The Single Cancer Pathway

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1 The Single Cancer Pathway

2 Background and Case for Change

3 Case for Change (1) Broadly patient experience of cancer services in Wales is good: 93% of patients rate their care as 7/10 or better (WPES) But survival compared to other developed countries is poor (ICBP)

4 The consistency of this finding suggests this is less related to use of treatment but the way the system is working (ICBP, Eurocare, Concorde) Five year relative survival rate comparisons for Wales 5-year-age-standardised relative survival for adult patients with cancer, diagnosed De Angelis R, Sant M, Coleman MP, et al. Cancer survival in Europe by country and age: results of EUROCARE-5 a population-based study. The Lancet Oncology 2013

5 International Cancer Benchmarking Partnership Module 1: Inferior survival likely related in part to late stage presentation (1 year survival surrogate for stage at presentation)

6 International Cancer Benchmarking Partnership Module 3: GPs in Wales less likely to refer and/or investigate for a given set of signs and symptoms This correlated with worse survival

7 International Cancer Benchmarking Partnership Module 4: After presentation patients in Wales spend longer in healthcare system before starting treatment than other countries/jurisdictions

8 State of Diagnostic Services in Wales 9-10% increase in CT, MR, Endoscopy year on year 10-50% posts vacant in Wales, all HBs outsourcing 30% of workforce could retire in next 5 years >50% current workforce >10 (many >12), unable to attract trainees, <50% primary care timely direct access to NICE recommended diagnostics 7 radiologists per 100, 000 compared to European average CT scanners per million, compared with 35 in Denmark Situation similar or worse across primary care and pathology

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11 Case of Mr Jones 72 year old previously fit male t0 PS 0 DG 1 72Kg Noticed food sticking in October 17, saw GP, prescribed PPI Rapid access OGD Jan, malignant stricture lower oesophagus Referred to Upper GI team (nusc), seen within 2 weeks CT scan and local MDT 2 weeks EUS (Carmarthen) and PET 3 weeks CPEX in further 2 weeks MDT 10 days after PET, T4N1M0 cancer, refer to oncology Seen within 2 weeks, unable to swallow, referred for a stent t90 PS 1 DG2 68Kg t120 PS 2 DG 3 64Kg

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13 April 2012 May 2012 June 2012 July 2012 August 2012 September 2012 October 2012 November 2012 December 2012 January 2013 February 2013 March 2013 April 2013 May 2013 June 2013 July 2013 August 2013 September 2013 October 2013 November 2013 December 2013 January 2014 February 2014 March 2014 April 2014 May 2014 June 2014 July 2014 August 2014 September 2014 October 2014 November 2014 December 2014 January 2015 February 2015 March 2015 April 2015 May 2015 June 2015 July 2015 August 2015 September 2015 October 2015 November 2015 December 2015 January 2016 February 2016 March 2016 April 2016 May 2016 June 2016 July 2016 August 2016 September 2016 October 2016 November 2016 December 2016 January 2017 February 2017 March 2017 April 2017 May 2017 June 2017 July 2017 August 2017 September 2017 October 2017 November 2017 December 2017 Percentage of people starting treatment within 62 days of referral Percentage of people USC 62 day performance (%) against target in Wales over last 5 years nusc 31 day performance (%) against target in Wales over last 5 years Percent Percentage of people starting treatment within 62 days of USC referral in Wales Apr Dec 2017 Percentage of people starting treatment within 31 days of agreeing their plan for all cancer sites in Wales % 90% 80% 95% 86% 100% 98% 98% 70% 96% 60% 94% 50% 92% 40% 30% 90% 20% 88% 10% 86% 0% 84% 82% Month 80% Year Wales Target

14 Variation in the System

15 Conversion rates for all cancers by HB in 2017 Detection rates for all cancers by HB in 2017 Conversion Rate for all cancer sites by health board for 2017 Detection Rate for all cancer sites by health board for % 60% 54.1% 10.0% 8.0% 6.9% 10.2% 7.4% 7.4% 8.2% 8.5% 7.9% 50% 40% 45.3% 44.2% 47.1% 33.1% 44.1% 44.8% 6.0% 30% 4.0% 20% 2.0% 10% 0.0% Betsi Cadwaladr University Health Board Hywel Dda University Health Board Abertawe Bro Morgannwg University Health Board Cwm Taf University Health Board Aneurin Bevan University Health Board Cardiff and Vale University Health Board Wales 0% Betsi Cadwaladr University Health Board Hywel Dda University Health Board Abertawe Bro Morgannwg University Health Board Cwm Taf University Health Board Aneurin Bevan University Health Board Cardiff and Vale University Health Board Wales

