RM Partners Accountable Cancer Network

Transcription

1 The Royal Marsden RM Partners Accountable Cancer Network Dr. Shelley Dolan, Chief Nurse The Royal Marsden Executive Director Cancer Vanguard 1

2 Overview of the Cancer Vanguard Dr Shelley Dolan Executive Director Cancer Vanguard

3 Overview of Cancer Vanguard Appointed in October 2015 The Royal Marsden together with The Christie and UCLH. One Cancer Vanguard with 3 separate delivery vehicles all trialling a different model to improve cancer services over a geography. Each delivery vehicle already had an existing Integrated Cancer System which is being transitioned. The Christie The Christie and RM trialling Lead Provider/pooled budgets. UCLH an Alliance. Total population 10.7 million Royal Marsden UCLH 3

4 4 The challenges we face The aim of the national cancer vanguard programme is to tackle three gaps: Health and wellbeing gap 1 in 2 people will get cancer in their lifetime. Cancer patients are diagnosed too late, survival is poor, cancer is not prevented. The incidence of cancer is increasing by about 2% a year and is the biggest cause of death from any disease in every age group. The shift in lifestyle is increasing the age standardised risk of cancer. Care and quality gap Patients receive inconsistent quality of care, long waiting times, widely varying outcomes, and often poor experience. Where it can be and living with and beyond cancer is not consistently prioritised. Funding gap The rising cost of cancer is unsustainable. The cost of delivering the capacity required to bring forward diagnosis and shift follow up care into the community is currently prohibitive. 4

5 Three key focus areas to address these challenges 1) Changing the system architecture 2) Transforming the clinical model of delivery Early diagnosis Whole pathways and new models of delivery 3) Implementing enabling infrastructure These will deliver the following objectives.. 5

6 Overall Aims for the ACNC using a new funding and contracting structure incentivise change to: 1. Improve: survival Early diagnosis & detection 2. Reduce unwanted variation, 3. Improve patient /family leadership, engagement and experience, 4. Improved access to clinical trials from a broad portfolio, 5. Improved access to high quality care during and following treatment. 6. Improved access to 24/7 expert palliative and EoLC 7. Improved utility / reduce excess costs Carter etc. 6

7 To deliver this across three systems we have adopted the following governance structure 7

8 What does the RM Partners system look like? 8

9 What have we done so far? 1. Pan London Informatics 2. Pan Vanguard Informatics also working with the national team 3. Pan Vanguard commisioning of CRUK and 20:20 to explore demand and capacity gap imaging and endoscopy and model for improvement. 4. Launched Patient / Family leadership work in partnership with PoC and iwgc 5. Worked with STPs to ensure Vanguard aligned 6. Set up RM Partners governance structure 7. Pan London Research Board 8. Launched the Pharma challenge 9. Written tender for partner to work with on new contracting and commissioning model out to procurement in July

10 Financial sustainability needs to be part of the Cancer Vanguard Many providers are already in deficit Cost of cancer is rising at 9% per annum the NHS budget is not and investment is needed to change the model of care to meet health and quality gap Transformational change is needed to deliver the scale of savings required for financial sustainability

11 These savings mean the Vanguard will be key to meeting the FYFV challenge for cancer in our areas Improved system architecture and infrastructure can have an impact quickly but alone will not generate the savings required The Vanguard is part of, but not the whole solution we are focusing on some top priorities in the National cancer strategy Traditional CIPs alone will not meet the efficiency challenge Expected impact from changing the care model takes a number of years to have a meaningful impact

12 Our new model of care will deliver savings as well as improving patient experience and clinical outcomes By Diagnosing cancer at an earlier stage Providing access to 24/7 palliative care Supporting people to live with and beyond cancer Reducing unwanted variation Shared accountability through payment system Sharing information supported by ICT Placing the patient at the centre We will make savings through Treating with low cost interventions at an early stage (for some cancers) Avoiding unnecessary and costly admission and A&E attendances Providing treatment in a lower cost, less intensive environment, improve prevention Improving efficiency and standardisation, reducing unnecessary activity Treating patients in the most efficiency setting and location, maximising capacity Avoiding duplication and ensuring the patient is treated by the right person at the right time Empowering patients to be involved in their care provide the support and interventions that matter, prevention and early diagnosis

