Australian Horizon Scanning: Fiscal Forecasting or Future Focus?
The manager has his eye on the bottom line; the leader has his eye on the horizon - Warren Bennis.
The establishment of a Horizon Scanning system is under active discussion in Australia. Given the range of applications and differing stakeholder needs, the sort of system that will eventuate and to whom it will be relevant is unclear.
In healthcare, Horizon Scanning represents a systematic approach that gives forewarning about the impact of new and emerging technologies, for planning and preparation. Where Horizon Scanning activities are focused can vary greatly depending on the needs of stakeholders, who naturally require information relevant to their’ responsibilities.
The different forms of Horizon Scanning relevant to key stakeholders in Australia can be grouped into four categories:
1. Workload planning
The main international use of Horizon Scanning, as estimated by the HTA Global Policy Forum in 2018(1) is for workload planning and topic selection by HTA bodies. This approach is typically labour intensive, as it usually focuses on identifying and prioritising individual products based on early clinical or cost signals.
2. Financial planning
Another use is to inform payers about the future adoption and budget impact of near-term innovations. For example, Sweden has a national Horizon Scanning process that informs regional health systems of potentially impactful products that are close to being launched, to enable planning for budget management, and managed introduction of new technologies(2).
3. Capacity and capability building
Horizon Scanning can also be used by agencies to determine the future skill sets they will need so they can understand and review emerging technological advances (e.g., digital medicine). The Department of Health has stated that such an approach would be useful for both the TGA and the Health Resourcing Group(3).
4. Awareness of emerging therapeutic advances
Lastly, Horizon Scanning can be used to identify and evaluate emerging therapeutic advances with the objective of enabling proactive system changes. This approach can range from high-level looking at the policy implications of a class of therapeutic advances such as ‘digital health’, to more specific implications that an advance might bring, such as changes to a care pathway to the level of individual products representing the cutting edge of the advance.
Exisiting Horizon Scanning in Australia
Australia already has experience with Horizon Scanning in health. There is currently a high-level Horizon Scanning Series(4) aimed at guiding decision-makers in relation to selected emerging scientific or technological changes such as ‘Precision Medicine’ that are commissioned by the Government and developed by the Australian Council of Learned Academies (ACOLA).
Historically, there was also a product-level Horizon Scanning system in Australia. The Australia and New Zealand Horizon Scanning Network (ANZHSN) was established in 2003 to provide early awareness in relation to potentially impactful devices, diagnostics, public health programs, and new surgical techniques and technologies.
The ANZHSN was overseen by the Health Policy Advisory Committee on Technology (HealthPACT), an MSAC subcommittee tasked with advising MSAC and the Australian Health Minister’s Advisory Council of the consequences of new and emerging health technologies(5).
While these committees are no longer operating, many stakeholders(3) perceive an immediate need for national Horizon Scanning for medicines and devices.
What sort of Horizon Scanning is under consideration?
Implementation of Horizon Scanning was one of the recommendations of the Zimmerman inquiry into approval processes for new drugs and novel medical technologies in Australia(3), and is also on the agenda of the Strategic Agreement between the Commonwealth and Medicines Australia(6).
What is common between the two is that their recommendations are focused on using Horizon Scanning to impact the health system and address barriers to patient access.
The Zimmerman inquiry recommended a comprehensive Horizon Scanning unit for emerging medicines and devices that would enable early adaptation of approval systems to maximise the benefits of new medical technologies.
As the committee noted a capability gap in terms of rare disease and precision medicine, it recommended the establishment of a Centre for Precision Medicine and Rare Disease within the Department of Health and suggested locating the Horizon Scanning Unit within that Centre(3).
While locating the unit within the Centre would certainly help focus on the immediate gaps of concern identified by the senate inquiry, it may also narrow the remit to that of the Centre’s scope - meaning a risk of missing technological advances that fall outside of rare disease or precision medicines.
The Horizon Scanning section of the Strategic Agreement describes a shared vision of improved understanding of new and emerging technologies coming through the developmental pipeline to facilitate faster patient access.
An annual forum, convened by MA, is proposed to identify major therapeutic advances with potential for ‘significant disruption in the treatment paradigm and/or require innovation in the health care system planning’, and then inform on the potential impact to the Commonwealth of such advances in terms of resources, systems, and processes.
The time horizon for review is within 18-24 months of entering the regulatory or reimbursement system. Whether it will be a showcase of individual products, or a more general discussion relating to new kinds of therapeutic advance for which the system needs preparation remains to be seen.
An additional question is how the output of the Forum will translate to meaningful impact from the perspective of the two parties of the Strategic Agreement, and ultimately the intended beneficiaries: patients.
