the winning principles - transforming inpatient care programme for cancer patients

NHSNHS Improvement

Transforming Inpatient CareProgramme for Cancer Patients

The Winning Principles

Assessmentprior to

admission

Definedinpatientpathways

Daily decisionmaking

Encourage selfmanagement

ContentsForeword

Acknowledgements

Introduction

Winning Principle 1: Unscheduled (emergency) patients should beassessed prior to the decision to admit - emergency admission shouldbe the exception not the norm

Winning Principle 2: All patients should be on a defined inpatientpathway based on their tumour type and reasons for admission

Winning Principle 3: Clinical decisions should be made on a dailybasis to promote proactive case management

Winning Principle 4: Patient and carers need to know about theircondition and symptoms to encourage self-management, choice andto know who, where and what to access first time

Test Sites

Case Studies CD-Rom

3Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles

www.improvement.nhs.uk/cancer

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4 Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles


ForewordInpatient care for patients with canceraccounts for around 12% of all inpatient beddays and for more than half of the totalexpenditure on cancer in England.Furthermore, inpatient admissions for cancerhave risen by around 25% in the past eightyears with emergency admissions rising bynearly 50%. A large proportion of theseemergency admissions are managed byphysicians in general medicine or geriatricians.

Over the past 18 months the Cancer ServicesCollaborative ‘Improvement Partnership’ (nowpart of NHS Improvement) and the CancerAction Team have been looking at ways toavoid unnecessary admissions and to reducelength of stay. It has become very clear thatmajor improvements can be made, withbenefits both for patients and for the NHS.

Some of the approaches to streamlininginpatient care pathways that have been testedby trusts across the country are set out in this‘Winning Principles’ report. I stronglycommend these approaches to commissionersand to service providers. The task now is toensure that the Winning Principles areembedded across the NHS.

Mike Richards

National Cancer Director

The four approaches set out here are basedon the actual experiences of local NHShospitals caring for their cancer patients. Thework of NHS Improvement and the pilot sitesas summarised here clearly shows howdifferent approaches to inpatient cancer carecan deliver major improvements, and make areal and positive difference to patients’experience of inpatient care.

The case studies in this publication serve asexcellent examples for other NHS trusts asthey consider how they can improve deliveryof inpatient care to ensure their patients haveaccess to the best cancer care.

Ann KeenParliamentary Under Secretary of Statefor Health Services

NHS Improvement would like to thank allthe test sites for their support and input intothis challenging area of work. Theircontribution and co-operation identified thehuge potential for improving the cancerinpatient pathway and also identified thatthe task is not always easy.

Many of the sites are continuing to take thiswork further into implementation and sharetheir learning both nationally and locallythrough the cancer networks.

Acknowledgement



One of the major commitments in the CancerReform Strategy is to shift care from an inpatientto an ambulatory care setting. Pilot schemeshave shown that there is considerable potentialto avoid unnecessary emergency admissions andto reduce lengths of stay, both for elective andemergency admissions. Making this happen willbe a major task for cancer networks, PCTs andacute trusts.

This document provides a summary of thelearning drawn from pilot sites across Englandand aims to support the organisations that areembarking on this challenging task and providesa basis upon which the cancer inpatientprogramme (Cancer Reform Strategy 2007) canbuild upon.

The Transforming Inpatient Care Programme isthe next stage. This will be supported by NHSImprovement, the Cancer Action Team alongwith key organisations, charities and professionalbodies. This new and exciting work will includefurther testing and spreading of new models ofcare in primary and secondary care settings,focusing on shifting care into the communitywhere appropriate and learning to transforminpatient care for cancer patients.

All test sites included in this document, workingin collaboration with NHS Improvement (CSC’IP’)have tried and tested different approaches inorder to reduce length of stay, avert unnecessaryadmissions, shift care to appropriate caresettings, provide value for money, efficiency andmost importantly value the patient’s time andexperience.

Introduction

1. Unscheduled (emergency)patients should be assessedprior to the decision to admit.Emergency admission shouldbe the exception not the norm.

