Trust Board of Directors Public. Denise Gale. For Assurance and Information NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE

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1 NLG(18)014 DATE OF MEETING 30 January 2018 REPORT FOR Trust Board of Directors Public REPORT FROM Richard Sunley, Deputy Chief Executive CONTACT OFFICER Denise Gale SUBJECT Cancer Performance and Backlog Presentation BACKGROUND DOCUMENT (IF ANY) Previous Performance Reports Received by Trust Board PURPOSE OF THE PAPER: For Assurance and Information EXECUTIVE SUMMARY (PLEASE INCLUDE A BRIEF SUMMARY OF THE PAPER, KEY POINTS & ANY RISK ISSUES AND MITIGATING ACTIONS WHERE APPROPRIATE) This presentation includes : Last 12 months performance and forecast position for December, Q3 and January. Background and context as it relates to NLaG Comparisons re referrals and treatments within Humber, Coast & Vale Cancer Alliance Backlog position (>62 days) from November 17 to January 18 Confirmed cancer diagnoses >63 days, volumes with and without TCI dates (by tumour site) Suspected cancer pathways without diagnoses >63 days (by tumour site) 62 day draft trajectory to meet compliance by end June 18 (with caveats) 62 day improvement plan key themes/issues Other cancer work streams HAVE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS? NOT APPLICABLE HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS? NOT APPLICABLE ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS? NO IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED? NOT APPLICABLE ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF? NOT APPLICABLE WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED? NOT APPLICABLE WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO SUSTAINABILITY IMPLICATIONS (QUALITY & NOT APPLICABLE

2 FINANCIAL) & CLIMATE CHANGE? THE PROPOPSALS OR ARRANGEMNTS OUTLINED IN THIS PAPER SUPPORT THE ACHIEVEMENT OF THE TRUST OBJECTIVE(S) For Information THE PROPOSAL OR ARRANGEMENTS OUTLINED IN THIS PAPER ENSRE COMPLIANCE WITH THE REGULATORY OR GOVERNANCE REQUIREMENTS LISTED THE PROPOSALS OR ARRAGEMENTS OUTLINED IN THIS PAPER TAKE ACCOUNT OF REQUIREMENTS IN RESPECT OF EQUALITY & DIVERSITY NOT APPLICABLE ACTION REQUIRED BY THE BOARD The Board is asked to note the contents of this report

3 Northern Lincolnshire & Goole NHS Foundation Trust Cancer Performance and Backlog >62 days Denise Gale 10 January 2018

4 This presentation includes : Last 12 months performance and forecast position for December, Q3 and January Background and context as it relates to NLaG Comparisons re referrals and treatments within Humber, Coast & Vale Cancer Alliance Backlog position (>62 days) from November 17 to January 18 Confirmed cancer diagnoses >63 days, volumes with and without TCI dates (by tumour site) Suspected cancer pathways without diagnoses >63 days (by tumour site) 62 day draft trajectory to meet compliance by end June 18 (with caveats) 62 day improvement plan key themes/issues Other cancer workstreams

5 Cancer Performance 1 The table below shows the current confirmed 62 day November performance (validated and uploaded to Open Exeter) and forecast Dec, Q3 and Jan performance (unvalidated). The deadline for upload to Open Exeter for December performance is 5 th Feb 2018 figures are always unvalidated/provisional until final upload has taken place 2ww 1 st seen (93%) forecast to breach in Jan. 40 breaches 50% (20) of are due to OPA capacity

6 Cancer Performance 2 The current weekly performance forecast is based on confirmed diagnosis patients with scheduled treatment dates in January as at 5 th January There are 36 patients with a confirmed cancer diagnosis >62 days, of which 24 do not have treatment dates; some are waiting treatment dates at NLaG whilst some are waiting treatment dates at tertiary providers. There are currently risks to delivery of the following cancer targets in January 2018: 2ww 1 st seen appointment 2ww Breast symptomatic 1 st seen appointment 62 day first definitive treatment

7 Background and Context 1 NLaG is a District General Hospital which delivers local cancer treatments. Specialist treatments, consistent with improving outcomes guidance (IOG), are delivered at specialist/tertiary centres, the main centre being HEY. NLaG has experienced a reduction in the volume of treatments over the past 12 months which has reduced the denominator against which performance is calculated In 2017, NLaG delivered an average 76.5 treatments per month (912.5 treatments over the period Jan 16 to Nov 17). This is considerably lower than the previous 12 months when NLaG delivered an average 86 treatments per month (1033 treatments over the period Jan 16 to Dec 16). Most tertiary centres deliver circa 120+ treatments per month. The Trust has also seen a rise in the volume of breaches of the 62 day standard over the past 12 months.

