achieving early diagnosis -...

1

SARA HIOM

DIRECTOR, EARLY DIAGNOSIS & CANCER

INTELLIGENCE, CANCER RESEARCH UK

ACHIEVING EARLY DIAGNOSIS

APPROACH TODAY

CONTEXT

WHAT NEEDS TO CHANGE?

MAKING IT HAPPEN

CONTEXT

THE POLICY AGENDA

Source: NCIN (2012)

SOCIOECONOMIC FACTORS

AGE

GENDER

ETHNICITY

INEQUALITIES IN EARLY DIAGNOSIS

0

1

2

3

4

5

6

Qtr 1 Qtr 2 Qtr 3 Qtr 4

FUNDRAISING ACTIVITIES 2011

Sponsorship Collecting Door-to-door

(except men aged 15–24)

http://www.cancerresearchuk.org/cancer-info/cancerstats/mortality/all-cancers-combined/#Cancer4. Original Data Sources: Office for National Statistics

CANCER: LEADING CAUSE OF DEATH FROM ILLNESS IN EVERY AGE GROUP

http://www.cancerresearchuk.org/cancer-info/cancerstats/mortality/all-cancers-combined/







WHAT NEEDS TO CHANGE?

Early Diagnosis is a complex, multifaceted challenge

The NAEDI hypothesis

Hiom et al. (2015) Diagnosing cancer earlier: reviewing the evidence for improving cancer survival. BJC

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.thegoodhealthsuite.co.uk/GP/contract/284-nhs-england-announces-first-29-vanguard-sites-for-new-models-of-care&ei=elQMVfTVCsrgasrZgbAE&bvm=bv.88528373,d.d2s&psig=AFQjCNHUeCLIuxmG4a9Eut9hRxRCFYSjNA&ust=1426957813242510

FACTORS AFFECTING EARLIER DIAGNOSIS

Patient delay Barriers to

secondary care referral

Lack of clarity around cancer

screening

Lack of primary care access to diagnostic

investigations

Poor communication between primary

and secondary care

PERCEIVED BARRIERS TO SEEING THE DOCTOR 2014 (% Agree)

Q. Which of the following might put you off visiting the doctor?

7.2

8.6

8.9

13.6

13.6

16

18.4

18.8

19.5

19.5

34.8

39.5

41.5

41.8

0 5 10 15 20 25 30 35 40 45

My doctor is difficult to talk to

I wouldn't feel confident talking about my symptom(s) with thedoctor

I find it embarrassing talking to the doctor about my symptoms

I would be too busy to make time to go to the doctor

I have too many other things to worry about

I've had a bad experience at the doctor's in the past

I would be worried the doctor wouldn't take my symptomsseriously

I would be worried about what tests they might want to do

I would be worried about what they might find wrong with me

I would be worried about wasting the doctor's time

I don't want to be seen as somebody who makes a fuss

I don't like having to talk to the GP receptionist about mysymptoms

I find it difficult to get an appointment with a doctor at aconvenient time

I find it difficult to get an appointment with a particular doctor

BARRIERS TO VISITING THE GP – 2015 RESEARCH

“You’ve got to get on with it. If you go to the doctor too much, it’s seen as a sign of weakness or that you are not strong enough to manage things on

your own.”

“At times I thought it was bad … but when it kind of fades away it doesn’t

seem worth pursuing really.”

Reasons for not attending GP:

Felt alarm symptoms were trivial

Felt shouldn’t make a fuss / waste NHS

resources

Attributed problems to ageing

Lacked confidence in healthcare system

Whitaker, K et al (2015) “Help seeking for cancer ‘alarm’ symptoms: a qualitative interview study of primary care patients in the UK”. Br J General Practice

Be Clear on Cancer

Did it diagnose people earlier? Did it flood the system? Did the right people attend? What has it taught us?

SCREENING

EMERGENCY PRESENTATIONS

LOWER RATES OF INVESTIGATION IN THE UK

Improving Outcomes: A Strategy for Cancer - First Annual Report 2011 - Produced the Department of Health – Published 13th December 2011

https://www.gov.uk/government/publications/the-national-cancer-strategy-first-annual-report

0

5

10

15

20

25

30

Procedures per 1,000

population

International Comparison of Crude Colonoscopy Rates per 1,000 in 2010/2011














THE DIAGNOSTIC PATHWAY

GUIDELINES FOR REFERRAL

OF SUSPECTED CANCER

20

• Greater flexibility to refer patients

• Lowering ‘symptom thresholds’ so that any that have a three in 100 chance (or more) of being caused by cancer are now included

• Ability to refer above the threshold for symptoms of concern

WHAT ELSE CAN PRIMARY CARE DO TO ADVANCE EARLIER DIAGNOSIS?

