OCCG Board Meeting. Oxfordshire Clinical Commissioning Group. Date of Meeting: 30 November 2017 Paper No: 17/80

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1 OCCG Board Meeting Oxfordshire Clinical Commissioning Group Date of Meeting: 30 November 2017 Paper No: 17/80 Title of Paper: SCAN Pathway Project Update Paper is for: (please delete tick as appropriate) Discussion Decision Information Purpose and Executive Summary: 1.0 Background This is a new project for Oxfordshire and the attached paper updates on progress. OCCG are working in collaboration with the OUHFT, NHSE Thames Valley Cancer Alliance, Nuffield Department of Primary Care Health Sciences, Cancer Research UK and Macmillan Cancer Support via the CRUK ACE Programme. The programme has come about to help improve the poor cancer performance rates in England, which falls behind many other countries in mainland Europe. After improving the current 2ww referral process across Oxfordshire with new mandatory forms (based on the 2015 NICE cancer guidelines) to ensure right slot, first time appointments, it was obvious that some patients did not fit specific criteria; however they were suspected of having cancer by the GP. People registered with an Oxfordshire CCG General Practice who are over 40 years of age are included within the scope of this ACE MDC Service, if they are suffering from vague or non-specific symptoms and clinical signs, that may represent cancer or serious disease, but do not already have a designated pathway for urgent investigation or referral 3.0 Progress to date All Oxfordshire GPs now have access to this pathway for their patients. The service is currently scanning referrals per week and has seen a total of 112 patients (Between 15/03/17 27/10/17). See appendix 1 for further detail The top systems for referral have been weight loss and GP gut feeling. 100% of these patients have received a diagnosis within 28 days and only two patients with a cancer diagnosis had had to undergo additional imaging following their CT scan. The current cancer conversion rate is 15% which is equal to 17 patients 3 patients have been diagnosed at an early stage. Paper 17/80 30 November 2017 Page 1 of 8

2 Financial Implications of Paper: Funding awarded by CRUK until end of FY18/19 Action Required: For information only OCCG Priorities Supported (please delete tick as appropriate) Operational Delivery Transforming Health and Care Devolution and Integration Empowering Patients Engaging Communities System Leadership Equality Analysis Outcome: This was completed and signed off at business case stage. Link to Risk: AF19 QPC AF22 QPC 798 QPC QPC Author: Zoe Kaveney, Planned Care Project Manager Clinical / Executive Lead: Shelley Hayles Clinical Lead shelley.hayles@nhs.net Date of Paper: 14 November 2017 Paper 17/80 30 November 2017 Page 2 of 8

3 Oxfordshire Clinical Commissioning Group The Oxford Suspected CANcer (SCAN) pathway 1.0 Background This is a new project for Oxfordshire. OCCG are working in collaboration with the OUHFT, NHSE Thames Valley Cancer Alliance, Nuffield Department of Primary Care helath Sciences, Cancer Research UK and Macmillan Cancer Support via the CRUK ACE Programme. The programme has come about to help improve the poor cancer performance rates in England, which falls behind many other countries in mainland Europe. A 2-Week Wait (2WW) referral pathway for suspected cancer was introduced in Nevertheless, a significant proportion of patients are diagnosed by other routes (c.24% of lung via A&E) and only a small proportion of 2WW referrals actually have cancer. There is an increasing incidence with age ( >50% in over 70 s) which is putting pressure on all aspects of the health service due to demographic changes, with a predicted 1 in 2 people being diagnosed with cancer by Cancer prevalence is predicted to rise by more than 3% a year, as more people are either living with or surviving cancer. After improving the current 2ww referral process across Oxfordshire with new mandatory forms (based on the 2015 NICE cancer guidelines) to ensure right slot, first time appointments, it was obvious that some patients did not fit specific criteria; however they were suspected of having cancer by the GP. An audit showed that this group of patients (low-risk-not-no-risk) can bounce around the system between specialists due to the lack of an obvious organ specific cause; often having many tests but not getting a diagnosis until late in the day, incurring emotional and financial sequelae. So, in line with the Five Year Forward View and NHSE s Achieving World Class Cancer Outcomes report; this area needed addressing, to increase earlier diagnosis at stage I and II. The proposed SCAN pathway includes a set of tests performed / requested by their GP, straight to test total body CT scan and having the patient seen by a specialist within 14 days. By using this approach, it is hoped to reduce the delay in diagnosis and increase the cancer pick-up rate by as much as 16% in line with the Danish study that took this approach 1 whilst also removing some patients from the 2ww system. 1 Ingeman et al. BMC Cancer (2015) 15:421 Paper 17/80 30 November 2017 Page 3 of 8