16 Conversion Rate Detection Rate Conversion rates for all UGI cancers by HB in 2017 Detection rates for all UGI cancers by HB in % USC Conversion rate for Upper Gastrointestinal Cancer by Health Board for 2017 Detection Rate of Cancer via USC pathway by Health Board for 2017 Upper Gastrointestinal Cancer 9% 8.5% 70% 8% 60% 58.4% 7% 6% 5% 4% 3.7% 5.9% 3.4% 4.3% 4.2% 50% 40% 30% 41.4% 35.7% 36.0% 34.3% 35.1% 3% 20% 2% 1% 1.7% 10% 11.1% 0% Betsi Cadwaladr University Health Board Hywel Dda University Health Board Abertawe Bro Morgannwg University Health Board Cwm Taf University Health Board Health board Aneurin Bevan University Health Board Cardiff and Vale University Health Board Wales 0% Betsi Cadwaladr University Health Board Hywel Dda University Health Board Abertawe Bro Morgannwg University Health Board Cwm Taf University Health Board Cancer Site Aneurin Bevan University Health Board Cardiff and Vale University Health Board Wales

17 Conversion Rate Detection Rate USC conversion rates by cancer site in 2017 Detection rates by cancer site in % USC Conversion rate for all Wales by Cancer Site for 2017 Detection Rate of Cancer via USC pathway by Cancer Site for all Wales for % 20% 19.8% 50% 46.6% 52.2% 15% 15.2% 40% 35.1% 37.0% 37.1% 30% 10% 7.9% 20% 5% 4.2% 4.7% 10% 0% Upper Gastrointestinal Lower Gastrointestinal Lung Breast Urological Cancer site 0% Upper Gastrointestinal Lower Gastrointestinal Lung Breast Urological Cancer Site

18 The Single Cancer Pathway

19 Percentage of people Percentage of people starting treatment in 62 days from referral Cancer Waiting Times (in Wales but similar to England) 100% 90% Percentage of people starting treatment within 62 days of USC referral for all cancer site groups in Wales % 80% 62 day pathway for Urgent Suspected Cancer (USC) primary care referrals from receipt of referral Performance Wales ~ 85-90% 70% 60% 50% 40% 30% 20% 10% 0% Wales Target Percentage of people starting treatment within 31 days of agreeing their plan for all cancer sites in Wales % 31 day pathway for non USC from point patient agrees treatment plan Performance Wales ~ 95-98% 98% 96% 94% 92% 90% 98% 88% 86% 84% 82% 80% Year Wales Target

20 USC Pathway 62 day pathway Day 0 Day 62 Point of Suspicion (PoS) Referral Diagnosis Date of Decision to Treat Treatment Time NOT currently captured by CWT ~35-45% of cancers diagnosed via USC pathway Time in system NOT currently captured by CWT ~55-65% of cancers identified via non-usc pathway Key: - These waits will be exposed under the proposed SCP reporting Non-USC Pathway 31 day pathway

21 Days Patient 1 - Dec-13 Patient 4 - Nov-15 Patient 7 - May-16 Patient 10 - Aug-16 Patient 13 - Sep-16 Patient 16 - Nov-16 Patient 19 - Dec-16 Patient 22 - Jan-17 Patient 25 - Jan-17 Patient 28 - Jan-17 Patient 31 - Feb-17 Patient 34 - Mar-17 Patient 37 - Mar-17 Patient 40 - Mar-17 Patient 43 - Apr-17 Patient 46 - Jun-17 Patient 49 - Jul-17 Patient 52 - Jul-17 Patient 55 - Sep-17 Patient 58 - Sep-17 Patient 61 - Oct-17 Patient 64 - Oct-17 Patient 67 - Nov-17 Patient 70 - Dec-17 Cancer Waiting Times (in Wales but similar to England) Average 70 Median 65 95th Percentile The majority (~55-65%) of cancer patients are diagnosed via the nusc pathway Approximately 50% of patients on complex pathways wait > 62 days on nusc pathway from point of suspicion This reporting of this CWT does not reflect patient experience, does not reflect diagnostic capacity challenges and does not drive pathway improvement OGD to Rx Median Expected Actual Patient Waiting times for UGI patients from Point of Suspicion i.e. OGD