• Audit

• Safety netting

• Significant event analysis

MAKING IT HAPPEN

QUALITY IMPROVEMENT

Effecting local change: Facilitators

Regional solutions: Working with SCNs

Templates and guidance: referral form templates, bowel screening workbook

Sharing best practice: ACE

EDUCATION

24

Blended Learning E-learning

Cascade workshops Faculty

workshops

Workshops

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&docid=iOCDCL0ctpcBYM&tbnid=BJ8kuMH87dcNDM:&ved=0CAUQjRw&url=http://www.childcarevouchers.co.uk/Employers/Whyus/Pages/Casestudies.aspx&ei=SGe9U-vAHI3-oQTx1ILQCA&bvm=bv.70138588,d.ZGU&psig=AFQjCNFy9fGTA2h59F_1x-8sNo_EZ14E8Q&ust=1405008044340043

NATIONAL AUDIT OF CANCER DIAGNOSIS IN PRIMARY CARE

2010 audit:

• 1,170 practices

• 18,879 patients

• 20 Cancer Networks

2016 audit:

• Will use 2014 data

• Minimum of 1000 practices

SUMMARY

• Cancer burden in society has increased significantly and will continue to do so

• In achieving our ambition of earlier diagnosis, we need to think about roles across and between primary and secondary care

• Capacity pressures need to be addressed, but actions can start now

THANK YOU

www.england.nhs.uk

Maureen Dowling

LWBC Programme Manager, NHS England

Living with and

Beyond Cancer

- a national update

15th October 2015

www.england.nhs.uk

• Following on from NCSI, NHS England, in partnership

with Macmillan Cancer Support established the Living

with and Beyond Cancer Programme

• A 2 year programme of work to embed the four priority

areas from NCSI into mainstream commissioning

through NHS England 2014 - 2016

• Publication of ‘Achieving world Class Cancer

Outcomes – A strategy for England 2015-2020’

Background

www.england.nhs.uk

• the recovery package

• stratified pathways of care

• HWB including physical activity

• consequences of cancer and its treatment

Original Four key priorities

www.england.nhs.uk

• To support Strategic Clinical Networks (SCNs),

Clinical Commissioning Groups (CCGs) and Clinical

Reference Groups (CRGs).

• Develop guidance, ‘products’ and activities to allow

informed decisions on commissioning to be made.

• Embed LWBC in to NHS England Long Term

Conditions, Older People and End of Life Care

Programme & Improving Rehabilitation Services

Programme

Aims

www.england.nhs.uk

• Work up implementation plan by end of year

• Priorities & milestones

• Costings

• Partnership working

Post strategy

www.england.nhs.uk

• Work ongoing e.g. partnership working,

commissioning, LTC integration

• Extension of current areas of work e.g. QOL

measures, rehabilitation, mental health, levers &

incentives

• New work e.g. research, data & metrics, workforce

LWBC Recommendations

www.england.nhs.uk

• HNA & Care Plan

• Health & Well being events

• Treatment Summary

• Cancer Care Review

• The recovery package interventions should be considered as an integral part of any commissioned pathway

• They are essential in the development of stratified pathways

• To be effective,they must be linked to the commissioning and provision of services required to meet the needs identified, for example consequences of treatment, rehabilitation services and psychological support.

‘unpicking’ The Recovery Package

www.england.nhs.uk

New NHS England Guidance for commissioning LWBC

Commissioning person centred care for people affected by cancer

• The Recovery Package

• Stratified pathways

• Managing consequences of treatment

• Long Term Conditions

• Levers & Incentives

Includes case studies and guidance for conversations with providers

Coming soon!

Nice Urgent Referral Guidance

Bernadette Lavery

TV Cancer SCN

15th October 2015

14/10/15 Cancer Commissioning Workshop Oct 2015

CCG Outcome Indicators for cancer


‘2ww’ – urgent cancer referral

• Introduced 1999 for breast, rolled out 2000 other tumour sites

• ‘GPs should use the referral guidelines to help them identify and refer urgently those patients who may have cancer and require a specialist appointment within two weeks’ (HSC 2000/013)

• Updated 2005: ‘The new guideline takes account of new research evidence and the findings of audits undertaken since the publication of the previous guideline’. (NICE CG27)

• Based on tumour sites rather than symptoms


NG12 2015

Suspected cancer: recognition and

referral

• This guideline updates and replaces NICE clinical guideline CG27

(published June 2005). It offers evidence-based advice on the recognition

of and referral for suspected cancer in children, young people and adults.

