Saving costs, saving lives, improving healthcare in the UK – the economic case for early diagnosis

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Introduction

Early detection and diagnosis of disease aims to prevent unnecessary pain, suffering and in some cases permanent disability or death by ensuring effective treatment and intervention. It is better medicine, and makes better economic sense. The change of Government and current NHS reforms, in particular, the proposed changes to commissioning, have distracted the attention of many in the NHS, and have resulted in a degree of inertia. This is likely to undermine the implementation of important changes to clinical care pathways that have been widely acknowledged as necessary if the NHS is to serve patients better. A key requirement in many of these pathways is the need for earlier diagnosis. During the last 12 months, many will have been newly-diagnosed with a disease requiring costly intervention and treatment. In England: some 255,000 people will have been diagnosed with cancer; 100,000 will have suffered a stroke and 20,000 a Transient Ischemic Attack; and some 26,000 will be newly diagnosed with rheumatoid arthritis. For many of these, earlier diagnosis could have led them to improved outcomes at a reduced severity, scale and cost of medical intervention. It is critically important that the focus on reform and the uncertainty it is causing among healthcare professionals does not distract from implementing innovation and good practice. Regardless of where responsibility for commissioning services lies, patients will continue to go to surgeries, walk-in-centres and A&E, with acute or chronic symptoms and concerns about their health that need addressing. Early and accurate diagnosis can make an enormous difference, but all too often, as the case examples in Annex A show, diagnosis is late and the interventions and treatment needed are consequently more aggressive, more costly and have poorer outcomes. This briefing highlights the rationale for early diagnosis, which can improve patient outcomes and make more cost effective use of NHS resources. By raising awareness among parliamentarians, we are seeking your help in putting earlier diagnosis where it needs to be: at the forefront of NHS care. Early, accurate diagnosis: better for patients, better for the NHS Whatever their concern, a lump, a new or persistent pain, unusual bloating or bleeding or a general feeling of being unwell, patients need the reassurance that comes with an accurate diagnosis. Academic research asserts that the earlier the diagnosis and the quicker and more targeted the treatment, the better the outcome for the patient. Even in cases where the prognosis is not good, the sooner this can be acknowledged and personal plans made, the better for patients and their families and carers. Yet successive external reviews over the past 10 years, by organisations like the National Audit Office (NAO) and the Kings Fund, have shown that, for far too many people, diagnosis is too slow and can result in much higher financial and nonfinancial costs, to patients, their families, the NHS and the taxpayer. These external reviews, which are underpinned by a strong body of clinical research and related evidence, support the economic case for early diagnosis. Despite being acknowledged in various national strategies and in the National Institute of Clinical Effectiveness guidance, in too many individual cases, lack of awareness by the patient, low confidence and limited expertise of the GP and difficulties accessing diagnostics and treatment, all mitigate against

Early, accurate diagnosis: better for patients, better for the NHS

Whatever their concern, a lump, a new or persistent pain, unusual bloating or bleeding or a general feeling of being unwell, patients need the reassurance that comes with an accurate diagnosis. Academic research asserts that the earlier the diagnosis and the quicker and more targeted the treatment, the better the outcome for the patient. Even in cases where the prognosis is not good, the sooner this can be acknowledged and personal plans made, the better for patients and their families and carers. Yet successive external reviews over the past 10 years, by organisations like the National Audit Office (NAO) and the Kings Fund, have shown that, for far too many people, diagnosis is too slow and can result in much higher financial and nonfinancial costs, to patients, their families, the NHS and the taxpayer. These external reviews, which are underpinned by a strong body of clinical research and related evidence, support the economic case for early diagnosis. Despite being acknowledged in various national strategies and in the National Institute of Clinical Effectiveness guidance, in too many individual cases, lack of awareness by the patient, low confidence and limited expertise of the GP and difficulties accessing diagnostics and treatment, all mitigate against early diagnosis. The UK has a sound record of innovation, but we lag behind many countries in the systematic uptake of even our own inventions. The NHS Institute for Innovation and Improvement and the NHS Innovations Council promote the development and sharing of good practice. Innovation and good practice are also put forward in national strategies, such as those for cancer, stroke, heart disease and dementia. However, as noted by Lord Darzi in his 2008 review and highlighted in the Department of Health‟s current Quality Innovation Productivity and Prevention challenge, too often these fail to be widely adopted. The NAO‟s 2010 report on The Management of NHS Productivity found that implementing good practice is seldom comprehensive or consistent within a whole hospital, and that innovation is often not adopted because of a lack of evidence or scepticism about the costs and benefits. New technologies exist to detect cancers earlier. Advances in techniques for breast cancer screening can pick up tumours much earlier and new therapies can deliver more targeted treatment. Likewise, for heart disease, early diagnosis with new scanning technology can help detect blockages before they do too much damage, reducing the risk of progression and helping prevent more serious disease. For stroke, rapid access to brain imaging and early treatment with thrombolytic drugs has huge benefits for patients and, as stated by Professor Roger Boyle the National Director for Heart Disease and Stroke, “can be the difference between long-term paralysis and walking out of the hospital after a few days”. Yet our slow adoption of new technologies and treatment pathways means our outcomes continue to lag behind those elsewhere. The Kings Fund report “How to improve cancer survival: Explaining England’s relatively poor rates” shows that, more than 10 years since the NHS Cancer Plan set a national imperative to improve cancer services; the UK still has worse rates of cancer survival than many other comparable countries. The report concludes that this is due largely to the stage of cancer at diagnosis and delays in diagnosis and treatment. It recommends the need for diagnosis at an earlier stage, including use of effective screening programmes and access to optimal treatment.

