National Peer Review Report: Cancer Services 2012/2013

Transcription

1 National Peer Review Programme National Peer Review Report: Cancer Services 2012/2013 An overview of the findings from the 2012/2013 National Peer Review of Cancer Services in England

2 2 National Peer Review Programme

3 National Cancer Peer Review Programme FOREWORD From the National Cancer Director I am delighted to introduce this overview of the findings from the 2012/2013 round of peer review for cancer services in England, which was undertaken between April 2012 and March This was the fourth annual round of the peer review using the current methodology, with the Chief Executive of the service provider endorsing their reports supported by external verification and risk based peer review visits. The work to ensure sustainability of the programme continues and services that demonstrated previous high performance have received less external assessment but maintained their internal governance. The quality of cancer services in England as a whole continues to improve. Services which have been part of the peer review process for a longer period have in general performed better and this indicates that a culture of quality assurance is becoming embedded but where services are new to the process further work is required. Significantly more patients and carers have accessed the peer review reports and Macmillan Cancer Support is now working in partnership with the programme to further development My Cancer Treatment the web tool that enables patients to have easy access to peer review reports. Since going live in December 2012, the site has received 29,904 visitors with 14% of visitors returning to the site. The programme has developed stronger links with the National Cancer Intelligence Network (NCIN) using outcomes data from the services profiles where they exist and developing clinical indicators where they don t, for Clinical Lines of Enquiry (CLE). The programme has also routinely used the findings of the National Cancer Patient Experience Survey (NCPES) as a key indicator for the quality of the service. The programme continues to strive to move towards a more clinical and patient outcomes focus rather than being reliant on structure and function alone. This report looks at the findings on the quality of cancer services for 1241 tumour multidisciplinary teams (MDT), and 277 tumour network groups, along with services for acute oncology, chemotherapy, radiotherapy, children s and teenage and young adults (TYA) cancer, cancer research networks, rehabilitation, complementary therapy, network partnership groups and network psychological support groups. The peer review programme now reviews the quality of 1842 clinical cancer services/ teams. I would like to express my heartfelt thanks to everyone who has contributed to the success of the programme whether as a reviewer, a member of the network / provider management team or as a member of the service being reviewed. The findings outlined in this report confirm once again the progress which has been made since the previous rounds of the peer review programme. This national report complements the detailed local area team overview reports on individual services which are already in the public domain ( uk). The national overview focuses on compliance with specific measures but also identifies key themes nationally and by tumour type. Reports for each tumour type, cross cutting services, children s 3

4 National Cancer Peer Review Programme and teenage and young adult services are included and provide a benchmarked performance of each team/ service. The full reports on individual teams in the network overview reports have highlighted many of the qualitative aspects of the delivery of cancer services. The reports have commented on numerous examples of a committed and enthusiastic workforce and team working and innovative clinical practice. The national overview shows that some teams and services continue to achieve very high levels of compliance with the measures. When considering all of the 1241 multidisciplinary teams (MDTs) and 277 network site specific groups (NSSGs), 745 (49%) achieved compliance with over 90% of the measures. In relation to cross cutting services 166 radiotherapy services, 323 chemotherapy services and 37 acute oncology services achieved compliance with over 90% of the measures. In children s and teenage and young adult s services, 169 achieved compliance with over 90% of the measures. However, the 2012/2013 round of peer review has again highlighted some significant challenges. We can see a group of significant outliers and work needs to be done to address these services. This is a particular concern in relation to acute oncology and neuroscience where some services have not yet been appropriately established. In light of the report of mid Staffordshire NHS Foundation Trust public enquiry (February 2012), the Keogh Review: Hospital Death Rates (July 2013) and more recently the Report: A promise to learn a commitment to act (August 2013) it is important we work together in the NHS as clinicians, managers and commissioners to address these services. Some of these will have already been addressed at a local level following the relevant visits and report. Others will need to be addressed now. In some cases, compliance could be improved through local effort, but without the need for additional resource. In other cases commissioners will need to consider whether it is practical for a team to achieve full compliance, or whether two or more neighbouring teams need to be merged to achieve sustainability both of workforce and throughput of patients. In summary this report demonstrates that much has been done to improve cancer services in this country, but more remains to be worked on to achieve our goal of providing optimal diagnosis, treatment, care and outcomes for all cancer patients. Sean Duffy National Cancer Director 4

5 National Cancer Peer Review Programme Contents 1 Executive Summary The 2012/13 peer review programme Multidisciplinary teams compliance with measures 2012/ Cross Cutting Services compliance with measures 2012/ Children s and Teenage and Young Adults services compliance with measures 2012/ Key themes Good practice Recommendations and next steps Introduction Internal Governance Patient Experience Multidisciplinary Teams Overview Overall compliance MDTs with compliance of 50% or below Good practice Immediate Risks and Concerns Cross Cutting Services Overview Overall compliance Cross Cutting Services with compliance of 50% or below Good practice Immediate Risks and Concerns Children s and TYA Services Overview Overall compliance Children s and TYA teams with compliance of 50% or below Good practice Immediate Risks and Concerns Networks Context of Network Changes Network Site Specific Groups (NSSGs) Network Cross Cutting Groups Network Children s and TYA Groups Other Network Groups Clinical Lines of Enquiry Improving Outcomes Guidance Future of Peer Review...54 Appendix 1: Background to National Peer Review Programme...56 Appendix 2: NSSG Compliance Graphs 2012/13 - Overall per Network and Tumour site Appendix 3: Cross Cutting Compliance Graphs 2012/13 - Overall per Network per Service Appendix 4: Children s and TYA Compliance Graphs 2012/13 - Overall per Network and per Service