Key considerations
1. Why: Align on purpose
Although there are many groups advocating for Horizon Scanning in Australia, there is a distinct mismatch of objectives for such an activity. As noted previously, Horizon Scanning can be used for different purposes ranging from short-term fiscal forecasting through to long-term system adaptation.
Clearly some categories can be combined; short term forecasting for topic selection with budget management, or longer-term capability building with system preparation for disruptive advances. As it is hard to imagine a single process providing for all potential uses, there is a need to clarify the purpose of any new Horizon Scanning activity for Australia.
2. When: Time horizon determines utility
The purpose of Horizon Scanning will determine the time horizon where the activity will focus.
For example, while Horizon Scanning for managed entry agreements or budget forecasting can occur as little as 12 months prior to market entry, the goal of Horizon Scanning is to enable adaptation of approval systems, pro-active changes to treatment paradigms or innovation in health care system planning, then a longer time horizon will be required.
For such activities, the HTAi Global Policy Forum recommended greater than three years before launch(1). However, as the time horizon lengthens, the degree of information uncertainty grows, and the level of urgency to act on the information decreases, leading to risk that the output of long-term Horizon Scanning might not have a meaningful impact.
3. What: Single product or therapeutic advance
The focus of Horizon Scanning can be at the level of individual products or more broadly on the nature of the therapeutic advance. The focus will in part be driven by the purpose of the scan.
While product-level evaluation is logical for short-term forecasting, as the time horizon increases and the purpose broadens to system adaptation or capacity building, then it may be more efficient to review the class of advance rather than individual products.
The rationale is that the review of individual products is labor intensive, and a significant amount of work may be abandoned when products under review fail.
For example, in consideration of the high failure rate of late-stage disease-modifying Alzheimer’s drugs, instead of conducting detailed Horizon Scan reports of every product from phase II onward, it is more efficient to address the issues that will result in system disruption, as these are likely to occur regardless of which product eventually succeeds.
4. How: Impact requires focus on the end user’s needs
Except for short-term budget forecasting(2) or use for workload planning, there is a lack of evidence that Horizon Scanning activities have had meaningful impact on health systems. For it to have meaningful impact it is critical that the reports are relevant to the end user.
Relevancy can include maximising signal over noise, including avoiding overwhelming the end user with unnecessary information. Hence a degree of pragmatism is required as, by definition, Horizon Scanning is relying on uncertain information. Developing a detailed mini-HTA with enormous confidence intervals or a conclusion of ‘more research needed’ may not lead to traction with the end user.
Limiting Horizon Scanning to only that information which is both relevant and important to the end user will help ensure uptake and impact.
5. Who: Centralise and connect
Is the right place for Australia’s new Horizon Scanning system a unit within the proposed Centre for Precision Medicine and Rare Disease, or an annual Forum hosted by Medicines Australia? Both or, something else?
Much will depend on the purpose of the activity. However, considering the complexity of both the Australian health system and the range of emerging medical advances, it would make sense to have a level of central coordination, standardised and transparent processes, and broad stakeholder engagement.
Siloed Horizon Scanning Units are at risk of various forms of information bias and miss the efficiencies, sense checking and insight that can come from engagement with other stakeholders, including end users, innovators, providers, and patients.
Summary
Horizon Scanning is being promoted as a mechanism that can help identify and address challenges presented by emerging medical advances to Australia’s innovation approval processes. Some approaches that assist managers with workload planning or budget forecasting may help reduce access barriers to medicines that are moving through the current system.
However, to realise a system that can adapt to emerging science that doesn’t fit within the predefined processes or that may disrupt existing care pathways, a longer-term and broader solution is likely needed.
Such a solution will require strong leadership and direction to align stakeholders around a relevant process and ensure that the output of such a process is meaningful and measurable.
References
Oortwijn W., et. al., (2018) How can health systems prepare for new and emerging health technologies? The role of horizon scanning revisited. Int J Technol Assess Health Care 34: 254-259 link
Eriksson I., et. al., (2019) Did we see it coming? An evaluation of the Swedish Early Awareness and Alert system. Appl Health Econ Health Policy 17: 93-101
The New Frontier – Delivering better health for all Australians. House of Representatives Standing Committee on Health, Aged Care and Sport. Nov 2021, Canberra
https://www.chiefscientist.gov.au/advice-to-government/horizon-scanning (accessed August 2022)
Mundy L et al., (2005) The Australia and New Zealand Horizon Scanning Network. Australian Health Review 29: 395-397
Medicines Australia Strategic Agreement 2022-2027. https://www.medicinesaustralia.com.au/wp-content/uploads/sites/65/2021/09/Medicines-Australia-Strategic-Agreement-2022-2027.pdf Accessed August 2022.