2. All patients should be on adefined inpatient pathwaysbased on their tumour typeand reasons for admission.

3. Clinical decisions shouldbe made on a daily basisto promote proactivecase management.

4. Patient and carers need toknow about their conditionand symptoms to encourageself-management and to knowwho to contact when needed.

By bringing together all the test sites experienceand learning, FOUR WINNING PRINCIPLEShave been identified that if applied can make asignificant difference to the management andexperience of the inpatient pathway.

Detailed case studies of the testing work to datecan be found on the accompanying CD and onwww.improvement.nhs.uk. This is ongoing workand will be updated as further learning emergesfrom the testing, spreading and implementation.

Assessmentprior to

admission






Winning Principle 1

Unscheduled (emergency)patients should beassessed prior to thedecision to admit -emergency admissionshould be the exceptionnot the norm

Assessmentprior to

admission



Different approaches have been tried and testedthat have successfully supported the aboveprinciples and realised the following benefits:

• Aversion of inappropriate/unnecessaryemergency admissions.

• Improved clinical decision making andassessment

• Proactive length of stay management.• Getting the patient onto the right pathway

first time.• Reductions in length of stay and re-admissions• Enabling improvements in supporting patientchoice and preferred place of care.

Sherwood Forest HospitalsNHS Foundation TrustReduced length of stay by 25% for lung cancerpatients by developing and testing a RecurringAdmission Patient Alert System (RAPA), andidentified the potential of releasing 560 beddays per annum. The success of this approachhas now been implemented across the wholehospital and won the 2007 Medical InnovationFutures Award.

RAPA is a simplecommunication solutionthat ensures that everyoneknows their patient is there.It has worked successfullyin cancer for known andunknown patients and nowthe idea is used acrossother specialities.

Jeffrey WorrellChief Executive, Sherwood ForestNHS Foundation Trust

United Lincolnshire Hospitals NHS TrustTested the transferability of the RecurringAdmissions Patient Alerts approach in urology(180 patients) and upper GI (77patients) foremergency readmissions and reduced length ofstay by three days per patient in urology andtwo days per patient in upper GI.

Analysis of the emergency admissions showedthat for urology 50% presented during workinghours and 50% outside. For upper GI 64%presented out of hours and 36% during. Thishas led to the next stage of testing to preventemergency admissions involving one out ofhours pathway for cancer patients with onesingle point of access.

Further analysis of urology emergencyadmissions identified a high number of referralsto A&E for acute urine retention and anundefined patient pathway for follow up care.Working in collaboration with primary care, aprimary care pathway for patients with acuteurinary retention has been developed and is atthe early stages of testing.

Unscheduled (emergency) patients should be assessed prior to the decisionto admit. Emergency admission should be the exception not the norm.

‘

’

R - Right care

A - A friendly face

P - Patient satisfaction

A - Appropriate place



Stage 1 Testing: Primary care pathway for male patientswith acute urine retention tested in Lincoln

Stage 2 Testing: Primary care pathway forpatients with acute urine retention



The acute urinary retentionpathway promotes partnershipworking to provide a seamlessservice for patients. It aimsto move care to a moreappropriate setting and avertunnecessary admissions. Italso aims to improve qualityand safety.Mr Nazeer DaharLead Cancer ClinicianUnited Lincolnshire Hospitals NHS Trust

University Hospitals of Morecambe BayNHS TrustTested in collaboration with primary care and theambulance service an emergency care pathwayfor palliative patients following a baseline reviewthat identified 23 patients out of 30 admissionsmay have been avoided, potentially releasing£93,778 funding to deliver care in the homeenvironment.

The Christie Hospital NHS Foundation Trustand Manchester Primary Care TrustThe baseline showed that 78% of hospitaldeaths were emergency admissions. This led totesting the potential of an alert system andprotocols focusing on supporting the dyingpatient and identifying preferred priorities forcare. During three months testing 76 bed dayswere saved, 22 admissions averted and 69% ofpatients died in their preferred place of care.