22 Percentage USC CWT performance by HB & Cancer Site Sept Dec % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 88% Percentage of people starting treatment within 62 days of USC referral for all cancer site groups by health board for Sept - Dec % Betsi Cadwaladr Hywel Dda University University Health Board Health Board 86% Abertawe Bro Morgannwg University Health Board 89% 89% 89% 88% Cwm Taf University Health Board Aneurin Bevan Cardiff and Vale University Health Board University Health Board Wales 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percentage of people starting treatment within 62 days of USC referral by Cancer Site in Wales Sept - Dec % 75% Upper Gastrointestinal Lower Gastrointestinal Lung Breast Urological 89% Cancer Site Group 94% 89%

23 April 2012 May 2012 June 2012 July 2012 August 2012 September 2012 October 2012 November 2012 December 2012 January 2013 February 2013 March 2013 April 2013 May 2013 June 2013 July 2013 August 2013 September 2013 October 2013 November 2013 December 2013 January 2014 February 2014 March 2014 April 2014 May 2014 June 2014 July 2014 August 2014 September 2014 October 2014 November 2014 December 2014 January 2015 February 2015 March 2015 April 2015 May 2015 June 2015 July 2015 August 2015 September 2015 October 2015 November 2015 December 2015 January 2016 February 2016 March 2016 April 2016 May 2016 June 2016 July 2016 August 2016 September 2016 October 2016 November 2016 December 2016 January 2017 February 2017 March 2017 April 2017 May 2017 June 2017 July 2017 August 2017 September 2017 October 2017 November 2017 December 2017 USC Referrals USC Referrals Numbers of Total USC referrals in Wales Number of USC Referrals in Wales by year between Jan Dec 2017 Measure Number of USC Referrals in Wales by month between April December Year Month

24 USC Referrals USC Referrals UGI numbers USC numbers treated UGI within time per quarter Sept Dec Run Chart: Number of USC Referrals in Wales by year between Jan Dec 2017 Upper Gastronintestinal 100% Percentage of people starting treatment within 62 days of USC referral for Sept - Dec 2017 Upper Gastrointestinal 100% Median % 80% 70% 88% 86% 72% 67% 69% 79% % 50% % % 20% 0 10% Year 0% Betsi Cadwaladr University Health Board Hywel Dda University Health Board Abertawe Bro Morgannwg University Health Board Cwm Taf University Health Board Aneurin Bevan University Health Board Cardiff and Vale University Health Board Wales

25 USC Referrals USC Referrals USC Referrals numbers UGI & LGI Run Chart: Number of USC Referrals in Wales by year between Jan Dec 2017 Upper Gastronintestinal Run Chart: Number of USC Referrals in Wales by year between Jan Dec 2017 Lower Gastronintestinal Median Median Year Year

26 Ministerial and CIG response Pressure on system to comply with current CWT targets 2015 asked for clinical review of CWT targets Clinical view Waiting times important for patients and clinicians System should work better and 62 days max time Not in favour of exclusions 2016/17 WG/Network response Pilot new suspected cancer (SC) pathway starting at PoS (where nec as defined by NG12) Pilot suggested 20% increased demand in diagnostics but requirement for improved pathways and not including required increase for NG12 Autumn 2017 Cabinet secretary indicated support for move to SCP Urged NHS Wales to prepare to be compliant with a 62 day SCP target

27 Summary Patients have relatively poor survival in Wales with stage at diagnosis a key factor in this Patients are waiting too long in the healthcare system before receiving treatment The current system of CWT reports contains hidden waits, does not reflect patient experience, does not report inadequate diagnostic and treatment capacity and does not drive improvement CEOs, Chairs, CIG, CSG, WCN, HB/Trusts agree: A single suspected cancer pathway that reports waiting times for all patients from the point of suspicion is.. THE RIGHT THING TO DO The benefits should lead to better patient outcomes (survival, experience), better patient support and less costly treatment No one underestimates the challenge but we must work together, share best practice and be open to change

28 Achievements to Date Briefing document for Cab Sec and CEOs Suite of best practice Peer review of HB SCP Plans 8 site specific optimum pathways Received and reviewed HB Implementation Plans Worked with NWIS to define PoS, impact assessment for DSCN Worked with DU to determine capacity and demand model Worked with 1000 lines re improvement approach and 5 workshops Meetings with Cab Sec and WG