8 Background and Context 2 The local commissioning decision to redirect skin referrals to Virgin Care has reduced the volume of cancer treatments delivered at NLaG. The reduction in treatments has coincided with a rise in referrals, following publication of revised NICE referral guidance (2016) for primary care. This has reduced the conversion rate from referral for suspected cancer to treatment in most Trusts from circa 10-15% down to 6-8% which reduces the denominator further. The impact has been more severe at NLaG (as with other District General Hospitals) as it delivers a smaller proportion of treatments than tertiary centres.

9 HCV CA referrals comparisons 1 The graphs below (produced by HCV CA) show the significance of the reduction in total referrals, and specifically in skin cancer referrals compared to HEY and York. The reduction in skin cancer referrals follows a local commissioning decision to manage all dermatology through Virgin Care. The graph on the left shows the volume of all cancer treatments delivered at NLaG compared to HEY and York.

10 HCV CA referrals comparisons 1 Urology : volume of referrals for Urology are equal to or greater than HEY which demonstrates the pressure on this service at NLaG. Testicular : the number of referrals for testicular cancer are almost equal to that of HEY, and are greater than York.

11 Humber, Coast & Vale Comparisons 3 Upper GI : referrals are equal to or greater than York which demonstrates the pressure on this service. Most cancer surgical treatments are performed at HEY, with only a small proportion of treatments performed at NLaG. This means most treatments (and breaches) are shared (0.5 accountable treatments/breaches) with HEY, and NLaG does not get the benefit of full accountable treatment for these patients. Skin : Significant reduction in treatments Jan 16 to Dec 17 Jan - Dec 16 : Average treatments per month 7.5 Jan - Dec 17 : Average treatments per month 4.0 (with average 2.0 June - Dec 17).

12 62 day pathway : Backlog position 1 The volume of patients currently on the PTL without diagnosis has an adverse impact on the quality and efficiency of the tracking. Specialities with the greatest volume of patients >62 days in the backlog cohort are : Colorectal Head & Neck Skin (majority of treatments at NLaG are in the Head & Neck region). Upper GI

13 62 day pathway : Backlog position 2 The table below shows the cohort of patients with confirmed diagnosis of cancer (>62 days) by tumour site, and those that have confirmed treatment dates the month treatment is scheduled (with TCI date). With diagnosis - confirmed cancer with diagnosis days days days days with TCI (month) without TCI with diagnosis with TCI (month) without TCI with with TCI diagnosis (month) without TCI with with TCI diagnosis (month) without TCI with with TCI diagnosis (month) 104+ days Total without TCI with with TCI diagnosis (month) without TCI Trustwide total Breast 0 1 (Jan) (Jan) 1 Colorectal (Jan) (Jan) 3 Gynae Haematology Head & Neck (Jan) (Jan) 4 Lung (Jan) (Jan) 5 Other Skin (Jan) (Jan) 2 Upper GI Upper GI-OG Upper GI - HPB (Jan) (Jan) 1 Urology 2 1 (Jan) (Jan) (Jan) (Jan) 7

14 62 day pathway : Backlog position 3 The table below shows the cohort of patients without diagnosis >62 days this cohort of patients are continuing on the diagnostic pathways. It is also split by tumour site. Without diagnosis days suspected cancer days days days 104+ days Total Trustwide total Breast Colorectal Gynae Haematology Head & Neck Lung Other Skin Upper GI Upper GI-OG Upper GI - HPB Urology

15 62 day draft trajectory Scenario C : To achieve compliance with 62 day standard in June 18 (data upload) Trust Total Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 No. of treatments No. of breaches % achievement 68.0% 69.9% 76.3% 79.7% 83.6% 86.7% 87.8% 87.2% 85.6% 85.9% 86.2% 86.5% 86.9% 86.2% 87.1% Assumes treatments are greater than rolling average, but continue to decrease throughout financial year. Assumes breaches are reduced to less than half that of current levels and rolling average The table and graph show the trajectory to achieve compliance of the 62 day standard by end June 18. This is caveated by the following : a) Volume of treatments are consistent with forecast b) Volumes of breaches are reduced to the levels indicated c) The existing backlog (cancer and undiagnosed patients) is cleared by end February 18 d) There is a reduction in late (> day 38) referrals to tertiary providers reallocation impact has not been built into this trajectory.