Manchester Primary Care TrustNurse led walk-in centre, early intervention toprevent admission crisis. Nurse-led walk-incentres across the UK have played a crucial rolein appropriately streaming patients to primarycare, alleviating the pressure on the A&E four-hour wait target and developing the skills ofnurses.

Barts and the London NHS TrustAverted 50% of cancer emergency inpatientsadmissions per week and reduced length of stayfrom 18.1 days to 13 days by testing anemergency pathway for cancer patients involvingearly oncology decision making at A&E. Thistesting is ongoing and working in collaborationwith Tower Hamlets PCT to identify furthertesting earlier in the emergency pathway.

‘

’The acute urinary retentionpathway will ensureaccessibility to a service thatis delivered closer to thepatient’s home. It will ensuresafe care is provided outsideof the hospital setting withaccess to acute services whennecessary. This is the firststage in testing the impact ofmoving particular clinicalservices from acute care toprimary care.Mrs Sarah FurleyCancer & Palliative Care Planning ManagerLincolnshire County Teaching Primary Care Trust

‘



The Hillingdon Hospital NHS TrustThe development of a palliative care patientpathway for acute admissions.

Proposed provsional palliative care patient pathway for acutecancer admissions to the Hillingdon Hospital NHS Trust

AimTo optimise appropriateness of admissions, placeof admissions, management and length of stay.



Winning Principle 2

All patients should beon a defined inpatientpathway based on theirtumour type and reasonsfor admission




Benefits• Promotes length of stay management incontrast to bed management

• Values patient’s time and sets patientexpectations

• Effective and efficient use of bed capacity• Reduces length of stay to match theappropriate stay required for treatment andcare

• Shifts care to alternative appropriate caresettings

• Supports changes in clinical practice andclinical decision making

• Reduction in the duplication of tests• Reduction of inappropriate diagnostic tests.

Breast

Sandwell & West BirminghamHospital NHS TrustReduced length of stay for breast patient’s(including mastectomy patients) from 6.6 days to23 hours. Approximately 300 patients a yearwill benefit. All breast patients are now treatedin the treatment centre. Changes in clinicalpractice have supported this with robust pre-operative screening and wound drains are notinserted. Current medical audit of this hasshown a reduction in hospital acquired infectionand patient’s satisfaction with this new model ofcare has been very positive.

The 23 hour stay wasuniversally popular withpatients from allbackgrounds.

Hamish BrownBreast Consultant, Sandwell &West Birmingham Hospital NHS Trust

This new early dischargepathway enhances recoverytime, as patients recover athome in their ownenvironment. All of thepatients have been satisfiedwith the pathway.Luna VishwanathBreast Consultant, Sandwell &West Birmingham Hospital NHS Trust

Heart of England NHS Foundation TrustReduce length of stay for breast patients from2.6 days to 1.7 days by streamlining the electivebreast pathway and drain insertion becomingthe exception rather than the norm. Thispotentially can release 849 bed days per year forthe trust. The long term aim is to achieve 80%of breast cancer patients to be admitted underthe 23 hour model of care and have no drainswith no increase in seroma rates.

University Hospital Birmingham NHSFoundation TrustReduced length of stay from 4.6 days to anaverage of 12-23 hours. Testing included a nowound drain policy without adverse event. Thisproved to be successful and is now offered toall suitable patients. There has been noreadmissions and patient satisfaction is high.This practice is now being embedded.

All patients should be on a defined inpatient pathway based on theirtumour type and reasons for admission

‘’ If the 23 hour model for breast care was

spread across the West Midlands SHAand all breast providers reduced lengthof stay to 1.9 day average, this couldhave the potential of releasing 14,396bed days per annum (10.5%).

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The biggest challenge tointroducing enhancedrecovery to our team wastrying to change their deeplyheld ideas about patientrecovery. The Cancer ServicesCollaborative ‘ImprovementPartnership’ brought withthem energy, vigour and amotivating influence whichwas instrumental in changingthe culture of our team.

