Using integrated commissioning to improve Cancer Outcomes Barnet CCG Board Report

Transcription

1 Using integrated commissioning to improve Cancer Outcomes Barnet CCG Board Report Contributors: Elizabeth Babatunde, Victoria Bradburn, Teresa Callum, Rajeshtree, Yasmin Faroouqui, Emma Savage, Neil Snee, Clare Stephens, Charlotte Stone. Author: Dr. Clare Stephens Local clinicians working with local people for a healthier future 1

2 New ways of working 2

3 The Cancer Context: The Independent Cancer Taskforce Published five year strategy for cancer in July 2015 with aim to improve cancer services across the entire patient pathway by 2020: Fewer people getting preventable cancers More people surviving for longer after a diagnosis More people having a positive experience of care More people having a better, long-term quality of life Spearhead a radical upgrade in prevention and public health Drive a national ambition to achieve earlier diagnosis Establish patient experience on a par with clinical effectiveness and safety Transform our approach to support people living with and beyond cancer Make the necessary investments required to deliver a modern, highquality service Overhaul processes of commissioning, accountability and provision 3

4 Local delivery infrastructure: Cancer Alliances & Vanguard 16 Cancer Alliance footprints have now been confirmed in addition to three Vanguard sites Alliances and the Vanguard will: lead delivery of the Taskforce strategy locally reduce variation in outcomes through taking a whole-pathway and wholesystem approach become the cancer workstreams of relevant STPs Alliances will explore potential to put in place models for hardwiring clinical and pathway change across whole systems learning from the Vanguard 4

5 Bowel cancer screening coverage March 2015 (age 60-74) 60% 50% 40% 30% 20% 10% 0% England London Enfield Barnet Camden Islington Haringey Data from Public Health Profiles available at

6 Variation in uptake among Barnet practices 2015/16

7 Improving the uptake of bowel cancer screening within Barnet CCG Intervention More personalised reminders for non participants General practitioner endorsement More acceptable screening test Effect on participation in previous studies (absolute increase)* Typical 10% Typical 2-3%, but up to 20% Current intervention Enhanced reminder letters sent by screening hub since April 2016 GP endorsement letters sent by screening hub since June 2016 Future interventions Potential for locally commissioned service to target non participants Offer of support from CRUK to practices (GP bulletin Nov 2016) 15-20% FIT TEST spring 2018 * Data from Duffy SW et al (2016). Rapid review of evaluation of interventions to improve participation in cancer screening services. J Med Screen 0 (0) 1-19

8 Screening is important, but most people are diagnosed outside of screening programmes

9 GP readiness to act could partly explain international survival differences ADD TITLE (IN CAPITAL LETTERS!)

10 Barnet Prostate Cancer Stratified Follow Up Service Update : Service Specification and Outcomes Defined Primary Care Local Implementation Plans GP comms and education IT support GP Practice Sign Up Engagement of Stakeholders led by Steering Group CCG Clinical Leads Commissioning Mangers Urology Board Acute Trusts clinical leads and management Local Approval & Governance CCG Internal Approval Acute Trust clinical and management oversight Acute Trust Discharge & Rereferral Process in place Approval and Governance 1 Service Spec approval by NCL board Business Case review by Dir of Commissioning x 5 CCGs Approval and Governance 2 Service Spec and business case approval by NHS England Service Spec review by LMC Service commencement April 2017

11 QUIZ: Cancer Waiting Times for Colorectal Cancer? Cancer waiting times targets in Barnet were not met in 2015/16 for lower gastro-intestinal cancer 2week wait referrals target 93% X % of patients referred with suspected lower gastro-intestinal cancer were seen by a specialist within 2 weeks 31 day treatment target 96% X % of patients with lower gastro-intestinal tract cancer received their first treatment within 31 days of a decision to treat 62 day treatment target 85% X % of patients with lower gastro-intestinal tract cancer who had been referred urgently by their GP had started treatment within 62 days of referral Source: TCST Cancer Waiting Times Dashboard March

12 NCL Cancer Performance November data NCL Description Two-Week Wait 31-Day Wait 62-Day Wait Symptoma All tic Breast Cancers Patients 1st Treat 2nd/Su b (Surger y) 2nd/Su b (Chemo ) 2nd/Su b (RT) Urgent Referral Screening Operational Standard 93% 93% 96% 94% 98% 94% 85% 90% Great Ormond Street Hospital for Children NHS Foundation Trust 100% 100% 100% Moorfield Eye Hospital NHS Foundation Trust 100% 95% 100% North Middlesex University Hospital NHS Trust 95.6% 97.2% 100% 100% 100% 95.2% 94.9% 86.7% Royal Free London NHS Foundation Trust 94.2% 96.9% 100% 97.9% 100% 98.3% 82.1% 91.9% Royal National Orthopeadic Hospital NHS Trust 98.9% 100% 95.5% 100% University Colleage London Hospital NHs Foundation 96.7% 96.5% 96.7% 97.4% 100% 99% 75.0% Trust 94.4% The Whittington Health NHS Trust 97.2% 100% 100% 100% 100% 84.2% 100%

