Delivering quality of services while using the resources wisely.

1. Presentation Title:
• ‘Delivering quality oncology services
in a constrained financial
environment’

2. 1. WHAT ‘FINANCIAL
CONSTRAINTS’ MEANS?
 1. A average family in developed countries
– Necessities: covered
– Sometimes: struggling with no serious financial
issues
 2. Scale in between:
Rights Duties
All members know an understand the resources
available to them.
All members understand their rights and duties

3. 1. WHAT ‘FINANCIAL
CONSTRAINTS’ MEANS?
 2. A country and hopefully the whole world
must be understood as a “big family” (if this
does not happen, there is no democracy):
Principles:[1]
- Non-Maleficiency
- Justice
- Respect to autonomy
- Beneficence
Values:[1]
- Publicity (transparency)
- Relevance
- Challenge and - Revision
- Regulation
[1]: See footnote below
[1]: Social Value Judgements. Principles for the development of NICE guidance.
Second Edition. (Year 2008).

4. This is a label I found in a Colombian
Court Building (inside the building),
Neiva, Huila (written in Spanish):
“Justicia es dar a cada uno lo que le
corresponde”
This is an English Translation:
“Justice is to give each his due” (The
Republic, Plato)
For the purpose of this presentation, I would like to
add another quotation:
Virtue is in the “middle position” between two
oposite extremes (Nichomachean Ethics,
Aristoteles)

5. 1. WHAT ‘FINANCIAL
CONSTRAINTS’ MEANS?
“Patients need good doctors. Good
doctors make the care of their
patients their first concern: they
are competent, keep their knowledge and
skills up to date, establish and maintain good
relationships with patients and colleagues, are
honest and trustworthy, and act with integrity
and within the law”
GMC, Good Medical Practice, April/2013, N. 1

6. 1. WHAT ‘FINANCIAL
CONSTRAINTS’ MEANS?
 Unacceptable financial constraints
 Acceptable financial constraints

7. 1. WHAT FINANTIAL
CONSTRAINT MEANS?
 Unacceptable financial constraints: this
puts our patients at risk of not
receiving a high quality of care. 
therefore they must be raised [1,2,3]
[1] GMC, Good Medical Practice, April/2013, (N. 56; N. 24 – 25)
[2] GMS, Raising and acting on concerns about patient safety, March 2012
[3] GMC, Leadership and management for all doctors, March/2012 (N. 27)

8. 1. WHAT FINANTIAL
CONSTRAINT MEANS?
 Acceptable financial constraints: they
are a reminder to use the resources
(limit resources) available to us wisely.
[1]
[1] GMC. Leadership and management for all doctors, March 2012 [N. 79- 88]

11. 2. Financial Constraints:
Acceptable vs Unaceptable
How to try to be fair with our patients
 Health Technological Appraisals (HTA)
/ Other systematic and independent
reviews (Regulatory Medicines
Agencies, NICE)
 Regulatory Bodies / Sources of
funding:
– NHS / NICE
– CDF Funding
 Patient advocacy / groups involvement

12. 2. Financial Constraints:
Acceptable vs Unaceptable
How to try to be fair with our patients
 Health Technological Appraisals (HTA)
/ Other systematic and independent
reviews (Regulatory Medicines
Agencies, NICE)
 Regulatory Bodies / Sources of
funding:
– NHS / NICE
– CDF Funding
 Patient advocacy / groups involvement

13. 2.a.
HTA
– Some questions to be answered by HTA:
 Should treatment “A” be reimbursed in a
National Healthcare System? (or be excluded
for implementations of new technologies)
 For which patients?
 For how long?

14. 2.a.
HTA
 Procedural principles of NICE[1]:
– Scientific rigour
– Inclusiveness
– Transparency
– Independence
– Challenge
– Review
– Support for implementation
– Timeless
[1]: Social Value Judgements. Principles for the development of NICE guidance.
Second Edition. (Year 2008).

15. Hello,
My name is…

16. 2. Financial Constraints:
Acceptable vs Unaceptable
How to try to be fair with our patients
 Health Technological Appraisals (HTA)
/ Other systematic and independent
reviews (Regulatory Medicines
Agencies, NICE)
 Regulatory Bodies / Sources of
funding:
– NHS / NICE
– CDF Funding
 Patient advocacy / groups involvement

17. 2.b.
NICE
 Public Agency, Internationally Recognize
 Advice of Clinical Management
 Includes Relevant issues to discuss with
patients regarding of their specific
conditions
 Includes Financial issues (cost effectiveness:
ICER < £30.000 per QALY gained)
 Binding
[1]: Social Value Judgements. Principles for the development of NICE guidance.
Second Edition. (Year 2008).

19. 2.b.
CDF: (only available in England)
A supplementary funding resource
 Label uses of specific medicines
(MHRA; EMA), but...
 Not granted by NICE
 Some of them: granted by CDF
 Subject to review each 4 months,
changes happen (more unstable?)
 What’s happening after 2016?

20. 2. Financial Constraints:
Acceptable vs Unaceptable
How to try to be fair with our patients
 Health Technological Appraisals (HTA)
/ Other systematic and independent
reviews (Regulatory Medicines
Agencies, NICE)
 Regulatory Bodies / Sources of
funding:
– NHS / NICE
– CDF Funding
 Patient advocacy / groups involvement

21. ICF Checklist, Version 2,1ª, Clinician Form for International Clasification of Functioning,Disability and
Health. It covers: Impairments of body functions and structures, activity limitations & Participation
restriction, enviromental factors (including social factors) and other contextual information
2.c.
Patients and Advocacy Groups
– It is the effect of illness and treatment on all aspects of
life that is one of the reasons that evidence from patients
and the public is so important
– Including the patient’s evidence in a way which can be
clearly understood
* There is a tool to translate into medical terms, disabilities
(ICF WHO) [1]

22. Integrating this…

23. Integrating this…
 Understanding Health Techonolgy
Assessment
– Possible values in conflict:
– How to cope with them:
Needs and preferences
of patients
Financial issues
Eficiency
“It is possible to achieve value for money in a health service system, whilst taking
account of the needs and preferences of patients, […] but only through transparent,
systematic processes to which all stakeholders can contribute and in which all
evidence is judged fairly and robustly”.
(Karen Facey Chair, Health Technology Assessment International Interest Group
on Patient/Citizen Involvement in HTA May 2008)
Medical
issues
Social
issues
Economical
issues
Ethical
issues

24. Earlier BSC+Oncol
Treatment vs Oncol
Treatment
NEJM, 2010;363:733
OS (Secondary End-Point)
11,6 vs 8,9
NEARLY +3 MONTHS!!!
SATURN trial (Erlotinib, as
per manteinance,
unselected EGFR status)
Cappuzzo et al, Lancet,2010.
Taken from Future
Oncol,2010;12:1827ss
+ 1,2 Months gained (12,3 vs
11,1).
Not granted by NICE
Not Funded by CDF

25. Conclusions
 Good doctors make the care of their
patients their first concern
 Financial Constraints may be a
reminder that we are dealing with limit
resources
 As we are working for the public,
Justice and Equality must direct our
practice to deliver a high quality of
care.