Q&A with Jeff Featherstone, Head of AMR at the NHS

In a nutshell, the need continues to be in the development of point-of-care tests (POCT) and rapid diagnostics which can support the timely identification of appropriate treatment. Gram-negative infections, especially urinary-tract infections (UTIs), are a current priority focus area. In these cases, the lack of timely, accurate diagnostics can typically lead to the  prescription of antibiotics in advance of a confirmed diagnosis or without confirmation of which bacteria is causing the infection. As the development of Integrated Care Systems comes into place, with integrated care pathways being the norm, there is an opportunity to embed appropriate approaches to UTI management across local pathways. Diagnostics are essential to this being a success. 

This is an area we are currently working on. The biggest issue is not the lack of opportunity for innovation but that it is well-evidenced as cost effective, from the viewpoint of patient and health outcomes, and that the payment mechanisms incentivise such innovation. The revised payment model for new antibiotic treatments which NHS E&I and NICE are currently piloting is an  example of how alternative arrangements could operate, with lessons for the future. 

We are also working with the Accelerated Access Collaborative (AAC) and Academic Health Science Networks (AHSNs) to develop greater strategic alignment with wider AMR priorities. Professor Dame Sue Hill Chief Scientist for NHS England and Improvement recently joined the AAC Board and work has begun to identify barriers to access and adoption of AMR diagnostics by the NHS. This will inform wider work to better support and funding focused on embedding diagnostic innovation.

Our intention is to build upon the current individual workstream-based approach (e.g. separate prescribing, diagnostics, infection prevention & control etc. workstreams) to develop pathway-based workstreams. These would bring different teams together to focus upon improvement across a pathway for a given aspect of AMR. 

A priority is integrating timely diagnostics into an integrated care pathway. The pathways of current focus are UTI (chronic, recurrent and acute), sepsis and, possibly, fungal infections. 

The priorities are built around the National AMR Plan ambitions of:

• halving healthcare associated Gram-negative bloodstream infections;
• reducing the number of specific drug-resistant infections in people by 10% by 2025;
• reducing UK antimicrobial use in humans by 15% by 2024;
• being able to report on the percentage of prescriptions supported by a diagnostic test;
• or decision support tool by 2024.

It may be ambitious but it is imperative. 

To better balance the risk and curb the rise of drug-resistant bacteria like E. coli, two important changes are from a diagnostics standpoint. First, we need clinical/diagnostic guidelines that have a default of no antibiotic and, second, we need a simple diagnostic that safely replaces – and supersedes – current tests, like the standard dipstick.

Additionally, other social and behavioural analysis measures must be put in place around these changes in tools and technologies. It is clear from data that there are significantly different E.coli/UTI infection rates and also differences in prescribing patterns between localities which cannot readily be explained by differences in populations or comorbidities.

 NHS E&I is working with NHSX and NHS Digital to develop an integrated AMR dashboard, with data capable of being cut at multiple levels, to help identify where the key causes of variation may lie. In addition, a key aim of the Gram-negative/UTI pathway work is for this to reach back into social care and public awareness in order to support understanding of what symptoms may or may not indicate a UTI, and also to support identification at an individual level of the reasons why recurrent UTIs may be occurring and the role which local practice may be playing in this.   

Apart from the work that Tony Young (National Clinical Lead for Innovation NHS E&I) and others are doing, what is missing is the capability to develop an IVD from a product development viewpoint. Depending on industry, it can be too expensive to produce and most academic innovators lack experience in the IVD development pathway. This would not be for the likes of a Longitude Prize to fund but there is an opportunity to work with the likes of the NHS and BEIS on nurturing and developing these innovative capabilities. 

Equally, another area that needs to be strengthened is ensuring there’s a clear pathway from product design to “the bedside”. Often, medtech innovation can lose sight of the real world context and clinical need of the people on the ground who will, ultimately, use these devices in their day-to-day work.

It is more than just bringing the clinicians and developers together. We need to bring funders, industry influencers, policymakers, health economists, patients; the whole ecosystem of players together. Clinicians, however, do have a key role to play. They need to be champions of what’s needed, leading the dissemination of information and helping to facilitate the creation of pilot schemes where innovation can be tested in practice.  Behaviour change – essential to the cultivation of stewardship best practice – of course applies to all parties.

Given the expectation of NHS commissioners to follow NICE guidance in determining their priorities, NICE’s Diagnostics Assessment Programme is central to securing commissioner support for embedding the use of new diagnostics tests. However, given that there are no separate payment mechanisms currently in place for diagnostics within this framework, there is no direct financial lever to incentivise much-needed adoption. 

It is for that reason we are prioritising both the pathway-based work and engaging with the development of Integrated Care Systems. The latter will support identification and embed the  key “levers of change” to maximise the likelihood of adoption of pathways. 

In October 2016, the AAC was established following the Accelerated Access Review. The AAC is chaired by Lord Ara Darzi and has members representing each of the collaborative’s key partner organisations. The AAC exists to get more proven innovations into the hands of clinicians and patients, faster, and to make the NHS a great place to innovate so that the development of valuable innovations can be accelerated.

The AAC and AHSNs are the key players in this field currently.

NHS E&I is working with NHSX and NHS Digital to develop a Trusted Research Environment for AMR data. This will facilitate both the linking of data across AMR pathways and the ability for authorised researchers to drill down and identify patterns across pathways for cohorts of patients.

The introduction of Integrated Care Systems will further facilitate at a local level the implementation of pathway-based approaches. This is a positive direction of travel but I would argue that even then there needs to be more of a patient-focused and patient-led approach as the transition from home to primary care to secondary care is not as seamless as it ought to be. The NHS AMR team is developing a patient-centred pathway for chronic and recurrent UTIs which could be a model for others to follow.

Generally, smaller companies don’t know who to approach within public health systems. From an AMR diagnostics perspective, there is just one team within the NHS that can help direct and inform them of public health priorities and opportunities. Then there is also the issue of procurement and adoption which are the responsibility of separate entities within the NHS. 

Covid-19 has accelerated public awareness of the role of point-of-care testing in the management of a health crisis. Most importantly it has also shown that industry and the NHS can work together efficiently and rapidly to provide both tests and vaccines. The key is to have the shared vision of patient benefit, cost effectiveness and market value.

As for Covid-19, there is no reason that if we can have a Target Product Profile (TPP), details on the minimum and optimal performance and operational characteristics of priority diagnostic tests, that meets all three criteria (patient benefit, cost effectiveness and market value) then there can be more rapid adoption of technologies. The approaches which have been taken to facilitate integration of data, and the creation of multi-organisational groups to rapidly authorise change, whilst still operating within a structured approach to decision-making, demonstrates that models can be built upon to facilitate  wider developments.

The big ticket item is the convergence of technologies. Data will be a key part of this evolution but, right now, I believe that new engineering technologies from outside the Life Sciences could improve theranostics (a combination of therapy and diagnostics) and be applied from one area to another, such as CRISPR (a technology that can be used to edit genes).