6 National Peer Review Programme Executive Summary 1.1 The 2012/2013 peer review programme This report presents a national overview of the findings from the National Peer Review Programme (NPRP) for 2012/2013. A total of 1842 clinical services were assessed in that period, covering a total of ten tumour groups (breast, lung, upper GI, urology, gynaecology, skin, colorectal, head and neck, brain and central nervous system (CNS), and sarcoma) along with radiotherapy, chemotherapy, acute oncology, children s cancer services and Teenage and Young Adults (TYA) cancer services. Table 1: Breakdown of services assessed in the 12/13 cycle Clinical Service No of Teams Multidisciplinary Teams 1241 Radiotherapy Services 56 Chemotherapy Services 159 Acute Oncology 193 Children's PTC 13 TYA PTC 13 TYA designated Hospitals 85 Paediatric Oncology Shared Care Unit (POSCU) Level 1 Core Paediatric Oncology Shared Care Unit (POSCU) Level 2 Core Paediatric Oncology Shared Care Unit (POSCU) Level 3 Core Total Multidisciplinary teams compliance with measures 2012/2013 There were a number of high performing multidisciplinary teams in 2012/2013: 45 teams (4%) achieved 100% compliance teams (81%) achieved 80% compliance Performance of services in 2012/2013 can be compared to previous rounds of peer review in 2010/2011 and 2011/2012. Improvement has been observed for most tumour groups with increases in median compliance scores. The exceptions being colorectal stand-alone liver, brain and CNS and sarcoma. Brain and CNS and sarcoma services have been subject to peer review visits rather than the self-assessment that took place in 2012/2013. Nationally peer review visits are more robust than internal assessments (see page 15) and if this was taken into account then overall these services would have also shown an improvement. As there are only 7 stand-alone liver services, it is more appropriate to look at these services on a case by case basis rather than nationally. 646 (52%) of MDTs scored over 90% against the peer review measures, compared with 28% in 2011/2012 and 34% of MDTs in 2010 /2011. However, there were also a small number of low performing teams: 25 teams (2%) had compliance of 50% or under (see page 23) compared to 19 teams (2%) in 2011/12. Many of these teams also had immediate risks (IR) or serious concerns (SC) noted by reviewers. These were reported to trust chief executives and action plans to improve these services have now been put in place and most services have already shown improvement. The increased number relates mainly to brain and CNS services which are new to the peer review programme. Details of brain and CNS services can be seen in the individual tumour site report on page 26. 6

7 Table 2: Multidisciplinary team s performance in 2012/13 Tumour MDTs No. reviewed SA IV EV PR % compliance (Median) % compliance (Mean) IR SC Breast % 92% 4 19 Lung % 90% 4 17 Gynaecology (L) % 91% 1 8 Gynaecology (S) % 91% 1 6 Upper GI (L) % 84% Upper GI (Oesophago-Gastric) (OG) % 85% 2 14 Upper GI (Pancreatic) % 84% 3 7 Upper GI (Pancreatic Liver Resection) % 94% 3 5 Urology (L) % 90% 6 11 Urology (S) % 89% 9 15 Testicular % 83% 1 1 Penile % 82% 0 2 Skin (L) % 85% 6 23 Skin (S) % 84% 5 15 Skin (Melanoma) % 91% 0 1 Skin (Supranetwork T-cell) % 94% 0 1 Colorectal % 90% 7 50 Colorectal (Stand alone liver) % 84% 0 3 Head & Neck UAT/Thyroid % 87% 0 12 Head & Neck Thyroid only % 85% 1 4 Brain (Cancer Network MDT) % 54% 0 13 Brain (Neuroscience MDT) % 62% 6 38 Sarcoma % 70% 1 9 Total for MDTs % 84% SA - Self Assessment IV - Internal Validation EV - External Verification PR - Peer Review 7

8 National Peer Review Programme Table 3: Multidisciplinary teams comparison of the median compliance over previous years MDTs 2009/ / / /13 Change from initial assessment to 12/13 Change from 11/12 12/13 Breast 86% 83% 90% 94% 8% 4% Lung 87% 84% 89% 89% 2% 0% Gynae (L) 85% 88% 86% 90% 5% 4% Gynae (S) 85% 91% 90% 90% 5% 0% Upper GI (L) 83% 86% 87% 88% 5% 1% Upper GI (OG) 81% 86% 85% 85% 4% 0% Upper GI (Pancreatic)* 81% 81% 79% 84% 3% 5% Urology (L) 82% 89% 87% 93% 11% 6% Urology (S) 78% 86% 88% 91% 13% 3% Testicular 85% 68% 81% 88% 3% 7% Penile 67% 78% 84% 89% 22% 5% Skin (L) 60% 84% 84% 87% 27% 3% Skin (S) 61% 82% 82% 87% 26% 5% Colorectal 89% 85% 90% 1% 5% Colorectal stand alone liver 92% 90% 88% -4% -2% Head & Neck (UAT & thyroid) 85% 77% 90% 5% 13% Head & Neck (thyroid only) 87% 81% 88% 1% 7% Brain Network 73% 62% -11% -11% Neuroscience 66% 60% -6% -6% Sarcoma 80% 69% -11% -11% 1.3 Cross Cutting Services compliance with measures 2012/2013 There were a number of high performing cross cutting services in 2012/ radiotherapy services (55%) achieved 100% compliance. 276 chemotherapy services (59%) achieved 100% compliance. 21 acute oncology services (4%) achieved 100% compliance. 191 radiotherapy services (91%) achieved 80% compliance. 388 chemotherapy services (82%) achieved 80% compliance. 66 acute oncology services (11%) achieved 80% compliance. Performance of radiotherapy services in 2012/2013 can be compared to previous rounds of peer review in 2011/2012 and 2010/ (79%) of radiotherapy services scored over 90% against the peer review measures, compared with 52 (25%) in 2011/2012 and 43 (22%) of MDTs in 2010 /2011. There was 1 service (0.5%) that had a compliance of 50% or below compared to 4 teams (2%) in 2011/12. It is not appropriate to compare chemotherapy and acute oncology services to the previous round as these services were subject to comprehensive peer review visits which were more robust than the self- assessment round in 2011/ It should be noted these numbers reflect the fact that there are multiple topics assessed for each service. 8