• New recommendations have been added about recognizing suspected

cancer and referral. The recommendations have been organized by

symptoms and investigation findings, as well as by the site of suspected

cancer.

• The guidance also updates and replaces recommendations 1.1.2 to 1.1.5

in Lung cancer (2011) NICE guideline CG121 and incorporates

recommendations from section 1.1 in Ovarian cancer (2011) NICE

guideline CG122.


…from bmj comment ‘It is difficult to recall the 1990s, when patients in the United Kingdom with suspected cancer sometimes waited months for investigation. In 2000 the Department of Health introduced guidelines for referral, structured pathways, and a waiting time target of two weeks for patients with suspected cancer. Fifteen years later guidelines published by the National Institute for Health and Care Excellence (NICE) represent an enormous overhaul, which reflect monumental scholarship and are unique in the world. This latest guidance differs greatly from its forebears in methodology, form, tone, and content.’

K Barraclough


Principles • Evidence from primary care used as basis of

guidance

• Diagnosis in UK needs to improve

• Concept of a Risk Threshold, informed by PPV

• Previous Guidance PPV 5% at lowest

• This guidance lowers threshold to PPV 3% to underpin suspected cancer pathway referral or urgent (enhanced) direct access testing


Anticipated benefits • early identification of cancer

• a reduction in cancer identified through emergency admission to hospital

• an optimised diagnostic process.

• more appropriate referrals to secondary care for suspected cancer

• extended survival for people with cancer

• reduced mortality from cancer


Potential impact • Increase referrals

• Decrease conversion rate

• Increase early stage diagnosis

• Increase use of direct access diagnostics


Costing Headlines • No overall impact on costs for breast, skin,

urology, H&N, Gynae

• Increased resources for:

• Lung – Increased referrals anticipated to 2ww

• UGI – Urgent direct access for endoscopy and CT anticipated, with possible reduced OPAs

• LGI – Increased 2ww referrals likely, plus need for endoscopy related to this.


(Un)Anticipated problems • Capacity and current ‘spend’

• Taking patients out of measured pathway

• Outsourcing diagnostics – need explicit and slick pathways into secondary care if cancer found

• Needs review of pathways, and planning for the future, bearing in mind ‘4 week diagnosis or exclusion’ target in 2020.


REDUCING BARRIERS TO BOWEL SCREENING 15TH October 2015

evidence & Resources

Monday, November 23, 2015 53

• evidence – summary of what works

• resources to help

• tips and sources of practical support

• Future? • - Regular updates - reflect the latest evidence • - Shared learning • - Interventions targeting Vulnerable groups

www.cancerresearchuk.org/health-professional/early-diagnosis-activities/bowel-screening-projects-and-resources/

RESOURCES


Bowel screening is used to check for early signs of bowel cancer by looking for hidden traces of blood in your poo. There is a national bowel screening programme for older men and women. They will receive a screening kit to use at home. Samples are sent away for testing.

Interventions that work


0

2

4

6

8

10

12

14

Enhanced

patient

leaflet

GP endorsement

letter

Telephone

advice

Face to face

health

promotion

Increase in FOBT screening uptake

(%)

Used independently Used in combination

- GP ENDORSEMENT LETTER

- ENHANCED PATIENT LEAFLET

- TELEPHONE ADVICE / FACE TO FACE HEALTH PROMOTION

Examples of good practice • LANCASHIRE – 2013/14 • GP FOLLOW UP NON RESPONDERS • RESOURCE PACK inc. Standardised read codes • Responsible LEAD • Sustainable – plans to run 2015/16 • OUTCOMES: letter 10.34%; telephone 9.62%; • face to face 8.11%

• London - current • GPs incentivised • Targeted • Data sharing • training


Joined up approach

Health professional engagement facilitators


• Facilitators in your area

• Work collaboratively with a wide range of stakeholders

• practical support to help improve cancer

• outcomes

• advice, training and useful resources

For more information, please contact [email protected]