13 Case study: Lung, colorectal, upper GI in NCEL Spike in activity in early years as patients are diagnosed in stage 1 and 2 By implementing initiatives such as bowel scope roll-out we can change the diagnosis profile In colorectal, there are materially different treatment costs by stage There are also savings in the rest of the pathway through reduced GP appointments (straight to test) and post treatment costs 5

14 Changing the payment and contract model will be key to delivering the new model of care and savings We would want our system architecture to support: Early diagnosis Implementation of best practice Innovation and rapid roll out Patient experience on par with clinical/safety Centralisation/decentralisation Strategic investment in capital System efficiency Entity efficiency Balance Risk/reward to those able to affect it (accountability) Co-ordination of care for patients and services Does the current model do this: Need to change public behaviours and ensure we operationalise best practise pathways in the next few months System not joined up enough to ensure best practice along pathways Tariffs do not keep pace Some excellent examples in London but not across the pathway Providers in isolation are incentivised to keep hold of activity Small numbers of big kit Variable, but in some key areas does not work No incentive between providers

15 There are four themes in our payments and contracts workstream each vitally important Recruitment of a team Need engagement to get best outcomes Knowledge of local issues and priorities Sustainability Improved accountability Reduced cost Why How Why How Named lead for each org Reference group set-up Report to programme group Workshops with NCM team Joint procurement of support with Christie and RMP Wider Vanguard process NCM learning How Why How Why Have done it before Demonstrable independence Capacity (temporary) Shared knowledge Better value for money Procured support (see next slide)

16 Support is needed for a substantial scope of work to decrease risk we have split into three phases Phase I Design: create a vision and consensus Phase II Build: detailed commercial considerations Phase III Implementation 1.Strategic advice and independent challenge 2.Vision and case for change 3.Scoping, including population analysis 4.Organisational form and legal entity options & governance architecture 5.Articulation of the targeted future cancer services delivery model 6.Contract design 7.Commercial and financial modelling 8.Risk analysis 9.Implementation road map 10.Identifying and assessing delivery capabilities 11.Support for shadow running and testing

17 Along with the rest of the programme we expect this work to deliver a number of key outputs Case for change Critical success factors High level options appraisal Articulation of desired model Finance and activity model Detailed business case for new model Contractual arrangements proposal/ documents Implementation plan NEW MODEL

18 Survival rates are higher for cancers diagnosed at earlier stages THE CASE FOR EARLY DIAGNOSIS Cancer Research UK has estimated that there would be a 0.5% increase in 10-year survival for all cancers combined, for every 1% increase in the proportion of patients diagnosed at Stages 1 2 Sources: 1 year survival by stage (Persons, 2012, England, age-standardised), Survival estimates by cancer type, Cancer Research UK, 18

19 Lung, colorectal and upper GI (OG & HPB) together account for nearly 50% of cancers diagnosed via emergency presentation TUMOUR GROUPS AND SCOPE Oesophago-Gastric (OG) Total: 404 Hepato-Pancreato- Biliary (HPB) Total: 634 Upper GI total: 1038 Sources: NCIN Routes to Diagnosis (London), , analysis produced by NCIN for London Cancer 19

20 Lung, colorectal & prostate together account for 60% of cancers diagnosed at late stage TUMOUR GROUPS AND SCOPE LATE STAGE DIAGNOSES Sources: Staging data by CCG, 10 tumour groups ( ), Cancer Toolkit, accessed February

21 We have explored proactive and reactive diagnosis options by tumour group EARLY DIAGNOSIS OPTIONS BY TUMOUR GROUP Levers for improving early diagnosis of cancer Proactive Reactive to symptoms Proactive referral of high-risk patients Screening Patient behaviour GP Liaison Referral pathways Recommendation 1: Periodic low-dose CT for patients at high risk of lung cancer Recommendation 2: Bowel Scope screening for colorectal cancer Recommendations