9 However, there were also low performing teams: 3 chemotherapy services (0.6%) had compliance of 50% or below. 383 acute oncology services (66%) had compliance of 50% or below. Implementation of acute oncology services continues to be a major concern. Details of this are shown in the individual report on acute oncology service on page 41. Table 4: Cross cutting services performance in 2012/2013 Service Type No. of Teams Cross Cutting Services Radiotherapy Services SA IV EV PR % compliance (Median) % compliance (Mean) Radiotherapy Department Generic % 87% 2 3 IR SC Radiotherapy Department External Beam % 96% 2 3 Radiotherapy Department IMRT % 98% 2 3 Radiotherapy Department Brachytherapy % 95% 1 4 Chemotherapy Services Clinical Chemotherapy % 79% Oncology Pharmacy % 97% 4 22 Intrathecal Chemotherapy % 98% 5 16 Acute Oncology Services Acute Oncology (i) % 40% Specialist Acute Oncology (ii) % 75% 1 6 General Acute Oncology (iii) % 53% Acute Oncology Inpatient Assessment Services % 31% Total % 77% (i) (ii) (iii) 11-3Y-1 Acute Oncology Measures specific to hospitals with A&E departments and/or Acute Medical on take rotas 11-3Y-2 Specialist Acute Oncology Measures specific to specialist cancer hospitals/units without an A&E department or an Acute General medical take 11-3Y-3 General Acute Oncology Measures for hospitals 9

10 Table 5: Cross cutting services comparison of the median compliance over previous years Cross Cutting Services 2010/11 Overall National Percentage 2011/12 Overall National Percentage 2012/13 Overall National Percentage Change from initial assessment to 12/13 Change from 11/12 12/13 Radiotherapy Generic 68% 77% 89% +21% +12% Radiotherapy External Beam 85% 94% 96% +11% +2% Radiotherapy IMRT 81% 100% 100% +19% 0% Radiotherapy Department Brachytherapy 84% 100% 100% +16% 0% Clinical Chemotherapy 83% 81% -2% -2% Oncology Pharmacy 100% 100% 0% 0% Intrathecal Chemotherapy 100% 100% 0% 0% Acute Oncology (i) 33% 50% +17% +17% Specialist Acute Oncology (ii) 84% 67% -17% -17% General Acute Oncology (iii) 55% 55% 0% 0% Acute Oncology Inpatient Assessment Services 25% 25% 0% 0% 1.4 Children s and Teenage and Young Adult services compliance with measures 2012/2013 There were a number of high performing children s and teenage and young adult s principle treatment centres in 2012/2013: There were no children s PTC core services that achieved 100% compliance. 1 children s PTC Diagnostic &Treatment MDT (3%) achieved 100% compliance. 1 children s PTC late effects MDTs (3%) achieved 100% compliance. 13 children s PTC core services (100%) achieved 80% compliance. 32 children s PTC diagnostic & treatment MDTs (89%) achieved 80% compliance. 11 children s PTC late effects MDTs (85%) achieved 80% compliance. 2 TYA PTC core services (15%) achieved 100% compliance. There were no TYA PTC MDTs that achieved 100% compliance. 4 TYA PTC core services (31%) achieved 80% compliance. 1 TYA PTC MDTs (8%) achieved 80% compliance. Performance of services in 2012/2013 can be compared to previous cycles of peer review in 2011/2012 and 2010/2011. Improvement has been observed for: All 13 children s PTC core services scored over 90% against the peer review measures, compared with 46% in 2011/2012 and 62% of MDTs in 2010 / (15%) TYA PTC core services scored over 90% against the peer review measures, compared with 0% in 2011/

11 National Peer Review Programme Table 6: Children s and Teenage and Young Adult Services Performance in 2012/2013 Service Type Children s and Teenage and Young Adult Services No. of Teams Children s Services SA IV EV PR % compliance (Median) % compliance (Mean) Children: PTC Core % 95% 0 2 PTC, Late effects MDT % 85% 0 0 IR SC PTC, Diagnostic & Treatment MDT % 88% 0 2 Paediatric Oncology Shared Care Unit (POSCU) Level 1 Core % 93% 2 2 POSCU Level 2 Core % 96% 0 1 POSCU Level 3 Core % 94% 0 1 POSCU MDT % 91% 2 5 TYA Services TYA PTC Core Measures % 60% 1 8 TYA PTC MDT % 58% 1 8 TYA designated hospitals % 74% 1 5 Total % 84% 7 34 Table 7: Children s and Teenage and Young Adult services Comparison of the Median Compliance over Previous Years Children s and TYA Services 2010/11 Overall National Percentage 2011/12 Overall National Percentage 2012/13 Overall National Percentage Change from initial assessment to 12/13 Change from 11/12 12/13 Children: PTC Core 90% 89% 94% +4% +5% PTC, Late effects MDT 57% 67% 83% +26% +16% PTC, Diagnostic & Treatment MDT 78% 79% 88% +10% +9% POSCU Level 1 Core 86% 84% 96% +10% +12% POSCU Level 2 Core 88% 88% 96% +8% +8% POSCU Level 3 Core 92% 89% 93% +1% +4% POSCU MDT 82% 79% 92% +10% +13% PTC Core Measures 62% 63% +1% +1% TYA PTC MDT 69% 63% -6% -6% TYA designated hospitals 11-1D-1z 71% 71% 0% 0% 11

12 National Peer Review Programme Key themes Multidisciplinary Teams A number of themes emerged during the reviews in 2012/ 2013: Clinical Nurse Specialist (CNS) staffing levels, workload and cover still remains a national issue. This has an unprecedented effect on the care patients receive and the experience they have along their pathway, for example there is an increasing theme emerging around CNS s not being available at breaking bad news. Non IOG configurations are still in existence with surgical workload numbers not meeting minimum numbers and complex surgery still taking place at local hospitals. Core MDT membership continues to not meet the required minimum attendance, in particular oncology and histopathology - resulting in patients not receiving true MDT discussion. Single-handed surgeons potentially leaving services vulnerable. Lack of appropriate video conferencing facilities which could exclude core members of the MDT from taking part in patient discussion. A number of MDTs not achieving the 31 and 62 day cancer waiting time targets due to increasing workload and issues with surgical waiting times. Cross Cutting Services A number of themes emerged during the reviews in 2012/ 2013: Obsolete and ageing radiotherapy equipment with lack of funding to replace the equipment is a real issue in many trusts. Radiotherapy staffing also remains a concern across some trusts with whole time equivalent numbers falling below recommended levels for all disciplines. Also, centres that offer brachytherapy are treating below the required 50 patients a year. Non-functioning and totally noncompliant acute oncology services without sufficient planning to address this. Pathways for acute oncology patients are also undefined with particular concerns around the metastatic spinal cord compressions (MSCC) pathway, neutropenic sepsis MSCC pathways are not sufficiently robust and in some instances have no formal documented pathway at all, resulting in patients not being discussed by appropriate clinical teams which has high levels of risk for this group of patients. Neutropenic sepsis pathways not being reviewed or audited and so remain unclear as to whether safe and effective care is being provided for these patients. Chemotherapy units have been congratulated for making patients and family areas as comfortable and pleasant as possible but there are still deficiencies in clinical areas. Such as, drugs not being stored in an appropriate way; either in unlocked storage areas or drugs not being stored at the correct temperatures. Also, extravasation and spillage kits out of date and missing in areas where chemotherapy is administered which has an impact on patient safety. Other areas of note are, no access to 24 hour chemotherapy advice lines in more remote areas of the country resulting in patients having to use 111 or make avoidable trips to A&E and competency levels for staff not being recorded or maintained. 12