Satish BhaleraoConsultant, Sandwell & West BirminghamHospital NHS Trust

Colorectal

Queen Mary’s Sidcup NHS TrustBaseline of the traditional pathway identifiedthat the average total length of stay was 21.3days. Length of stay from the date of surgery forcolorectal patients was found to be 16.6 daysand the average stay in the intensive care unitwas 6.3 days. Readmission rate (within fourweeks) was found to be 11.6%. Testing of anintegrated care pathway supporting enhancedrecovery after surgery for colorectal patientsreduced the length of stay to 8.2 days average.Readmission rates have remained stable.

Sandwell & West BirminghamHospital NHS TrustPatients undergoing major colorectal surgerywere experiencing long variable lengths of stay.Testing the principles of enhanced recovery incolorectal identified that length of stay could bereduced significantly.

Procedure

Colectomy

Colostomyformation

Colostomyclosure

Baseline LOS(average)

16 days

12 days

12 days

Test Pathway

6 days

5 days

2 days

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Neurology

North London Cancer Network, TheNational Hospital and Norwich ParkHospitalSince its inception in February 2008 this projecthas succeeded in significantly reducing thepre-admission and post operative repatriationand discharge waiting times. In total, the timetaken from referral to repatriation - the entirecare pathway has been reduced by a mean of76% (60% reduction for pre-admission wait and84% for repatriation). This has been achievedby agreeing the length of stay and confirmingdischarge dates prior to transfer. The patientsare tracked through a trigger pathway thatcommences at the time of referral.

Referral toAdmission

AwaitingDischarge

Total

Mean WaitBaseline

2.5

5.5

8

No. of PilotPatients

21

14

Mean WaitPilot

1.1

0.8

1.9

Days Saved

1.4

4.7

6.1

Reduction%

56.4

85.6

76.5

This testing clearly demonstrated the need forhospitals to improve their collaboration andcommunication when transferring patients fortreatment. As a result of this work the NationalHospital for Neurology and Neuro-surgery isimplementing the strategy as a Service LevelAgreement (SLA) with all tertiary referringhospitals.



Shifting procedures from inpatient to day case

Barking, Havering and RedbridgeHospitals NHS TrustAnalysis showed that 65% of inpatient referralsfor tests and procedures came from theconsultant outpatient clinics. Many patientsspent hours waiting for procedures to be carriedout. Patients having a computerised tomography(CT) guided biopsy waited on average four daysfor the test to be performed and a further dayto be discharged.

The trusts aim was to avert inpatient admissionsfor procedures for all tumour groups by 50%.The outcome of testing indicated improvedinpatient bed utilisation by 80% by identifyingthe procedures that could be conducted as a daycase as timed procedures.

The diagram below shows a diary comparing thesame patient admitted for intravenousantibiotics to the haematology oncology ward inApril 2007 (baseline data) compared to day unitbed in May 2007 testing period.

Testing results suggest:• Inpatient admission avoidance for 80% ofpatients

• Access to specialist nurse advice duringassessment/treatments

• Enhanced continuity of care.

Inpatient assessment bed hours comparedto outpatient assessment bed hours



Carcinoma of Unknown Primary:Inpatient Pathways (Elective andEmergency)

St Helens & Knowsley Hospitals NHS TrustA retrospective audit covering a 15 monthperiod showed delays in referral to appropriatespecialists, inappropriate lengths of stay, lack ofcoordination and inappropriate investigationswith poor understanding of results andmanagement.

A joint Unknown Pathway was tested thatinvolved a multidisciplinary approach, radiologyalerts and improved clinical decision makingwithin 24 hours of referral.

The impact of this approach has resulted in areduction in unecessary investigations andreduction in length of stay by 20%.

Test Period Pathway

Early assessment by specialistservices is essential if furtherprogress is to be made in thisoften complex area ofdiagnosis and management.All cases of suspected cancershould be referred at theearliest opportunity andbefore extensive and oftenunhelpful investigation.

Ernie MarshallMacmillan Consultant in Medical Oncology

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Winning Principle 3

Clinical decisions shouldbe made on a daily basisto promote proactivecase management




Benefits• Reduction in length of stay• Proactive clinical decision making• Effective use of bed capacity• Valuing patient’s time• Enhance clinical governance and riskmanagement.