EARLY DIAGNOSIS

• RESOURCE ‘GP GOOD PRACTICE GUIDE’

• identifying and sharing GOOD practice

• sharE insights to bring about positive change

• feed ‘on the ground’ knowledge and understanding back into research


Could you provide further evidence of good practice? Please contact: [email protected]

Any questions? For more information contact: Rachael Ogley Early Diagnosis Manager [email protected] 07717646459 For local info and support, your Thames Valley CRUK Facilitators are: Berkshire - Bridget England [email protected] 07500881933 Oxfordshire and Swindon – Allyson Arnold [email protected] 07557 566298 Buckinghamshire and Milton Keynes – Louise Forster [email protected] 07785 441814

Accelerating diagnosis of cancer by improving clinical systems

Ben Tunstall Health Professional Engagement Facilitator

Waltham Forest, City & Hackney

Background

In 2014 CRUK Facilitator met with GP practices in City & Hackney Identified a wide variation in coding in EMIS. This slowed the process of finding appropriate patients to; -include in the RCGP audit of cancer cases -follow up on 2ww referrals in a systematic and timely way -endorse bowel screening -offer a comprehensive cancer care review ….and code these actions appropriately in EMIS

Background

• With the support of the Macmillan GP Lead, the facilitator identified a local Practice Manager who built templates that standardised coding in EMIS and searches that targeted appropriate patients

• These tools have since been developed further by NE London Clinical Effectiveness Group and are central to the City & Hackney CCG cancer contract for 2015-16

• All C&H practices have adopted the tools

• The facilitator now trains GPs and practice staff to use these tools in Waltham Forest

EMIS templates

• Standardises read codes and captures clinical and administration actions

• Enables searches to find appropriate patients

EMIS searches

Targets appropriate patients in order to;

• improve communications between practice and patient

• streamline communications between primary care and secondary care

• provide a more holistic standard of patient care

Clinical / admin actions captured by templates and searches

• Safetynetting 2ww referrals

• Bowel screening GP endorsement

• Search for cancer patients diagnosed in previous 12 months for RCGP audit

• Cancer care reviews for patients diagnosed 6-12 months previous (opportunity to discuss HNA and informed by treatment summary)

Safetynetting 2ww referral template

Bowel screening template

Building a search (rising 60s)

Auto report for eligible patients (rising 60s)

Contacts for further information

For more information about this project contact Ben Tunstall [email protected] 07919 295 562 For local info and support your Thames Valley CRUK Facilitators are: • Berkshire - Bridget England

[email protected] 07500881933 • Oxfordshire and Swindon – Allyson Arnold

[email protected] 07557 566298 • Buckinghamshire and Milton Keynes – Louise Forster

[email protected] 07785 441814

mailto:[email protected]




Raising awareness in the Public

Dr Anant Sachdev

GP, Cancer Lead Berkshire East

[email protected]

“Be Clear on Cancer”

• Cancer Reform Strategy (2007) and Improving

Outcomes: A Strategy for Cancer (2011),

• the Government set it’s ambition to save an additional 5,000 lives per year

• through earlier diagnosis and better access to treatment.

• The Department of Health started the awareness raising activity in 2010:

“Be Clear on Cancer”

Thames Valley Cancer Network 77


“Be Clear on Cancer” Media campaign TV, newspapers, magazines, radio-stations Posters: Surgeries, Public services eg libraries, radio-stations, football stadiums, motor-way services Leaflets



“Be Clear on Cancer” Evaluation?

For each campaign there is a comprehensive evaluation process by PHE and NCIN from 2013, (and was previously done by CRUK) Data collected on a number of metrics: • symptom awareness, pre- and post-campaign • attendances at primary care, • urgent suspected cancer referrals • diagnostic investigation activity, • Cancers diagnosed However, data for some of these metrics inevitably take much longer to come through. Wherever possible, results were compared to control data

Are people seeing the campaign and is it raising awareness of the signs and symptoms of cancer?

“Following each of the campaigns, people’s knowledge of signs and symptoms of cancer have increased, along with confidence in

that knowledge.”