13 Children s services A number of themes emerged during the reviews in 2012/ 2013: Allied health professional (AHP) staffing levels remain low in particular play specialists, physiotherapists, occupational therapists and psychologists which has a direct impact on patient experience. Training for nursing staff i.e. foundation internal training not being completed by required numbers of staff. Part time lead clinicians and no succession training with pending retirements, leaving services possibly vulnerable. Lockable fridges and cupboards for chemotherapy drugs still remains an issue in some trusts from the 2010/11 and 2011/12 rounds Good practice Throughout the 2012/2013 round of peer review, reviewers found examples of good practice in almost every team and organisation that was reviewed. Particular areas of good practice noted were: Primary care educational awareness programmes and all round stronger links with GPs and primary care. Increase of nurse led activities, such as follow up and post-operative clinics. Patients accessing state of the art and cutting edge treatment techniques such as: Motor Cortical mapping, Integrated HDR brachytherapy and robotic surgery. Increased provision of one stop diagnostic clinics. Implementation of enhanced recovery programmes across a number of tumour types Recommendation and next steps This report provides a national picture against which both commissioners and providers can benchmark local performance. At a national level it is clear that progress continues to be made in most areas despite the difficult financial climate, but a few services are becoming significant outliers. The introduction of acute oncology services was a key recommendation of the National Chemotherapy Advisory Group in 2009 following the National Confidential Enquiry into Patient Outcomes & Death (2008). However, many hospitals have not fully established an acute oncology service and in some cases there appears to be a lack of commitment to do so, which is a significant concern. Further details about acute oncology services can be found in the separate report which is linked to this report on page 41. Brain and CNS services are also a cause for concern, in particular the establishment of non-surgical rehabilitation MDTs (Cancer Network MDTs). Further details about neuroscience services can be found in the separate report which is linked to this report on page 26. It is important to recognise that although the peer review measures largely reflect the structure and process of core delivery, these are based on the Improving Outcomes Guidance (IOG) developed by the National Institute of Health and Clinical Excellence (NICE). The structure and process measures therefore reflect those aspects of care 13

14 National Peer Review Programme where delivery is most likely to impact on patient outcomes. In parallel with the publication of this report, specialist commissioners are being alerted to those services which were identified as scoring below 50% and where there are concerns about the implementation of service specification. In order to ensure future sustainability of the peer review programme a number of changes have been introduced for the 2013/2014 round which is currently in progress. A new style of measures has been introduced for breast, lung and haematology Services. This new style contains significantly fewer measures some of which however include previous measures that have been merged together. These measures will be reviewed during 2013/2014 to establish if they should be adopted for all tumour types and services in 2014/2015. The change introduced in 2012/2013 that self-assessment evidence is only required every three years and Internal validation is only required every third year will continue in 2013/2014. With the appointment of a new clinical director and recent changes to the NHS environment, discussions are currently taking place to ensure the peer review programme remains fit for purpose. It is likely that the future peer review programme will be expanded to include other clinical services and the programme will complement the work of the new chief inspector of hospitals (CIOH), Professor Sir Mike Richards, at the Care Quality Commission (CQC). Peer review will continue to support commissioners and it is planned to formalise arrangement with the clinical directorate for specialised commissioning to provide information on the implementation of services specification and to inform the work of clinical reference groups. 14

15 National Peer Review Programme Introduction This report summarises the findings of the 2012/2013 round of the National Peer Review (NPRP) programme for cancer. The findings are based on peer review reports of the cycle which took place between April 2012 and March The peer review reports may be either self-assessment reports, internally validated self-assessment reports or peer review visit reports. The analysis makes clear which of these report types has been used. Findings from previous rounds of NPRP have also been used in order to assess progress. The report principally summarises the numerical data contained within the Cancer Quality Improvement Network System (CQuINS) which records the level of compliance by individual networks, teams and services against the measures contained within The Manual for Cancer Services. In addition reference is made to the comments made by reviewers in their reports on aspects of the qualitative information that were gathered during the reviews. The identification of good practice for dissemination and recommendation is a vital positive component of the peer review process. This report therefore highlights examples of good practice that have been identified by peer reviewers during this cycle. The report also identifies the key messages that have emerged from the reviews and highlights some of the challenges facing cancer networks, providers of services for patients with cancer, and commissioners, as they strive to ensure the delivery of effective and high quality care. The annual self-assessment is now embedded in the peer review process and this is the fourth annual national overview report based on this methodology. This report includes maps for specialist services showing the configuration of services and benchmarking of individual teams in each of the tumour site sections. Clinical indicators were developed by NPRP and the NCIN Site Specific Clinical Reference Groups (SSCRGs). These have been used for six tumours sites in 2012/2013 demonstrating an increased focus on outcomes. The background to the national peer review programme can be found in Appendix 1 and further details of the methodology used for the 2012/2013 peer review programme can be found in the National Cancer Peer Review Programme Handbook (2011) on the CQuINS website Internal Governance The peer review process has adopted an annual self-assessment process supported by a targeted visit programme, with the four key stages of the process being self-assessment, internally validated self-assessment, externally verified self-assessment and peer review visits. In order to ensure public confidence, all internally validated self-assessment reports are subject to external verification. Where the external verification identifies a significant difference with the internal assessment then the services is identified for a peer review in the next cycle. The robustness of the internal governance processes is reflected in any change in percentage compliance from self-assessment to internal validation for those teams on the internal validation cycle, and from self-assessment to peer review compliance for those on the peer review cycle. 15

