination of medical technologies, diagnostics and digital products in particular” (Taylor, 2016, p.51).
10	Horizon scanning: In Digital Health AHSNs are seen to have a key role in the earliest stages where “AHSNs identify unmet needs” at the ideas generation and identification phase (Taylor, 2016, p.26).

The following figure shows how the AHSN Network will embed within the system to enable speedier spread and uptake of innovation.

Figure 2: Local and national spread of innovation (Taylor, 2016, p.51, reproduced with permission)

At the Health Innovation Network we, along with colleagues across the other 14 AHSNs, warmly welcome the Accelerated Access Review and are keen to progress its findings at scale and pace, to speed up the best in health and care, across the country.

 

Reference
Taylor, H. (2016). Accelerated Access Review: Final Report. Department of Health, available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/565072/AAR_final.pdf