Regional bowel extension (Oct 2012 – Mar 2013) • Spontaneous awareness of key symptoms related to the campaign (blood in stools/loose stools/change in bowel habits) rose from 61% to 74% in those aged 55 and over. Regional breast in women over 70 (Jan – Mar 2013) • 7% of women aged 40 and over at the pre-campaign stage believed that women in their 70s are more likely to develop breast cancer, with a statistically significant rise to 25% post-campaign. Regional ‘blood in pee’ (Jan – Mar 2013) • Statistically significant increase in knowledge that blood in pee is a definite warning sign of kidney/bladder cancer, from 41% pre-campaign to 65% post-campaign, in those aged 55 and over. • Statistically significant increase in people aged 55 and over saying they would see their GP the same day if they noticed a change in their bladder habits, from 18% pre-campaign to 27% post-campaign. Local ovarian (Jan – Mar 2013) • 57% of women aged 55 and over agreed that the advertising campaign had told them some thing new, the highest level recorded to date for Be Clear on Cancer campaigns. • Statistically significant increase in recall of ‘bloating for 3 weeks or more’, from 16% to 28% in women aged55 and over.

Are more people going to their GP with the symptoms promoted by the campaign, and is there any shift in

the profile of the patients presenting?

National lung (May – Jun 2012) 486 practices analysed • statistically significant 62% increase in attendances for a persistent cough in the over 50s compared with the same period in the previous year, equating to an additional 2.99 visits per practice, per week Regional ‘blood in pee’ (Jan – Mar 2013) 54 GP practices • GP attendances for visible blood in urine macroscopic haematuria) in those aged 50 and over saw a statistically significant increase of 32% when compared with the same period in the previous year. This is equivalent to an additional 0.29 visits per practice, per week. Local ovarian (Jan – Mar 2013) • a 22% increase in GP visits within the target area for patients aged 50 and over with the key symptom highlighted in the radio campaign, unexplained bloating, compared with the same period in the previous year (NSS**). The increase in activity was equivalent to 0.04 additional visits per practice, per week

Yes: At a GP practice level these equate to small but manageable increases that do not put an undue burden on GPs

But the impact of these attendances is considerable

Are more people being referred urgently for Suspected cancer?

National bowel (Aug – Sept 2012) • Statistically significant 29% increase in urgent referrals for suspected lower GI cancer Regional lung (Oct – Nov 2011) • Urgent referrals for suspected lung cancer saw a statistically significant increase of 32% Regional ‘blood in pee’ (Jan – Mar 2013) • During the campaign, pilot areas saw a statistically significant 28% increase in urgent referrals for suspected urological cancers Local ovarian (Jan – Mar 2013) • The number of urgent referrals for suspected gynaecological cancers saw a statistically significant increase of 8% across all pilot sites, with the increase being highest in the Mount Vernon Cancer Network (14%).

Of those referred urgently for suspected cancer, how many actually turn out to have that cancer?

Whilst there are increases during the campaign period in the number of cancers diagnosed following a 2WW referral, we often see decreases in the conversion rates

(of the 2WW referrals into diagnosed cancers), since more people are referred during a campaign.

National bowel (Aug–Sept 2012) • 7% increase in the number of lower GI cancers diagnosed following a 2WW referral, but a statistically significant decrease in the conversion rate, from 5.6% to 4.6%. National lung (May – Jun 2012) • a statistically significant 18% increase of lung cancer and a decrease in the conversion rate, from 24% to 21.5% Regional ‘blood in pee’ (Jan – Mar 2013) • a 22% statistically significant increase in the number of urological cancers diagnosed following a 2WW referral and the conversion rate remained around the same; 15.6% to 14.9% (NSS**).

Are we seeing a shift towards earlier stage disease?

The Lung Campaign data shows there has been a shift towards earlier stage disease, which is widely recognised as

indicating better outcomes for patients

• Increase seen in surgical resection rate (National lung)

• Shift towards earlier stage distribution of lung cancers diagnosed (Regional and national lung)

Local cancer event to public Bracknell & Ascot CCG

June 2014 Local Church Hall Agenda: • Cancer facts

• What is cancer • Prevention • Causes • Investigations and Treatments • Signs and symptoms of some

cancers • Support Services – Macmillan • Cancer Rehabilitation Services

Total Attendees = 185 171 Patients (this incl. x 25 who hadn't booked) 14 Practice/Guests Feedback from 62

Feedback

1) Over-all, did you find the Event informative and useful = YES 100%

I was most impressed with this community event

Good Presentations - Very Useful

Informative, a little sad & a little funny!

Extremely informative

An excellent presentation, informative, clear, laymans language

Learned a lot, very helpful

Presented in a friendly & informative/down to earth way

Very good introduction to Cancer - succint/good relevant info

A well-structured & informative day. Appreciated touches of humour. A huge subject to cover but done well.