29 Plans Meeting with CEOs, Chairs and Cab Sec Oct 22 nd Submit advice re requirement for increased funding for diagnostics and national SCP Programme HB to use C&D to inform IMTPs (meet current gap and forecast demand) Q Implement new Tracker 7 and embed in HB PAS systems by May 2019 Likely to publish SCP performance from April/May 2019 Continuous improvement work in 2019? 95% compliance by April 2020

30 SCP Performance

31 SCP Upper GI overall monthly average Apr 17-Dec 17 by HB 70%

32 SCP Lower GI overall monthly average Apr 17-Dec 17 by HB 58% 65% 55% 59% 54% 69%

33 SCP Urology overall monthly average Apr 17-Dec 17 - by HB

34 SCP Lung overall monthly average Apr 17-Dec 17 by HB 70% 75% 74% 71% 71% 59%

35 SCP Gynaecology overall monthly average Apr 17- Dec 17 by HB 70% 54% 50% 50% 57% 24%

36 SCP Head & Neck overall monthly average Apr 17-Dec 17 by HB 80% 76% 70% 60% 54% 57% 63% 57% 50% 45% 40% 30% 20% 10% 0% AB ABMU BCU CT C&V HD

37 SCP Breast overall monthly average Apr 17-Dec % 90% 87% 94% 96% 86% 96% 80% 70% 72% 60% 50% 40% 30% 20% 10% 0% AB ABMU BCU CT C&V HD

38 New rules.. Single Suspected Cancer Pathway Definitions pathway start date Date: March 2018 Version: Wales Cancer Owner: Network and Welsh Government Status Published

39 How do we do this? Best Practice Principles Implementing enabling systems and infrastructure Standardising and improving the whole patient pathway Point of suspicion Tracking Information and Intelligence Capacity and Demand Pathway Improvement Referral/Primary Care PoS to Last Diagnostic <28days DDT to Treatment < 21 days Clinical Engagement Patient Centred Care

40 Work streams Information and Intelligence Capacity & Demand Communication Primary Care Diagnostic Pathway Treatment Pathway CSG s and Clinical Engagement Patient Centred Care Improvement

41 Priorities To understand the additional capacity required for the NHS to be able to treat all patients from the PoS within 62 days or 95% of patients to be diagnosed and staged < 28 days and treated < 21 days from decision to treat To understand where capacity required eg OPA, imaging, endoscopy, treatment Understand whether increased capacity due to rising referrals, improved USC performance or accelerated nusc pathway To standardise pathways across Wales consistently using best practice principles such as use of NG12 and entry points into system eg straight to test

42 Priorities To establish informatics systems to link with HB PAS systems that can receive e-referrals, can be easily started on clinical suspicion of cancer, can make system aware patient on accelerated pathway, track patient and record component and total waiting times To understand better where support systems should be introduced eg patient information, prehabilitation, holistic needs support and research To undertake a set of improvement workshops within HBs and across boundaries in Cancer Site Groups to reduce delays due to decision making in MDTs or weekly clinics or introduce accelerated steps such as same day/next day to CT from endoscopy or CXR

43 Priorities To establish a set of local and National reports that highlight variation between HBs and Cancer Sites and specific pathway steps, to understand the causes of this variation and share best practice across Wales To compare and contrast HB SCP Delivery Plans to help a local and National understanding of what required to achieve compliance with an SCP (assuming 95% compliance with 62 day target)

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46 Summary Patients have relatively poor survival in Wales with stage at diagnosis a key factor in this Patients are waiting too long in the healthcare system before receiving treatment The current system of CWT reports contains hidden waits, does not reflect patient experience, does not report inadequate diagnostic and treatment capacity and does not drive improvement CEOs, Chairs, CIG, CSG, WCN, HB/Trusts agree: A single suspected cancer pathway that reports waiting times for all patients from the point of suspicion is.. THE RIGHT THING TO DO!

47 Summary The benefits should lead to better patient outcomes (survival, experience), better patient support and less costly treatment Benefits beyond accelerated pathway, more structured and standardised pathways allow for better information and holistic support, access to research and capacity/demand modelling No one underestimates the challenge but NHS Wales, WG, 3 rd sector and cancer services stakeholders are working together, sharing best practice and are open to change