Conclusion

Commissioners are currently in survival mode. Whichever form commissioning groups eventually take, there is a need to ensure that they clearly grasp and act upon the advantages of early diagnosis to both patients and to the economics of the healthcare system. If the reformed NHS is to deliver improved patient care with improved outcomes, there needs to be investment in early diagnostic tools underpinned by modern IT systems to deliver diagnostic information more rapidly, accompanied by earlier treatment using more precise therapies. Such a focus should go a long way towards ensuring our country catches up with the performance of the best. Costs should not be seen as a barrier, rather as an investment, as earlier diagnosis improves health outcomes and is more cost-effective. The longer the NHS prevaricates, the greater the number of people that will be diagnosed late and the poorer the outcomes for the patient, the NHS and the country. The central tenet of the NHS reforms is “No decision about me, without me” without an early and accurate diagnosis any such decisions are likely to be flawed.

Earlier diagnoses of cancer can save some 10,000 lives

Situation: Survival varies by type of cancer and, for each cancer, by a range of factors such as age, sex, treatment received and stage of disease at diagnosis. UK survival rates for cervical, colorectal and breast cancer remain amongst the worst in Europe as stated by the Organisation for Economic Co-operation and Development (OECD). The National Awareness and Early Diagnosis Initiative launched in November 2008, estimates that up to 10,000 deaths could be avoided per year in England by bringing survival rates up to the best rates in Europe. Economic modelling, of the impact of earlier detection and diagnosis shows that in general earlier diagnosis is cost-effective, but not necessarily cost-saving with increases in testing costs, generally offset by a modest reduction in treatment costs, the main benefit however is a substantial improvement in health outcomes. Source: National Audit Office Report: Delivering the Cancer Reform Strategy (November 2010) and Kings Fund Report: How to improve cancer survival: Explaining England’s relatively poor rates (May 2011)

Early Diagnosis of Rheumatoid arthritis can substantially reduce the damage caused and enable people with the disease to be economically active for longer

Rheumatoid arthritis (RA) attacks joint tissues and delayed treatment causes the joint to lose shape and alignment, and eventually be destroyed completely. Three quarters of people are first diagnosed when of working age and a third will have stopped working within two years of onset with around half unable to work within ten years. . Prompt early diagnosis and treatment can limit progression of the disease. Treating 20 per cent of people within 3 months of onset (compared to the current figure of 10 per cent) whilst initially increasing treatment costs to the NHS by £11 million over five years would result in productivity gains of £31 million for the economy due to reduced sick leave and lost employment. This would also increase quality of life by four per cent over the first five years, Source: National Audit Office Report: Service for people with rheumatoid arthritis (15 July 2009)

Early diagnosis of dementia allows more to be done to delay progression of the disease and help people to remain independent for longer

The number of people with dementia in England is expected to double within 30 years, and estimated costs are expected to increase from £15.9 billion in 2009 (of which around £8.2 billion are direct health and social care costs to £34.8 billion by 2026. Early diagnosis and intervention in dementia is cost-effective as it enables more to be done to delay progression of the disease, yet there is a significant diagnosis gap and only a third to a half of people ever receives a formal diagnosis. UK performance in the provision of anti-dementia drugs is in the bottom third in Europe, and the average time to diagnosis is up to twice as long. A clear diagnosis can also reduce the number/length of acute hospital episodes and delay the need for admission to more expensive long-term care. Efficiency savings of at least £284 million a year could be realised immediately, dependent on the widespread adoption of good practice in diagnostics and treatment. Source: National Audit Office reports: Improving Dementia service in England: An interim report (14 January 2010) and Improving Services and support for people with dementia (4 July 2007)

More responsive early diagnosis of stroke and treatment on a stroke unit reduces disability and death and saves money

The direct care costs of stroke are at least £3 billion annually, with a wider economic cost of about £8 billion. Around one in four people who have a stroke die of it and half of stroke survivors are left dependent on others for everyday activities. Treatments such as thrombolysis, can represent the difference between being severely disabled and making an almost complete recovery, but can only be administered within a few hours of the onset of symptoms. A mini-stroke or Transient ischaemic attack (TIA), significantly raises the risk of having a stroke and requires rapid investigation in a specialist neurovascular clinic. The costs are outweighed by the benefits in terms of prevented strokes, with savings of around £600 per patient assessed and treated. Improving the organisation of stroke services reduces stroke patients‟ chances of dying and the reductions in death and disability (quality-adjusted life years – QALY) can be substantially improved at an incremental cost-effectiveness ratio of £5,500 per QALY.

Heart disease is still a “big killer” in the UK due to late diagnosis.

Around 2.6 million people in the UK are living with coronary heart disease (CHD), and it kills more than 110,000 people a year, of whom more than 41,000 are under the age of 75. CHD accounts for about 3% of all hospital admissions in England with direct costs to the NHS of £3.3 billion per year and total costs (including loss in productivity and informal care) of almost £9 billion per year. Investment in new technologies has led to significant improvements in outcomes with death rates from heart disease falling as the number of people receiving cholesterol- and blood pressure-lowering drugs is increasing steeply. Now, no one waits more than three months for heart bypass surgery and treatment of acute chest pain, responsible for around 700,000 patient attendances per year, has improved due to the introduction to emergency departments of a reliable point of care (POC) test preventing as many as 500,000 hospital admissions a year by allowing earlier diagnosis and earlier discharge. Now, over 70% of people with heart attack symptoms are treated with thrombolytics („clot-busting‟ drugs) within 60 minutes of calling for help, compared with 24% in 2000.