Feedback

What one or two points will you take away from the event today?

Knowledge & symptoms, knowledge of support services and how to run an awareness day.

• seven measures of cancer. Exercise good preventative

Realisation of how wide-spread it is.

Exercise is 'Key' to Health

Likelihood of Prostrate Cancer / importance of activity

HOPE - Lots of care available

My sons aged 40&32 NEED a prostrate check soon!

1. Pay more attention to your body 2. Make lifestyle changes

Urge them to seek medical attention

Early diagnosis is imperative

Ensure use screening facilities

Feedback

Any other comments

Could have done with another hour.

An inspirational afternoon.

Kindness coupled with expertise good to 'see' people rather than leaflets.

Very informative afternoon and so well done.

A wonderful afternoon, congratulations on such a well organised presentation on cancer.

Most informative.

Summary

Every opportunity to prevent cancer, and to pick up cancer early • Health promotion • Screening programmes • Share signs and symptoms of cancer with public

• Give tools • such as ABCDE of skin cancer • CAUTION

• Encourage early attendance • Personal motivation – not frighten! • Peer or family and friends • Appropriate access

Remember:

ONE CANCER DIAGNOSIS made by yourself states that

YOU HAVE MADE A DIFFERENCE to not only one life

but to many”

Thank you !

Any Q?

Maureen Dowling

LWBC Programme Manager, NHS England

Living with and Beyond Cancer - case studies

15th October 2015

• Examples of commissioning in local strategies, commissioning intentions and contracts

• Your conversations with providers

Examples of commissioning in local strategies, commissioning

intentions and contracts

Local Strategies

• The Wessex Clinical Commissioning Groups (CCGs) tasked the Strategic Clinical Network with describing a strategic vision for cancer services over the next five years. This includes: ‘Within 5 years all Wessex patients with a new cancer diagnosis will be offered a holistic needs assessment, a primary care cancer review and a detailed treatment summary, as a consequence of the implementation of the Recovery Package’.

• Mid Nottinghamshire CCGs have developed a strategy that includes their commissioning intentions for delivering adult cancer services. It describes the growing need to review and redesign cancer services across Mid Nottinghamshire and the opportunities to deliver structural and cultural change as part of a wider health economy cancer service redesign programme.

Commissioning Intentions

• Transforming Cancer Services for London (TCS) has developed commissioning intentions including: recovery package, pathways for COT including Lymphoedema, bladder/bowel/sexual dysfunction, fertility, hormonal treatment and psychological support; and stratified pathways for breast, colorectal and prostate (some commissioners are choosing a primary care led prostate follow up pathway).

• Thanet CCGs have a focus on commissioning intentions in the light of better integrating care. This includes primary care working with community nursing, and secondary care clinicians supporting patients in the community. The CCG is supportive of integrating cancer into these services.

Contracts

• A service specification for self-supported management of colorectal cancer has been developed by Sheffield CCG. It includes risk stratification within secondary care prior to discharge.

Levers and incentives

• The Waltham Forest and East London and the City (WELC) CCGs have a CQUIN that states: ‘Every patient with a cancer diagnosis will have at a minimum, a holistic needs assessment and care plan around the time of diagnosis and on completion of treatment and that a treatment summary record will be completed.’

• Mid Nottinghamshire CCGs have developed a Cancer Care and Pathways CQUIN. The indicator includes: ‘Every patient with a cancer diagnosis will have at a minimum, a holistic needs assessment and care plan around the time of diagnosis and on completion of treatment, and that a treatment summary record will be completed. These key documents will be shared with the patient’s GP.’

Long term conditions and comorbidities

A number of NHS England resources are available to assist commissioners and providers:

• Transforming participation in health and care

• Personalised care and support planning handbook: The journey to person centred care

• Guidance on delivering personalised care and support planning: The journey to person-centred care

• Long term conditions improvement programme

Your conversations with providers

Holistic Needs Assessment and care planning

• The Integrated Cancer Services in London have developed a London-wide Holistic Needs Assessment template.

• Macmillan Cancer Support has developed an Electronic HNA (eHNA). This allows the person affected by cancer to complete the HNA questionnaire on a touch screen tablet. The information is then sent to the clinician through a secure website to begin the process of care and support planning.

Treatment Summary

• Macmillan Cancer Support has developed a Treatment Summary Template and Guidance (2015) describing its use from both a secondary and primary care perspective.