22 Case study: iwantgreatcare Dr Shelley Dolan Executive Director Cancer Vanguard

23 What we do Collect and process patient ratings, reviews and outcomes and feed results and insights back to providers in real time to understand patients experience of their service and the impact on patients quality of life. 23

24 What we do 24

25 The vanguard strategy outcomes and objectives VANGUARD STRATEGY OUTCOMES VANGUARD OBJECTIVES Improved survival Raise public awareness to increase early diagnosis Reduction in incidence Create timed pathways for definitive treatment within 28 days Improved experiences of care, treatment and support Increase awareness of clinical trials Improving the quality of life of patients after treatment and at the end of life Improve access to 24/7 specialist care and palliative care Improved efficiency and effectiveness of cancer service delivery Improved utility and reduction in costs Standardise pathways and treatment plans to improve outcomes (improve hand over between clinicians), and create a cost effective service by the creation of new pathways such as straight to test, stratified follow-up and self-managed care to shift resources from secondary care to the community. Financial sustainability Increase self-managed care Share reporting to improve efficiency and reduce cost Standardise radiology protocols to enhance the quality of diagnostics Establish new self-referral rapid diagnostic centres Speed the uptake of straight to test; direct access and multidisciplinary diagnostic centres for vague symptoms 25

26 Understanding the Patient Journey 26

27 Reporting iwgc will deliver to stakeholders: Visual monthly reports at Vanguard, organisation, site and service levels for front-line teams and public display, similar to the examples below: Data analysis tools for deep-dive interrogation of the qualitative and quantitative data, with trend lines to track changes in patient responses over time. Raw data files with transcribed free text comments. Benchmarking tools across services and Trusts to correlate and compare outcomes across stakeholder sites and to act as an early warning system. Quarterly analysis and insight reports to provide the regional balanced scorecard for cancer presented to their boards as described in the Value Proposition document. 27

28 Interactive dashboard quantitative analysis 28

29 Interactive dashboard qualitative analysis 29

30 Case study: Research Dr Shelley Dolan Executive Director Cancer Vanguard

31 Current and proposed research areas in early diagnosis Tumour group Established screening methods Recommended model within Vanguard LUNG CT in high risk Low-dose CT for asymptomatic patients at high risk Straight to CT for symptomatic patients COLORECTAL Bowel screening program: Faecal occult blood test (>60) Bowel Scope (55-60) Straight to Test Colonoscopy for symptomatic patients Examples of exploratory research Circulating biomarkers and methylation Robotic endobronchial optical tomography Circulating biomarkers, e.g. TRACC Cologuard (multitarget stool DNA test) 31

32 Health Services Research: current and proposed areas in London Reduction in variation Variation in use of urgent referral pathway by GPs (Thomas Round) Factors affecting survival in women with breast cancer (Henrik Møller) Provision of the recovery package in patients with breast or prostate cancer (Susie Stanway) Cancer in Older People - Improving outcomes for older women with ovarian cancer (Lucy Dumas) - Comprehensive geriatric screening tool in management of older patients with colorectal cancer (Ross, Harari, Bridgewater) Palliative and Supportive Care (Fliss Murtagh) 32

33 Opportunities for Pan-London & Vanguard research Early diagnosis: Acute Diagnostic Oncology Clinic, Multidisciplinary diagnostic clinic, integration of primary/secondary care Novel mechanisms for early detection Use of circulating biomarkers in various settings Living with and beyond cancer Variation in clinical practice, including: treatment recommendations, management of older patients etc Pan-London/Vanguard clinical trial strategy Research at the scale of pan-london/vanguard should add value and not duplicate 33

34 Potential advantages to a pan- London/Vanguard approach Clinical Trials Directory Build on potential for contrasting outcomes/variations based on socioeconomics Build on expertise in specific areas of developmental therapy e.g. immunology, stereotactic radiotherapy, molecular diagnostics Build on expertise in imaging research Build on insight of relevance of studies in cancer biology, tumour heterogeneity, cancer evolution Increased potential for collaboration across ECMC/BRC/CRUK centres 34

35 General discussion/reflections Thank you for invitingme 35