Royal Berkshire NHS Foundation TrustBaseline of emergency admission comparingtime from admission to being seen by a doctorhighlighted a significant difference betweenhaematology and oncology.

Time of admission to first seen byoncologlist

Clinical decisions should be made on a daily basis topromote proactive case management

Average time for Haematology = 23hours(range 12 to 46)Average time for Oncology = 41 hours(range 1-72)

Total length of stay

Average length of stay Haematology = 88hours(range 72-120hours)Average length of stay Oncology = 185 hours(range 72-360 hours)

Operating a haematologist of the week system,where by a consultant is freed from clinicalcommitments in order to carry out daily ward-rounds significantly reduces length of stay.Building upon the same concept differentmodels have been tested in oncology andfurther work is underway, early indication is thatthe medical consultant model as used inhaematology offers potentially more benefit.

Ensuring that patients withcancer are reviewed by anappropriate specialist on adaily basis is an importantstep in improving the qualityand efficiency of the care weoffer to our patients.Dr Jane BarrettConsultant, Royal BerkshireNHS Foundation Trust

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Milton Keynes HospitalNHS Foundation TrustTested the following hypothesis: Can the referralof patients with new or suspected cancerdisease recurrence to an advanced nursepractitioner at the point of emergency admissionreduce length of stay for these patients? Thereal problem identified was that patients werebeing admitted through various emergencyroutes resulting in poor co-ordination,communication and decision-making. Earlyintervention by an advanced nurse practitioner(ANP) at the point of entry resulted in areduction in the length of stay (baseline 23.8days to eight days). The ANP also providedadded value to the patient’s journey andexperience by reducing repeated tests,administrative duplication and a central point ofcontact. A number of initiatives as resulted fromthis work including the development of asupportive care integrated pathway for all(cancer and non cancer) emergency palliativecare patients.

Milton Keynes Supportive Care Integrated Pathway (MKSCIP)

Patient is referred to the trust and is assessed by the Advanced Nurse Practitionerand referred into the most appropriate stage of the MKSCIP, based on clinicalcomplexity and patient consent using a combination of assessment approaches.

Stage 1

New/suspecteddisease recurrence

Stage 2

Confirmed diseaserecurrence withcomplications/exacerbation

Stage 4

Liverpool CarePathway

Stage 3

Palliative Care



Brighton & Sussex UniversityHospitals NHS TrustThis testing site became one of the winners ofthe 2008 South East Coast Best of HealthWinners in the improving access category for re-designing, developing and instigated a new styleadmissions policy balancing the needs ofemergency and elective patients, by improvingclinical decision, the better utilisation of bedsand management of length of stay.

Area of Performance

% of all elective patients admittedon their original planned date

Actual length of stay comparedwith required/anticipated

% of priority elective (new primarycurative) patients admitted onoriginal planned date

Baseline

50%

29% exceeded planneddischarge date

64%

Results of Testing

81%

5% exceeded dischargedate

93%

The results indicate a significant improvementin the management of elective stays. Withapproximately 500 elective admissions per yearat the same level of improvement this has thepotential of releasing up to 250 bed days.Three key improvements have led to thissuccess.

• Developing an admissions priority table• Daily ‘paper ward rounds’• Weekly inpatient review meetings.

The pleasing aspect of this work is that theimprovements have been implementedseamlessly into ‘business as usual’ and they arenow accepted working practice. The next stageof this work is to investigate the emergencypathway and the use of RAPA alert systemswhich has been successfully tested atSherwood Forest NHS Foundation Trust.

We are absolutely delightedthe implementation of ourtimely clinical decision makingstrategies made such animpact. It certainly made themost efficient use of stafftime, but also undoubtedlyimproved the experience forthe patient.

Angus RobinsonConsultant Oncologist

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Winning Principle 4

Patient and carersneed to know abouttheir conditionand symptoms toencourageself-management,choice and to knowwho, where and whatto access first time




The above principle was identified bypatients and carers drawing upon theirexperiences, advice and requirements

Benefits• Reduced emergency admission andlength of stay

• Enhanced patient choice, awareness andself-management.