16 National Peer Review Programme Table 8: Comparison of percentage changes on IV and PR cycles 2009/10, 2010/11, 2011/12 and 2012/ / / / /2013 Self-assessment to Internal Validation 2 4% 4% 3% 4% Self-assessment to Peer Review 3 20% 15% 13% 16% 2 3 This is the change in percentage compliance from self-assessment to internal validation for those teams who were on the internal validation cycle. This is the change in percentage compliance from self-assessment to peer review for those teams who were on the peer review cycle. Whilst the self-assessment to internal validation gap has remained relatively static, the gap between self-assessment to peer review has increased this year. This is due to the topics which have undertaken peer review visits for the first time. Namely, sarcoma, brain and CNS and acute oncology services. It is accepted that services need time to understand the interpretation of the measures and have the confidence to be transparent about their service. If these services were excluded then the gaps has remained constant at 13%. Further work is therefore necessary to develop and improve the culture of internal governance and enable patients to be confident in the quality of NHS services without the need for external review. Where services have become embedded in the peer review programme, internal governance continues to improve. This is particularly true in relation to colorectal services where the gap between self-assessment and peer review was just 5% this year Patient Experience There were a number of recurrent themes at each stage of the peer review process relating to patient experience. These were related to patient pathways; clinical nurse specialist support and capacity; the level and means of user involvement; the NCPES, and other issues related to holistic needs assessment and the survivorship agenda. There were also additional issues relating to particular tumour sites which will be explored in the individual sections. National cancer patient experience survey (NCPES) The NCPES has been discussed by NSSGs and MDTs with appropriate actions being taken as a result. There are however teams that have not acknowledged the survey in their reports. Where local audits have been undertaken due to a low score on the NCPES, outcomes are generally improved. This is thought to be because of the local aspect and it being more suited to their patient group. Key issues highlighted in the NCPES are availability of financial help and informing patients about their eligibility for free prescriptions. Clinical Nurse Specialist The clinical nurse specialist is often cited as a pivotal role in ensuring that patients receive the best experience possible on all parts of their pathway. 16

17 National Peer Review Programme There are difficulties in clinical nurse specialist capacity (i.e. numbers and workload), and this often impacts on their ability to be present at the breaking of significant news and therefore has a detrimental effect on patient experience. Patient Pathways Nurse led activity such as follow up clinics and telephone consultations increase the level of satisfaction for patients and has a positive impact. There are challenges in rehabilitation pathways across a number of tumour sites, and follow up and support in the community is variable. Psychological support is often difficult to obtain due to lack of resources, although in a number of networks and trusts this is under development. Enhanced recovery, the introduction of more less-invasive procedures are reducing lengths of stay which are having a positive impact on patient experience. There were new initiatives being introduced to further the survivorship agenda and experience e.g. NHS Improvements Survivorship Project (moving on programme), ontreatment workshops and annual survivorship events. Other points relating to patient experience Holistic needs assessment is a high priority for some networks, but not necessarily for others. Patient prescriptions implementation appears more widespread than in the 2011/12 peer review round. There were also good practices highlighted in relation to patient experience and user involvement A high level of focus on patient input/ feedback and taking patient views and experiences in to account when looking at service development. Public awareness campaigns. Improved written patient information. Introduction of telephone consultations for patients who may need to travel long distances. Production of a video entitles "patient experience of a palatal obturator" which is available on YouTube. The use of DVDs for the provision of information. Participation in national survivorship initiatives. Revised patient satisfaction questionnaire for brain cancer patients to reflect the complex needs of this patient group. Development of health and wellbeing clinics. The provision of psychological and psycho-sexual services for urology patients. Implementation of the distress thermometer. This is a holistic assessment tool for patients at key stages in their pathway. Workshops designed for patients to develop skills in self-management, with their results accessible on the Internet. Patient group directives for nurses and placing of sepsis trolleys in appropriate areas to improve first time dose of antibiotics. 17

18 3 Multidisciplinary Teams Overview 3.1 Overall compliance A total of 1241 multidisciplinary teams were reviewed as part of the 2012/2013 peer review programme. 568 (46%) teams were on the self-assessment cycle; 521 (42%) on the internal validation cycle and 137 (11%) were subject to a full peer review assessment. The number of multi-disciplinary teams achieving 100% compliance with the measures was 45 (4%); the number of multi-disciplinary teams achieving over 90% compliance with the measures was 646 (52%); the number of multidisciplinary teams achieving over 80% compliance with the measures was 1006 (81%) and the number of multidisciplinary teams achieving over 75% compliance with the measures was 1088 (88%). The following figures and table show a comparison of compliance of teams reviewed in 2010/2011, 2011/2012 and 2012/2013, and the overall national compliances for all teams. A more detailed breakdown on compliance and commentary on all tumour sites can be found in the individual tumour sections. Figure 1: Median Comparison per Tumour Specific MDT 2010/11, 2011/12 and 2012/13 100% Median comparisons 10/11, 11/12 and 12/13 90% 80% 70% 60% 50% 40% 30% 2009/ / / / % 10% 0% 18

19 Figure 2: Overall Compliance Ranges per Tumour Specific MDT Figure 3: Overall Compliance Ranges per Tumour MDT Peer Review * NB These include SA, IV and PR compliances, depending on the cycle. For those teams with a compliance of below 50%, the specific type of assessment may be found in Section