13 % Meeting Standard Royal Free London Cancer Performance RFL performance against 62 day GP referral standard Jan-16 to Nov % 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% 55.0% Not yet compliant with the 62-day standard but performance has been on an upwards trajectory since January % Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 % Meeting Standard 69.4% 69.0% 79.1% 79.5% 81.6% 85.8% 78.9% 76.0% 78.0% 73.7% 82.1% Target 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 13

14 Local Pathway improvements Lung straight to test. Patients referred on 2 week wait pathways now go straight to having a CT test before their first outpatient appointment. This eliminates a step in the pathway and increases efficiency as patients without cancer have fewer contact points. Reducing the wait for a diagnosis also reduces patient anxiety. We are monitoring to ensure this continues to deliver improvement. Prostate hot reporting. Hot reporting MRI scans is active in three prostate one-stop clinics, enabling patients to receive MRI results on the day and be booked directly into biopsy slots where required. Two further clinics will start hot reporting by the end of January. This process reduces the diagnostic pathway by approx.15 days, enabling us to refer more patients by day 38 for treatment. Teledermatology and Dermatology one-stop clinics A new teledermatology service was launched in Barnet and Enfield in November 2016, offering an alternative to 2WW referral with prompt response. For those patients who do need to attend a face-to-face appointment, one-stop surgical biopsy/excision clinics have been set up to streamline the pathway. Renal and HPB one-stop clinics. Both the Renal and HPB tertiary services have set up new one-stop clinics for patients referred for surgical treatment from other Trusts, incorporating consultant appointment, pre-assessment and imaging all on the same day. This reduces the time waiting for treatment, enabling us to treat more of our tertiary patients with 24 days of referral. MDT and RCA processes. The Trust has expanded the MDT Coordinator team, creating six new MDT Trackers so support pro-active tracking of patients along the cancer pathways. We have also introduced a new robust RCA process, with operational managers and clinical leads involved in investigating breaches and agreeing action plans to address issues. Pathway navigators. The clinical pathway navigators at the Royal Free Hampstead site are working closely with the consultants, CNSs and MDT Coordinator to help coordinate diagnostic pathways. They also act as a crucial link between the clinical team and patients during the diagnostic phase, liaising closely with patients to provide encouragement to attend appointments and tests, and support with taking bowel prep. 14

15 Quality assurance for patients on 62 day cancer pathways at RFL Below is a summary of the actions the CCG has taken and the improvements it is making in its work with RFL Quality Concern Patients breaching 62 day cancer pathways in 2016/17 Timeliness of completing Clinical Harm Review and Root Cause Analysis for patients who breach 104 days Legacy cohort of 104 day breaches from July 2014 to September 2015 Actions already taken and further improvements being made 1. The CCG has a local CQUIN 2016/17 in place with RFL to reduce the 2 week wait to 7 days for 40% of all patients seen. The Trust has to meet this improvement target by quarter 4 of 2016/17 2. The CCG has a sub group of RFL CQRG meeting which meets monthly/six weekly to seek quality assurance on 62 day cancer pathways. This meeting is attended by the RFL Medical Director 3. There were a total of 135 patients who breached the 62-day GP referral standard from July to September 2016, of which 36 related to breaches of 104 days or more. RFL has undertaken a Clinical Harm Review and Root Cause Analysis of all 36 patients, of which 33 have been classified as no/low harm and 3 have been classified as moderate harm. All lessons are learned to identify where further improvements could be made to the cancer pathways 1. There is no national guidance on how long a Clinical Harm Review and Root Cause Analysis takes to complete. The CCG are written to the RFL asking that reviews are completed within 60 working days (same as a serious incident) to ensure timely learning and actions from 104 day breaches 1. There were 129 patients who breached 104 days from July 2014 to September All patients were confirmed and no or low clinical harm following independent clinical review 2. There are a further 16 patients where an additional specialty review was requested to provide added assurance of the clinical harm rating owing to the cases being complex. Preliminary review is significant harm was unlikely. Final conformation will be provided to the Cancer Assurance Sub-group meeting in February 2017.