• Increase patient confidence in owndecision making

• Right pathway, right person, first time• Identified symptom pathways enhancingproactive prevention and care.

Blackpool, Fylde and Wyre HospitalsNHS Foundation TrustTested multiple approaches involving patientsand clinicians to reduce mortality and length ofstay through developing an emergency pathwayfor the management of emergency patients withneutropenic sepsis (see diagram on oppositepage). Winner of the 2007 Blackpool, Fylde andWyre Innovation Award.

Swindon and Marlborough NHS TrustBase lining identified that only 36% of patientswere treated with IV antibiotics within the firsthour of admission for neutropenic sepsis. Duringtesting, 78% were given Tazocin within onehour and 60% of those patients confirmedneutropenic were given Gentamicin within twohours.

East Sussex Hospitals NHS TrustInpatient paracentesis length of stay rangedfrom one to six days, testing involved carryingout the paracentesis procedure in the hospiceenvironment. This testing proved to besuccessful in enhancing patient choice, preferredplace of care and avoiding unnecessaryadmissions.

Further areas are being now explored includingParacentesis in radiology outpatients.

Patient and carers need to know about their condition and symptoms toencourage self-management, choice and to know who, where and whatto access first time.

Hull and East Yorkshire Hospitals NHS TrustPalliative care rapid response clinics avoided 63inpatient admissions, released 208 Bed daysduring the testing period and reduced length ofstay from 23.7 days – to average 7.7 days anaverage saving per patient of 26 days.

Northampton General Hospital NHS TrustTested the impact on length of stay foremergency lung patients by taking a stagedapproach that include:

• A strategy for the non-pharmacologicalmanagement of breathlessness in thecommunity with the aim of empoweringpatients and carers to manage their symptomsat home where appropriate. Working incollaboration with the PCT using agreedcriteria for assessment unnecessary admissionshave been avoided.

• Alert system for reducing emergency lungcancer patients.

Applying the principle of a communication alertsystem for known lung patients reduced lengthof stay from 12.5 average to 9.7 days.



Neutopenic Sepsis - Reduce mortality - Reduce length of stay (LOS)

Late emergencypresentation

High risk ofmortality

AimImprove patientawareness/promoteearly presentation,self management andpatient’s confidence

Save lives

Tested solutionsPromote self management andconfidence in the system

• Patient held alert card• 24 hour help line• Patient experience DVDcreated by patients for patients

ImpactCancer Partnership Groupundergoing audit of patientviews - positive feedback

Divisional audit onneutropenic sepsis toinclude presentation times

Multipleemergency accesspoints

Only 42% ofpatients go to theright place firsttime

AimRight place, first time

Improve patient,primary and secondarycare awareness

Tested solutions• One entry point• Direct admission to ward• Awareness campaign to GPs• Press release• Direct admission policy• Neutropenic sepsismanagement policy

Impact100% admitted went todesignated ward

Blackpool, Fylde and Wyre HospitalsNHS Foundation Trust

NHS

Delay intreatment

Only 8% ofadmissions receivedantibiotics withinan hour ofadmission

AimImprove door totreatment time for100% of patients

Tested solutions• Patient group directive forantibiotics given at pointof entry by nurse

Impact55% of patient’s receivedantibiotics within an hourof arrival

• No deaths

The approach to improving the emergency pathway for patients with Neutropenic Sepsis is underpinned byan agreed Neutropenic Sepsis Management Policy, listening and using the views of our patients.

This DVD is a good idea verbal information and leaflets donít really sink in because it is such adifficult time. You can’t take it all in itís a bit to much, but I think the DVD will stick in peoplesminds. Husband of a patient

Thanks for the DVD which I found very powerful. Every patient on chemo should have a copy.Diana’s statement that ‘I didn’t want to be any trouble, because they are so busy’ rang verytrue to me and it could have been my late wife speaking. Husband of a patient

I do think it is important that itís patients that feature on the DVD. I thought I knew better anddidn’t follow all the written advice but that’s what patients need to do. Patient

The patient’s stories in the DVD are very powerful and makes much more impact on otherpatients and carers understanding of the importance of presenting early. Lead cancer nurse



Further case studies, details and examples ofthe tools used and lessons learned can befound in the detailed case studies foundon the accompanying CD or at:www.improvement.nhs.uk

This is ongoing work and all the studies arereflecting the learning and stage of testing todate.