• A London-wide TS template has been developed by the Integrated Cancer Services in London.

• Sheffield CCG has developed a Treatment Summary template

Health and wellbeing events

• London Cancer (LC) has developed information and guidance on the development and implementation of health and wellbeing events in order to embed them within cancer pathways: Health and Wellbeing Events Specification

• The Ashford and St. Peter’s Hospitals NHS Foundation Trust (ASPH) held their first health and wellbeing event in February 2015. The programme consisted of a range of expert speakers from clinicians and psychologist to dietitians as well as presentations on more practical issues such as seeking financial benefits, carers’ support, medical coaching and advice on physical activity for cancer patients. Exhibition stands supported by 14 cancer charities were included to ensure patients and their families and carers are provided and supported with additional information and guidance. A video was produced showing highlights of the day.

Stratified pathways of care

• Broomfield Hospital, Mid Essex NHS Trust has provided stratified follow up for colorectal cancer patients for almost 10 years for approximately 600 outpatient appointments per year, with 200 new cases a year. About half the patients are suitable and they have received 85 per cent positive feedback. Data is captured on Infoflex and they would also like it to go onto Somerset. A journal paper describing this work has been published in Colorectal Disease ‘Remote surveillance after colorectal cancer surgery: an effective alternative to standard clinic based follow-up’.

Managing the consequences of treatment

• The Consequences of Cancer and its Treatment Collaborative (CCaT) was created in 2009, as a ‘community of influence’, supported by Macmillan, to improve the experience and outcomes of people living with and beyond cancer.

• NHS England has developed ‘Principles and Expectations for Good Adult Rehabilitation’ which outlines the principles and expectations of an improved adult rehabilitation service for the NHS

Long term conditions and comorbidities

• The CQUIN developed by Mid Nottinghamshire CCGs was developed as an enabler for wider system change that aligns with the LTC agenda. The focus is on information sharing across secondary and primary care, and is part of a wider approach to development of community and primary care services; underpinned by a person centred approach to care seen in their Better Together Transformation Programme Strategy.

• In North West London (NWL) ‘Whole Systems Integrated Care’ brings together health and social care providers, commissioners, the third sector, and service users to co-produce and implement new models of care. Through 18 months of collaborative design work the partners produced a joint 'Integration Toolkit', which local areas have used to develop their proposals in more detail.

Demand and Capacity Modelling in a

diagnostic modality

John Turner

Intensive Support Manager

Elective Care Intensive Support Team

NHS IMAS

www.nhsimas.nhs.uk/ist

http://www.nhsimas.nhs.uk/ist

Intensive Support Team

• NHS national funded team (part of NHS IMAS/NHS England) • Free resource to NHS organisations • Supporting NHS organisations to deliver improved patient

access performance standards • Works with local health communities (LHCs) that are facing

particular challenges in key patient access areas: – Elective care:

• Cancer • 18 weeks RTT pathways • Including diagnostic elements such as imaging and endoscopy

– Emergency and urgent care access

109

Our Approach

• Transfer knowledge and skills to the organisation, which in turn enables the performance improvement to be maintained

• Supporting, enabling and constructive (“a critical friend”) • To use our skills, knowledge and experience to work with and

across the NHS: • to improve service delivery • to minimise waiting times and improve the overall

patient experience

110

The IST’s cancer work

• Providing an objective, external view of how cancer systems are managed within organisations and local health communities: – Leadership and management

– Performance management

– Data capture and information quality

– Access policy/processes

– PTL tracking and use

– Inter-provider transfer management

– Support development and implementation of local recovery and action plans

– Demand and capacity planning

The context of cancer

• Cancer services are typically part of wider services: – Urology : Prostate

– Dermatology : Skin

• In the context of RTT Oxford University hospitals: – Urology – RTT 480 treatments : Cancer 47 treatments on 62 day pathway

– Gynaecology – RTT 688 treatments : Cancer 10.5 treatments on 62 day pathway

– Dermatology (skin) – RTT 1081 treatments : Cancer 45 treatments on 62 day pathway

• Characterised by relatively short pathways

Key issues consider when

planning C&D modelling

• A word of caution

• Treatment pathways

• Clarity of definition

• Recurrent balance

• Waiting list size

Benefits and

limitations of models

• Models are essentially mathematical calculations, therefore: – they cannot predict the precise variations of reality

– they don’t guarantee compliant waiting times performance

– they become less reliable where data quality is poor

• However, models can support more informed, less anecdotal discussions (but they are not designed to replace them)

• Models get people talking and help to increase the level of understanding of services

TREATMENT PATHWAYS

1st Outpatient Appointment Follow-Up

Outpatient Appointment

Receipt of Referral

Diagnostics

Admission

Pathways

What typically happens What order should it happen

When should it happen What is the maximum wait for each stage

Which part(s) is/are not working?