16 DRAFT FOR DISCUSSION The London Cancer Commissioning Operating Model How does Barnet fit in? Provides advice and reports to Accepts priorities presented by CCB and supports delivery Ensures strategic proposals for cancer fit with the wider spec comm strategy Agrees priorities and makes final decisions Cancer Commissioning Board (CCB) London Cancer Learning Partnership Cancer Vanguard (London) RM Partners ACN Two way relationship Provides input, information (and representatives) Alignment of priorities Formulates the pan-london programme and provides recommendations NWL STP NCL STP NEL STP SEL STP Commissioning governance SWL STP UCLH Cancer Collaborative SEL Cancer Alliance Delivery governance Specialised Commissioning Executive Group Cancer Commissioning Board Clinical Advisory Group (CCB CAG) Pan London Informatics Steering Group (PLISG) Pan London Cancer User Partnership 16

17 Cancer Strategy and Planning Contracting for Cancer Services Clinical Quality Review of Cancer Services Cancer Waiting Time Performance Roles and Responsibilities of the Commissioners: CCG Roles and Responsibility NCL Cancer STP Roles and Responsibility Lead commissioners to manage NHS standard contract performance Lead commissioners to review clinical quality of cancer services for local populations at CQRM/G Re-state and monitor contractual obligations for managing cancer waiting times performance and issue good practice guidance Where performance issues are shared across a pathway or locality, NCL CCB will working jointly to resolve issues in the Performance Leadership Group Re-state and monitor contractual obligations for conducting CQRM/G in relation to cancer and issue good practice guidance Where cancer services are commissioned at a level above local populations, NCL CCB will ensure the review of clinical quality of such services by either: Appointing a lead commissioner; Or convening an SPG/STP level CQRM/G as a sub group of the Performance Leadership Group Lead commissioners to manage the NHS standard contracts held with cancer service providers Monitor contract KPI status in relation to cancer services and issue good practice guidance Lead commissioners to submit an operating plan for local cancer services, to hold a local strategy for cancer and to plan implementation accordingly Monitor the status of local plans for strategy implementation and issue good practice guidance Where cancer services are commissioned at a level above local populations or across entire pathways, NCL CCB will function as a programme board to support delivery. 17

18 DRAFT FOR DISCUSSION Strategic priorities across London: North Central London North Central London Overview of governance Develop Primary NCL Cancer Care Priorities Commissioning Board to ensure links with NEL maintained and ensure relevant reporting arrangements in place Strong local working arrangements across NCL already in place Local groups will continue to support clinical/provider collaboration and pathways Joint performance management and governance with work with NEL given pathways and performance. Key aims Ensure best patient care through delivery of the national strategy, with emphasis on 62 day target Work with providers and primary care to understand and address performance issues Earlier diagnosis Review and address variations between level of 2ww between practices Raise awareness in GP Practices in relation to cancer wait times across providers Prevention smoking, lifestyle issues, improve and address screening variation. Key commitments for 2017/18 Achieve median wait of 7 days for breast, urology and 1 other tumour site Establish alternative referral routes: direct access, MDC Training for GP s on NICE guidance and informing patients regarding referral ITT s: transfer by day 38 in accordance with national guidance Tumour site sector deep dives for urology, lung Reduce polling time for 7 days to prevent build up of backlog Consider further consolidation and integrate vanguard advances in pathways to support early diagnostic or reduction of pathway times. 18