1. Unscheduled (emergency)patients should be assessedprior to the decision to admit.Emergency admission shouldbe the exception not the norm.

2. All patients should be on adefined inpatient pathwaysbased on their tumour typeand reasons for admission.

3. Clinical decisions shouldbe made on a daily basisto promote proactivecase management.

4. Patient and carers need toknow about their conditionand symptoms to encourageself-management and to knowwho to contact when needed.

Would you like to become involvedin this work?

For further information contact:

Ann DriverDirector, NHS Improvement.Email: [email protected]

Angie RobinsonNational Improvement LeadEmail: [email protected]

www.improvement.nhs.ukAssessment

prior toadmission






Winning Principle 1

Sherwood Forest HospitalsNHS Foundation Trust

United Lincolnshire HospitalsNHS Trust

University Hospitals ofMorecambe Bay NHS Trust

The Christie Hospital NHSFoundation Trust

Manchester Primary CareTrust

Barts and the London NHSTrust & Tower Hamlets PCT

Nottinghamshire CountyTeaching Primary Care Trust

Oxford Radcliffe HospitalsNHS Trust

United Lincolnshire HospitalsNHS Trusts/LincolnshireCounty Teaching PrimaryCare Trust, Sherwood ForestHospitals NHS FoundationTrust and NottinghamshireCounty Teaching PrimaryCare Trust (New ways ofworking with theAmbulance Service to avertadmissions)

Sherwood Forest HospitalsNHS Foundation Trust(Management of UnknownPrimary)

Whipps Cross UniversityHospital NHS Trust

The Hillingdon HospitalNHS Trust

Winning Principle 2

Sandwell & WestBirmingham HospitalNHS Trust (Breast)

Heart of England NHSFoundation Trust

University HospitalBirmingham NHSFoundation Trust

Queen Mary’s SidcupNHS Trust

Sandwell & WestBirmingham HospitalNHS Trust (Colorectal)

North London CancerNetwork, The NationalHospital and Norwich ParkHospital

Barking, Havering andRedbridge HospitalsNHS Trust

St Helens & KnowsleyHospitals NHS Trust

Kings College Hospital NHSFoundation Trust*

Scarborough and NorthEast Yorkshire HealthcareNHS Trust*

St Mark’s Hospital*

Queen Elizabeth The QueenMother Hospital, Margate,Kent*

Aptium - Focus onOncology and HaematologyWards*

Winning Principle 3

Royal Berkshire NHSFoundation Trust

Milton Keynes HospitalNHS Foundation Trust

Brighton & SussexUniversity HospitalsNHS Trust

Winning Principle 4

Blackpool, Fylde andWyre Hospitals NHSFoundation Trust

Swindon andMarlborough NHS Trust

East Sussex HospitalsNHS Trust

Hull and East YorkshireHospitals NHS Trust

Northampton GeneralHospital NHS Trust

* These trusts were not part of the testing work, but provided evidenceof good practice that supported and advised the areas of testing.


Assessmentprior to

admission






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Formed in April 2008, NHS Improvement bringstogether the Cancer Services Collaborative‘Improvement Partnership’, Diagnostics ServiceImprovement, NHS Heart Improvement Programmeand Stroke Improvement into one improvementprogramme.

With over eight years practical service improvementexperience in cancer, diagnostics and heart, NHSImprovement aims to achieve sustainable effectivepathways and systems, share improvementresources and learning, increase impact and ensurevalue for money to improve the efficiency andquality of NHS services.

Working with clinical networks and NHSorganisations across England, NHS Improvementhelps to transform, deliver and build sustainableimprovements across the entire pathway of care incancer, diagnostics, heart and stroke services.

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the winning principles - transforming inpatient care programme for cancer patients

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