16 62 day improvement plan: Key Themes 1 Tumour site / issue Actions 62 day improvement trajectory The Trust is developing an improvement trajectory at trustwide and tumour site level to reduce the volume of breaches from current levels (24.0 per month) to 10 accountable breaches per month. This will be particularly difficult, once the national inter-provider transfer standard (Day 38) is implemented in April 2018 but is necessary to deliver the 62 day standard. Reduction in 104+ backlog (confirmed cancer and suspected cancer) Reduction in 63+ days backlog (confirmed cancer and suspected cancer) The Trust aims to a) ensure that all confirmed cancer patients, where the treatment is undertaken at NLaG, will have confirmed treatment dates by the end of January. b) that all suspected cancer patients, where the diagnostic pathway is undertaken at NLaG, will have a definitive diagnosis by end January 18, c) Ensure all confirmed cancers have a TCI date (where treatment is undertaken at NLaG) by end February. d) Work with tertiary providers to ensure these patients have a treatment date as quickly as possible (confirmed cancer) and reach definitive diagnosis (undiagnosed).

17 62 day improvement plan: Key Themes 2 Tumour site / issue Incorrect priority on test request/histology samples OPA and surgical capacity Colorectal Straight to Test pathway Delays in clinical decision making Risk stratified follow up pathways MDT discussions Histology reporting capacity Diagnostic capacity Actions Divisions are working with clinical teams to ensure that the 2ww priority is clearly marked and visible on all samples where the patient is on a cancer pathway. Plans are being developed internally to address capacity shortfalls. The Royal Marsden Partners Vanguard work on the STT colorectal pathway has been shared internally and is being considered. As a result of shortfall in clinical manpower, a number of specialities have seen delays in reviewing notes for removal from pathways, which has impacted on the backlog (undiagnosed) position. To be developed to support capacity improvements Multiple MDT discussions/differential practice between SGH and DPoW; particularly when test results are non-diagnostic. Path Lincs is continuing to recruit locums (short-term) and substantive staff. Plans are being developed internally to reduce reporting turnaround time for 2ww priority to 7 days. There remain challenges with capacity at SGH for Colonoscopy, CT Colonography and Upper GI Endoscopy.

18 62 day improvement plan: Key Themes 3 Tumour site / issue Diagnostic- repeat tests Cancer Weekly PTL Cancer reporting CWT data validation CWT training Clinical Harm Reviews >104 days Clinical Harm Reviews Backlog (April to December) Actions There are a number of specialties where repeat tests occur when the result is non-diagnostic. Review of PTL processes, actions and escalations. Working with NHSI (IST) team to improve effectiveness of PTL. Work is ongoing to ensure that the information team support the cancer team with weekly, monthly reporting and dashboard development to give the Executive Team greater transparency. Discussions are ongoing within the Trust to develop a central team who will support cancer waiting times (and SACT - Systemic Anti Cancer Therapy) data validation and submission. Development of a training programme in awareness of CWT rules aimed at administrative teams who record CWT data, MDT clinical leads, Cancer Nurse Specialists. This is part of a programme of work with NHS Improvement. RCA timelines are being produced by the cancer team, sent to clinicians/ business groups to agree reasons for breach. They are saved into a folder within one month of treatment taking place, and are ready for upload to the COBRA system, which will instigate the harm review with clinical teams. Harm reviews will then be tracked through COBRA and outcomes used to improve cancer pathways. The backlog of patients April-December are ready for dissemination to clinical teams/business groups. That is to say the RCAs are completed and ready for upload to COBRA.

19 Other Cancer Workstreams Workstream Management of CSC team Haematology/chemotherapy QST (formerly peer review) SACT (Systemic Anti Cancer Therapy) data Cancer Board Review of CSC workforce Planned Care Board Actions It is intended to centralise the management of the Cancer Co-ordinator team under the Cancer Management Team to give greater support to these staff members. A consultation paper will be drafted by end Jan 18. The hospital received a visit from the national QST team in December. A number of immediate risks and serious concerns were raised and the Trust is developing an action plan to address these issues. This will be led by the Corporate QST lead with support from the Cancer Team. A workstream to look at extracting SACT data direct from the e-prescribing system (Varian) has commenced, in conjunction with HEY. This will enable the Trust to become compliant with national requirements. Deadline for achieving this has been set at 31 st March The Trust is in the process of establishing an internal Cancer Board comprising clinicians, nurses, managers and supported by the Cancer Management Team. This will have a strategic overview of cancer, will be accountable to the Trust Board through its governance structures, and will provide advice and recommendations to the Trust Board on all cancer issues. It is anticipated to hold the first meeting in February. A review of the CSC workforce is planned during January using NHS Improvement team tools to compare the current workforce (hours) with the time required for each tumour site. Development of cancer work programme is in progress which will be monitored at the internal planned care board.