19 NCL Cancer Improvement Plan 1. NCL s aggregated 62 day wait cancer performance improved in November - the system is now 3.1%* behind on its trajectory Novembers 62 day Performance: Actual Performance: 81.9% NCL Trajectory: 85.0% Cancer Standard: 85.0% NMUH hospital & Royal RNOH achieved the 62 day cancer standard Whittington Health achieved 84.2%, which was 0.8% away from the standard RFF (L) performance was 82.1% ULCH s performance was 75.0% Priority Pathways linked to performance Urology Reason: Urological pathways consistently account for the largest breach type and there have been 61 Urology breaches in the last 3 months Breast Reason: Breast pathways achieving mean of 7 days days is vital to support internal compliance Lower GI Reason: After Urology the next highest number of breaches were 21 attributable to Lower GI Diagnostics Reason: Timely access to diagnostics is an essential part of meeting all cancer access and RTT targets. Progress made A detailed root caused analysis (RCA) for breach patients has been completed with the Urology Tumour Board. Jointly with the NCEL Cancer Performance Leadership Group three key areas were identified to improve performance and patient experience The first urology task and finish group was held on 19 th January On the 7 th November 2016 the NCL Cancer Commissioning Board requested a sub group look at current provisions of breast services in North Central London Each provider has self assessed themselves against the Pan London endorsed service specification. On the 12 th January 2017 the NCL Cancer Commissioning Board requested a root caused analysis (RCA) to be undertaken patient breaches within Lower GI Working with TCST providers and commissioners attended diagnostic optimisation workshop. Based on the information gathered at the workshop a number of diagnostics issues were priortised. Each Trust submitted plans to address the key prioritises within their endoscopy and radiology services. Next Steps * Based on NHSE figur Project scope being defined including timescales and deliverables on 3 key areas Reduction in biopsy waiting times & reporting Reduction in admin delays Alignment of MDTs The next NCEL Cancer Performance Leadership Group will review and sign off deliverables on 24 th January All self assessments are due to be completed on 27/01/17. Working with the Breast Tumour Board a stocktake meeting will be held on 20/02/17 with clinicians from all providers. The gap analysis and high level recommendations will be presented at the next NCL Cancer Commissioning Board on 7 th March 2017 One to one meetings with trusts breeching the 62 cancer standard in Lower GI TCST and NCL SPG to confirm any support arrangements to late submitting trusts The NCL Cancer Commissioning Board will be resonsbilbe for the on-going monitoring of progress against the trust diagnotsic optmisation plans ITTs ITTs SoP currently being developed across NCEL to ITT SoP to be signed off and implemented across NCEL.

20 DRAFT FOR DISCUSSION Delivery of cancer services in London There are many examples of excellent service delivery in London The Institute of Cancer Research, London, is the topranked academic research centre in the UK BMJ award Innovation Team of the Year; Innovations in Prostate Cancer, University College London Hospital and UCL GP endorsement of centralised bowel screening and roll out of electronic urgent, suspected cancer referral forms will support 2020 ambitions for early diagnosis Stratifying patients into supported selfmanagement pathways has the potential to release 44,000 outpatient appointments BMJ award Cancer Care Team of the Year. Barnet Ambulatory Lung biopsy service 2016 Health Business Award- Guys Cancer Centre for hospital building of the year But there is more to do to respond to some of the current challenges. Cancer wait performance against the 62 day standard in London has not improved over the past 12 months and overall the capital is still not meeting the standard For many Trusts, diagnostics is a significant bottleneck; rising demand is expected to continue for the next few years. Workforce is a significant challenge Satisfaction with primary and community cancer care is below the England average London performs significantly below national 2020 ambitions for supporting early diagnosis, including screening uptake and diagnosing cancer at stage 1 or 2 20

21 St George's Healthcare Royal Marsden Kingston Hospital Epsom & St Helier Croydon Healthcare South London Healthcare Lewisham Healthcare Kings College Guys & St Thomas West Middlesex Royal Brompton & Harefield North West London Imperial College Hillingdon Ealing Hospital Chelsea & Westminster Data as a motivator I :London Cancer Alliance Staging Completeness 2011 / % Target 0% 25% 50% 75% 100% Complete Full Stage Partial Partial Stage

22 St George's Healthcare Royal Marsden Kingston Hospital Epsom & St Helier Croydon Healthcare South London Healthcare Lewisham Healthcare Kings College Guys & St Thomas West Middlesex Royal Brompton & Harefield North West London Imperial College Hillingdon Ealing Hospital Chelsea & Westminster Data as a motivator 2 : London Cancer Alliance Staging Completeness Year to Sept % Target 0% 25% 50% 75% 100% Complete Full Stage Partial Partial Stage

23 Opportunities in Barnet with CRUK: Increase the focus and support available to the NHS to increase the uptake of cervical & bowel screening. support the implementation of the NICE guidance at a GP practice level support and encourage Significant Event Audits at a practice level. Extend the programmme to build knowledge amongst pharmacists and dentists. Begin to promote the evidence base in primary care for Very Brief Advice (VBA) as a strategy for behaviour change and provide support and training as required. Highlight issues raised in general practice regarding referral/diagnostic pathways to commissioners. 23

24 Messages for Barnet Improve the whole pathway :- Promotion of screening / Earlier Diagnosis / Stratified follow-up / LWB / Insist on Excellent data unleash the potential of robust large data sets Innovative commissioning solutions segmentation of pathways with activity and resourcing requirements also identified Consider if clinical service needs rationlisation of delivery to ensure best care provision Ensure a Clinically led Strategy The Art of Good Commissioning: consider potential ripple effects, be innovative, be persistent. 24

25 Achieving results for cancer care in Barnet: commissioning, integration, pathway innovation and improving outcomes Thank you 25