4 2.0 Project Aims and Objectives To develop a Suspected CANcer (SCAN) Multi-Disciplinary Centre (MDC) Pathway. The pilot introduced a new diagnostic pathway for patients with low-risk but not norisk symptoms of cancer (such as fatigue, anaemia and weight loss) who fall outside the regular 2-week-wait referral pathways. Following GP direct access tests there is an MDC triage system, run by senior generalist clinicians, offering the options of further GP management in primary care, further testing in secondary care, or movement into the relevant treatment pathway. This pathway should take no more than 2 weeks and aims to; Improve patient experience by reducing time from first referral to diagnosis Reduce the number of emergency presentations Support GP referral processes Measure the impact on referrals made to existing 2ww pathways Reduce cancer stage at diagnosis by lowering the referral threshold for suspected cancer Identify the optimal configuration of GP and specialist input to diagnose cancer in this group By treating patients on this pathway it is hoped that demand on secondary care services will also be relieved, as it is likely that fewer investigations will be required overall and patients will see the correct clinican first time. This should enable increased capacity and consultant resource along exsiting 2ww pathways in secondary care. 2.1 Scope of the service People registered with an Oxfordshire CCG General Practice who are over 40 years of age are included within the scope of this ACE MDC Service, if they are suffering from vague or non-specific symptoms and clinical signs, that may represent cancer or serious disease, but do not already have a designated pathway for urgent investigation or referral. The scope also covers; Patients who have been referred on a 2ww pathway and have received a negative result but where the GP still suspects cancer. Patient choice and appointment booking Community based diagnostics and treatment Secondary care based diagnostics and treatment Referral, triage and assessment processes Special requirements for patients with a disability 7 day turn-around from referral to review of results by the MDC Exclusions Those patients already on a designated pathway for urgent investigation or referral Those patients who are suitable for a 2ww pathway Referral via secondary care emergency attendance Paper 17/80 30 November 2017 Page 4 of 8

5 2.2 The Pathway This pilot has been developed to address a range of features outlined in the ACE Programme briefing documentation: Establish if triage is best conducted within the remit of primary care or secondary care Establish the advantages of GP access to direct access diagnostics and an MDC, over greater GP direct access to diagnostics alone Establish the breadth of tests i.e. what tests should be included within the boundaries of triage versus investigative diagnostics Establish if there is an optimum sequencing for the tests/diagnostics e.g. conducted in parallel or in series Determine appropriate referral thresholds and performance metrics; understanding impact of changes on current or new cancer targets Explore how best to organise for efficiency and patient experience Rapid turnaround of triage tests and investigative diagnostic test results. E.g. in Denmark triage/filter tests results provided in 4 days Explore access channels for GP & self-referral routes e.g. digital, telephone, face-to face Outline Design The proposed MDC diagnostic pathway will replicate the Danish pathway for patients with non-specific symptoms and signs of cancer (NSSC-CPP) (Ingeman 2015, Vedsted 2015). The pathway will retain GPs gate-keeping function, requiring patients to first attend their GP with symptoms to access the pathway. Stage 1: GP direct access triage tests using a standardised multidisciplinary referral algorithm with rapid turnaround of <5 days, to include a panel of blood tests, faecal immunochemical testing, and appropriate low-dose CT imaging GPs will retain clinical responsibility for the patient, and will be asked to indicate their suspicion of malignancy (their gut feeling ) at this stage. The resulting body of samples will provide a huge resource for retrospective analysis at a later date should this be required. Stage 2: The clinical information obtained in stage 1 will direct the patient s subsequent flow through the pathway: A] Referral for additional direct access investigation such as OGD within 1 week. B] Automatic referral to Cancer site group via agreed patient pathway C] Referral to MDC Stage 3: At the point of referral to the MDC the accepting hospital clinician will become the responsible MDC clinician. At MDC, the sequence of testing will be determined by the accepting clinician. Stage 4: If no diagnosis is reached by moving through the pathway, the patient will be followed up for 2 years, led by the GP using a structured follow-up plan allowing re-entry to the pathway if necessary. By passing through the MDC, the patient will be granted access to allied health professional input (dietician, physiotherapy, psychology) where necessary. Paper 17/80 30 November 2017 Page 5 of 8

6 3.0 Progress to date All Oxfordshire GPs now have access to this pathway for their patients. The service is currently scanning referrals per week and has seen a total of 112 patients (Between 15/03/17 27/10/17). See appendix 1 for further detail The top systems for referral have been weight loss and GP gut feeling. 100% of these patients have received a diagnosis within 28 days and only two patients with a cancer diagnosis had had to undergo additional imaging following their CT scan. The current cancer conversion rate is 15% which is equal to 17 patients 3 patients have been diagnosed at an early stage. Feedback from GPs who have used the service so far has been very positive o 90% GPs find referring to SCAN either fairly or very convenient o 100% very satisfied with the speed that their patients were seen by the SCAN team o 100% would be willing to recommend SCAN to a colleague o 100% likely to refer to SCAN in the future We have also had very positive feedback from patients who have used the service; o Exceptionally friendly and professional staff. If I had any concerns they were dealt with in a kind and friendly manner o A smoothly run operation o Clear explanations Paper 17/80 30 November 2017 Page 6 of 8

7 Name Zoe Kaveney Job Title Project Manager Planned Care Date 14/11/2017 Paper 17/80 30 November 2017 Page 7 of 8

8 Appendix 1 Oxford SCAN Pathway Activity No. of patients referred to SCAN No of referrals rejected No. of patients scanned No. of referrals to MDC No. of referrals to cancer MDT No.of patients referred back to their GPs Date (w/b) Weekly Cumulative Weekly Cumulative Weekly Cumulative Weekly Cumulative Weekly Cumulative Weekly Cumulative 03/04/ /04/ /04/ /04/ /05/ /05/ /05/ /05/ /05/ /06/ /06/ /06/ /06/ /07/ /07/ /07/ /07/ /07/ /08/ /08/ /08/ /08/ /09/ /09/ /09/ /09/ /10/ /10/ /10/ /10/ Paper 17/80 30 November 2017 Page 3 of 8