20 Table 9: Comparison of Overall National Compliances per Tumour Specific MDT (Mean) , 2009/10, 2010/11, 2011/12 and 2012/13 MDTs 2004/08 Overall National Percentage 2009/10 Overall National Percentage 2010/11 Overall National Percentage 2011/12 Overall National Percentage 2012/13 Overall National Percentage Breast 76% 85% 80% 88% 92% Lung 73% 84% 84% 87% 90% Gynae (L) 69% 80% 86% 84% 92% Gynae (S) 82% 83% 91% 89% 92% Upper GI (L) 64% 76% 84% 83% 84% Upper GI (OG 72% (NB 77% 83% 83% 85% OG & Pancreatic Upper GI (Pancreatic) 76% 80% 77% 84% combined) Colorectal 88% 82% 90% Colorectal Standalone Liver 87% 87% 84% Urology (L) 63% 76% 87% 85% 94% Urology (S) 73% 75% 87% 86% 90% Testicular 69% 78% 69% 82% 89% Penile 78% 65% 74% 83% 83% Skin (L) 58% 81% 82% 82% Skin (S) 61% 81% 83% 85% Skin (Melanoma) 75% 78% 92% 84% Skin (Supranetwork T-cell) 75% 88% 100% 91% Head & Neck UAT/Thyroid 83% 77% 87% Head & Neck Thyroid only 80% 73% 85% Brain Network MDT 63% 54% Neuroscience 61% 62% Sarcoma 78% 70% 20

21 Table 10: Comparison of Tumour Specific MDTs 2004/08, 2009/10, 2010 /11, 2011/12 and 2012/13 Number of Teams 2004/ / / / /13 Total change in teams Initial assessment to Change in number of teams Breast Lung Gynae (L) Gynae (S) Upper GI (L) Upper GI (OG) 74% (OG & Upper GI (Pancreatic) Pancreatic) UGI (Pancreatic put forward as liver resection) to Urology (L) Urology (S) Supranetwork Testicular Supranetwork Penile Skin (L) Skin (S) Skin (Melanoma) Skin (Supranetwork T-cell) Head & Neck UAT/Thyroid Head & Neck Thyroid only Colorectal Colorectal (Stand alone liver) Brain (Cancer Network MDT) Brain (Neuroscience MDT) Sarcoma Totals

22 Figure 4: All MDT Sites Reviewed in Combined Stage Percentage 100% Overall (Mean) National Percentage (SA, IV & PR combined) % 80% 70% 60% 50% 40% 30% 20% 10% 0% Figure 5: All MDT Sites Reviewed in by stage 100% Overall National percentage (SA, IV & PR separately) % 80% 70% 60% 50% 40% 30% 20% SA IV PR 10% 0% 22

23 3.2 MDT s with compliance of 50% or below There were 25 tumour specific MDTs with compliances of 50% or below. This equates to 2% of teams, compared with 33 teams (3%) 2011/2012. However, it should be noted that 19 of teams with a compliance of 50% or below in 2012/2013 were subject to their first peer review assessment. Of those 33 teams identified as having compliances of 50% or under in 2011/2012, only 3 of those teams still had below 50% compliance (highlighted in purple below) in 2012/2013. One of these teams also had under 50% compliance in 2010/2011 (Scarborough and North East Yorkshire Health Care: Local Skin). It is the first year of peer review assessment for brain and neuroscience MDTs which accounts for most of the teams with 50% and below. Table 11: Tumour specific MDTs with 50% or under Compliance 2012 /2013 Team Tumour site / section Compliance Cycle Ipswich HPB HPB 9% PR Sunderland Penile 45% PR Morecambe Bay Hospitals Local Skin 29% PR Scarborough And North East Yorkshire Health Care Local Skin 37% PR Nottingham NHS Treatment Centre Specialist Skin 44% PR Shrewsbury & Telford Hospitals Thyroid Only 44% PR National Hospital for Neurology and Neurosurgery Cancer Network Brain 15% PR Gloucestershire Hospitals NHS Foundation Trust Cancer Network Brain 42% PR University Hospitals Southampton NHS Foundation Trust Cancer Network Brain 0% PR Maidstone Hospital Cancer Network Brain 19% PR Addenbrookes Cancer Network Brain 27% PR Walton - Pituitary MDT 2k-2- Neuroscience 50% PR Addenbrookes 2k-2- Neuroscience 47% PR Hull And East Yorkshire Hospitals 2k-3- Neuroscience 43% PR University Hospitals Southampton NHS Foundation Trust 2k-3- Neuroscience 47% PR Addenbrookes 2k-3- Neuroscience 43% PR Newcastle 2k-3- Neuroscience 50% PR University Hospitals Southampton NHS Foundation Trust 2k-4- Neuroscience 23% PR Nottingham University Hospitals NHS Trust 2k-4- Neuroscience 31% PR National Hospital for Neurology and Neurosurgery 2k-4- Neuroscience 43% PR Kings College 2k-4- Neuroscience 40% PR National Hospital for Neurology and Neurosurgery 2k-5- Neuroscience 50% PR University Hospitals Southampton NHS Foundation Trust 2k-5- Neuroscience 20% PR Hull And East Yorkshire Hospitals Sarcoma 50% PR Royal Liverpool & Broadgreen Sarcoma 44% PR Of the above 25 teams, 8 teams are being re-reviewed in the 2013/14 cycle whilst the rest will be closely monitored on SA and IV cycles. The CQC has been notified of all teams whose compliance falls below 50% along with the Chief Executives of the trusts concerned, requesting remedial action. 23

24 3.3 Good Practice Throughout the 2012/2013 round of peer review, reviewers found examples of good practice in almost every team and organisation that was reviewed. Particular areas of good practice noted throughout the tumour MDTs were: Primary care educational awareness programmes and all round stronger links with GPs and primary care. Increase of nurse led activities, such as follow up and post-operative clinics. Patients accessing state of the art and cutting edge treatment techniques such as: Motor Cortical mapping, Integrated HDR brachytherapy and robotic surgery. Increased provision of one stop diagnostic clinics. Implementation of enhanced recovery programmes across a number of tumour types. Development and establishment of patient support groups leading to more informed and higher quality patient information resources such as leaflets and DVDs. Continued commitment to research. Many teams had built on the comments from previous reviews to achieve good practice in those areas in Further details of those good practices can be found in the individual peer review reports and on the CQuINS database. They include many examples of excellent leadership and clinical engagement. Three key areas of good practice identified in relation to the internal validation process were where the internal validation panel included one or more of the following: Trust Executive Director Commissioner Patient / Carer (Users) The inclusion of these members improved the focus and status of the panel. In relation to quantitative findings, this report shows that 646 (52%) of the 1241 MDTs achieved over 90% compliance with the measures and 45 MDTs (4%) achieved 100% compliance with the measures. 3.4 Immediate Risks and Concerns A key feature of the national peer review programme is the identification of immediate risks (IRs) and serious concerns (SCs). Peer review is unlike other quality assurance programmes in the NHS, in that if an immediate risk is identified the service is asked for it to be resolved within two weeks. The majority of the immediate risks identified have now been resolved. An immediate risk is an issue that is likely to result in harm to patients or staff or have a direct impact on clinical outcomes and therefore requires immediate action. A serious concern is an issue that, whilst not presenting an immediate risk to patient or staff safety, could seriously compromise the quality or clinical outcomes of patient care, and therefore requires urgent action to resolve. In the table below the green shading shows tumour sites where the percentage of teams with immediate risks or serious concerns had decreased since 2011/2012, the red shading indicates where the percentage of teams with immediate risks or serious concerns had increased since 2011/2012 and lack of shading that the percentage had remained constant. 24