Receipt of Referral

Diagnostics

Admission

Pathways

What typically happens What order should it happen

When should it happen What is the maximum wait for each stage

Diagnostics



Receipt of Referral

Diagnostics

Admission

Some pathways are more complex

Triage

Pathways should:

Issues or concerns must be raised promptly and escalated in line with local policy.

be compliant

with the Cancer standards;

not have minimum waits

built in;

keep demand and capacity in

balance

Maximum numbers of patients at each stage should be

understood; be treated in chronological

order (with the usual caveats);

be tracked to ensure they are

where they should be.

Remember

Which part / parts of the pathway / whole pathway do you need to model

• Have you built the right model

When you have built the model(s) does it represent the service / system

• Have you built the model right

Key questions

• Designed for elective healthcare

• Must be used within the context of a pathway with target milestones for key events

• Use demand to calculate the required level of supply

• Help to quantify current capacity of the service

• Calculate ideal waiting list sizes consistent with a chosen maximum wait

• Give an indication of changes required to current capacity to keep pace with demand and clear excess waiting list

IST Models for Elective Care


Current suite includes models that cover:

• First outpatient

• Two week wait cancer

• Inpatient / day-case

• Endoscopy

• Diagnostic imaging

• Advanced Flow (1st, F/U & Admissions)

IST Models for Elective Care


• Demand and its variability

• What the service can currently deliver - Capacity

• Maximum sustainable waiting list sizes

• Translating the outputs of models in to actions

Important factors

DEMAND

What we should be doing e.g. referrals, requests DTA

CAPACITY

Maximum amount that the service can currently deliver linked to job plans

WAITING LIST

Numbers of service users (patients) in the service waiting to be seen/treated

Remember to take account of demand that does not need to be met (ROTT) and wastage through lost capacity and re-bookings

Definitions

The 3 core elements of

D&C modelling

1. Setting maximum waiting times (milestones) for:

– 1st outpatient appointment

– Diagnostics

– Follow-up

– Decision to Admit

2. Fully identifying and understanding the demand into the service and total core capacity available

3. Determining the current and desirable waiting list sizes

Demo 1

• Endoscopy example.xlsx

Endoscopy example.xlsx

Favorable factors:

• Low variation in demand

• Pooling of referrals

• Size of the specialty

• The ease with which you can flex your capacity:

– flex the timing of clinics (e.g. annualised contract)

– ability to provide ad hoc slots/clinics quickly and easily (e.g. overbooking or ad hoc clinics)

• A good distribution of appointment offers (low median)

Unfavourable factors:

• High variation in demand

• High variation in clinic capacity e.g. no absence cover, bank holidays

• Carve out e.g. different hospital sites

• High levels of rebookings and DNAs

• Not offering patient choice

• Inflexible working practices e.g.

– high clinic utilisation demanded

– poor or lengthy authorisation/escalation

Monday, 23 November 2015 130

Even if you have capacity in balance with demand,

If the waiting list is too big

Patients will wait too long

A group of people who:

Are organised in to sub-queues according to their clinical urgency;

Are chronologically and sequentially ordered within their sub queues;

May, (in the case of admitted pathway waiting lists) join the queue ahead of others, for example: join a potentially constantly changing queue;

May change their relative position as they wait to be seen;

May not be pulled from the “queue” in the order of the position that they currently occupy, for example: listing short cases out of order to make full use of a list.

What is a clinical waiting list?

Lists look a bit like this…

If average demand = average capacity this variation mismatch = queue

time

Demand Capacity

Queue

Can’t pass unused capacity forward to next week

Target

Not planning at average demand is good because…

Why is waiting list size important?

Capacity = what we could do

Demand and capacity definitions

Activity

= what we did

Demand = All requests for a service

= what we should do

Waiting list, queue = what we should have done

Capacity is overwhelmed and a

long tail is created…

Demo 2

• MRI example.xlsx

MRI example.xlsx

achieving early diagnosis -...

Documents