25 National Peer Review Programme Table 12: Immediate Risk and Serious Concerns per Tumour Specific MDT 2011/12 and 2012/13 Tumour site IR 11/12 SC 11/12 No. of Teams assessed in 12/13 SA IR IV IR PR IR IR total SA SC IV SC PR SC SC total Breast 5 (3%) 26 (17%) (3%) (13%) Lung 4 (3%) 19 (12%) (3%) (11%) Gynaecological (L) 8 (12%) 18 (27%) (2%) (13%) Gynaecological (S) 3 (7%) 14 (32%) (2%) (14%) Upper GI (L) 7 (7%) 25 (24%) (10%) (32%) Upper GI (S) (Oesophago-gastric) 3 (8%) 12 (30%) (5%) (35%) Upper GI (S) (Pancreatic) 3 (13%) 8 (33%) (13%) (29%) Upper GI (S) (Pancreatic/Liver) 0(0%) 7 (58%) (20%) (33% Urology (L) 4 (4%) 30 (34%) (6%) (13%) Urology (S) 6 (12%) 16 (31%) (18%) (31%) Urology Testicular 1(8%) 4 (31%) (8%) (8%) Urology Penile 0 (0%) 2 (22%) (0%) (22%) Skin (L) 5 (5%) 23 (25%) (6%) (25%) Skin (S) 4 (9%) 11 (25%) (11%) (34%) Skin (Melanoma) 0 (0%) 1 (50%) (0%) (50%) Skin (Supranetwork T-Cell Lymphoma) 0 (0%) 0 (0%) (0%) (20%) Colorectal 21 (13%) 55 (34%) (4%) (30%) Colorectal Liver 0 (0%) 0 (0%) (0%) (43%) Head & Neck UAT/ Thyroid 8 (15%) 22 (41%) (0%) (24%) Head & Neck Thyroid only 2 (8%) 12 (46%) (3%) (14%) Brain (Cancer Network MDT) 2 (10%) 9 (43%) (0%) (62%) Brain (Neuroscience MDT) 2 (4%) 9 (16%) (11%) (72%) Sarcoma 1 (7%) 4 (27%) (7%) (60%) Total (6%) (25%) 25

26 National Peer Review Programme The majority of immediate risks and serious concerns were resolved in the appropriate timescales, or had on-going action plans in place to address the issues. There has been an overall reduction in both immediate risks and serious concerns across the 1241 MDTs from 2011/12 to 2012/13. While it is disappointing that the number of IRs and SCs has increased in some tumour sites what is particular heartening is the transparency and internal governance of providers in identifying issues and not being reliant on the external peer review visit programme alone. The key themes to note at MDT level are: the lack of CNS posts and CNS cover; a number of MDT s who are non IOG compliant with surgical caseloads (minimum numbers performed) not being met and there also remains an issue with complex pathways taking place with no network guidelines. There are a number of core team members who do not fulfil the minimum 66% attendance at MDT meetings and in some cases have never attended the MDT meetings which may impact a patient s best course of treatment. There are still a number of MDT s that are still not meeting the Department of Health s 31 or 62 day Cancer Waiting Times targets. For an in depth look at the immediate risks and serious concerns for each tumour site, please refer to the individual tumour reports. Links to Tumour Specific Reports Tumour site or services Breast Lung Gynaecology Upper GI Urology Skin Colorectal Head & Neck Brain and CNS Sarcoma Link to report Breast Report Lung Report Gynaecology Report Upper GI Report Urology Report Skin Report Colorectal Report Head & Neck Report Brain and CNS Report Sarcoma Report 26

27 4 Cross Cutting Services Overview 4.1 Overall Compliance A total of 1260 cross cutting services were reviewed as part of the 2012/2013 peer review programme. 452 (36%) teams were on the self-assessment cycle; 36 (3%) on the internal validation cycle and 772 (61%) were subject to a full peer review assessment. The number of cross cutting services achieving 100% compliance with the measures was 412 (33%); the number of cross cutting teams achieving over 90% compliance with the measures was 526 (42%); the number of cross cutting teams achieving over 80% compliance with the measures was 645 (51%) and the number of cross cutting teams achieving over 75% compliance with the measures was 699 (55%). The following figures and table show a comparison of compliance of teams reviewed in 2011/2012 and 2012/2013, and the overall national compliances for all teams. A more detailed breakdown on compliance and commentary on all cross cutting sites can be found in the individual sections. Figure 6: Median Comparison of Cross Cutting Services 10/11, 11/12 and 12/13 100% Median comparisons 10/11, 11/12 and 12/13 90% 80% 70% 60% 50% 40% 30% 20% 2010/ / / % 0% 27

28 Figure 7: Overall Compliance Ranges per Cross Cutting Service % Overall Compliance Ranges: Cross Cutting Services (SA, IV and PR 12/13) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Radiotherapy Department Generic Radiotherapy Department External Beam Rad IMRT Rad Brachy Chemo clin Chemo oncol pharm Red vertical lines: complete range Blue box: inter-quartile range Orange horizontal line: median value Team below 50% (If more than one team, number in brackets) x 31 x 25 x 2 x 34 x 6 x 82 Chemo ITC AO AO spec AO gen AO inpatient x 9 x 12 x 13 x 8 x 9 x 7 x 6 x 5 x 3 x 40 Figure 8: Overall Compliance Ranges per Cross Cutting Service MDT % Overall Compliance Ranges: Cross Cutting Services (SA, IV and PR 11/12) 90% 80% 70% 60% 50% 40% x 18 2 x 5 30% 20% x 32 x 37 x 2 x 14 x 3 x 2 x 8 x 8 x 8 x 40 10% x 6 0% Radiotherapy Department Generic Radiotherapy Department External Beam Rad IMRT Rad Brachy Chemo clin Chemo oncol pharm Red vertical lines: complete range Blue box: inter-quartile range Orange horizontal line: median value Team below 50% (If more than one team, number in brackets) x 52 x 6 x 82 Chemo ITC AO AO spec AO gen AO inpatient *NB These include SA, IV and PR compliances, depending on the cycle. For those teams with a compliance of below 50%, the specific type of assessment may be found in Section

29 Table 13: Comparison of Overall National Compliances, Cross Cutting Services (Mean) , and Cross Cutting Service 2010/ / /13 Overall National Percentage Overall National Percentage Overall National Percentage Radiotherapy Department Generic 67% 79% 87% Radiotherapy Department External Beam 85% 94% 96% Radiotherapy Department IMRT 82% 91% 98% Radiotherapy Department Brachytherapy 84% 95% 95% Clinical Chemotherapy Services 82% 79% Oncology Pharmacy Services 97% 97% Intrathecal Chemotherapy Services 99% 98% Acute Oncology (i) 31% 40% Specialist Acute Oncology (ii) 79% 75% General Acute Oncology (iii) 53% 53% Acute Oncology Inpatient Assessment Services 29% 31% Table 14: Comparison of Cross Cutting Teams , and / / /13 Total change in teams Initial assessment to Change in number of teams Radiotherapy Generic Radiotherapy External Beam Radiotherapy IMRT Radiotherapy Brachytherapy Clinical Chemotherapy Oncology Pharmacy Intrathecal Chemotherapy Acute Oncology (i) Specialist Acute Oncology (ii) General Acute Oncology (iii) Acute Oncology Inpatient Assessment Services Totals to

30 4.2 Cross Cutting Services with compliance of 50% or below There were 291 cross cutting services that had compliances of 50% or below. This equates to 23% of teams, compared with 396 teams (31%) 2011/2012. However, it should be noted that all of these teams with a compliance of 50% or under in 2012/2013 were subject to their first peer review assessment. Table 15: Cross Cutting Services with 50% or below compliance 2012/2013 Team Tumour site / section Compliance Cycle Mid Cheshire Intrathecal Chemotherapy 0% SA Blackpool Teaching Hospitals Trust Acute Oncology In-Patient 0% PR East Lancashire Hospitals Acute Oncology In-Patient 0% PR Rochdale Acute Oncology In-Patient 0% PR Oldham Acute Oncology In-Patient 0% PR Wrightington, Wigan And Leigh Acute Oncology In-Patient 0% PR Stockport Acute Oncology MDT 0% PR University Hospital of South Manchester NHS Foundation Trust Acute Oncology In-Patient 0% PR Trafford Acute Oncology MDT 0% PR Trafford General Acute Oncology 0% PR Trafford Acute Oncology In-Patient 0% PR Tameside & Glossop Acute Acute Oncology MDT 0% PR Tameside & Glossop Acute General Acute Oncology 0% PR Tameside & Glossop Acute Acute Oncology In-Patient 0% PR Central Manchester & Manchester Childrens Acute Oncology MDT 0% PR Central Manchester & Manchester Childrens General Acute Oncology 0% PR Central Manchester & Manchester Childrens Acute Oncology In-Patient 0% PR Bury Acute Oncology In-Patient 0% PR North Manchester Acute Oncology In-Patient 0% PR Warrington & Halton Acute Oncology MDT 0% PR Harrogate Acute Oncology In-Patient 0% PR Dewsbury Acute Oncology In-Patient 0% PR Pinderfields Acute Oncology In-Patient 0% PR Hull Royal Infirmary Acute Oncology In-Patient 0% PR Northern General Acute Oncology MDT 0% PR Northern General Acute Oncology In-Patient 0% PR Barnsley Acute Oncology In-Patient 0% PR Chesterfield Acute Oncology In-Patient 0% PR Lister Acute Oncology In-Patient 0% PR Luton & Dunstable Acute Oncology In-Patient 0% PR Queen's Acute Oncology In-Patient 0% PR MDT - King George Acute Oncology In-Patient 0% PR Whipps Cross Acute Oncology In-Patient 0% PR Newham Healthcare Acute Oncology MDT 0% PR Newham Healthcare Acute Oncology In-Patient 0% PR Homerton Acute Oncology MDT 0% PR Barts Acute Oncology In-Patient 0% PR The Royal London Hospital Acute Oncology In-Patient 0% PR 30

31 Team Tumour site / section Compliance Cycle PRUH Acute Oncology In-Patient 0% PR QEW Acute Oncology In-Patient 0% PR Plymouth Acute Oncology MDT 0% PR Plymouth Acute Oncology In-Patient 0% PR Royal Cornwall Acute Oncology MDT 0% PR Royal Cornwall Acute Oncology In-Patient 0% PR Royal Devon & Exeter Acute Oncology In-Patient 0% PR South Devon Acute Oncology In-Patient 0% PR North Devon Acute Oncology In-Patient 0% PR Royal Bournemouth and Christchurch Hospitals Acute Oncology In-Patient 0% PR North Bristol Acute Oncology In-Patient 0% PR Taunton Acute Oncology In-Patient 0% PR UHB Acute Oncology MDT 0% PR Weston Acute Oncology MDT 0% PR Weston Acute Oncology In-Patient 0% PR Gloucester Royal Acute Oncology MDT 0% PR Gloucester Royal Acute Oncology In-Patient 0% PR Cheltenham General Acute Oncology MDT 0% PR Cheltenham General Acute Oncology In-Patient 0% PR Hereford Hospital Acute Oncology In-Patient 0% PR Buckinghamshire Healthcare NHS Trust Acute Oncology MDT 0% PR Buckinghamshire Healthcare NHS Trust Acute Oncology In-Patient 0% PR Stoke Mandeville Acute Oncology MDT 0% PR Stoke Mandeville Acute Oncology In-Patient 0% PR Portsmouth Acute Oncology MDT 0% PR IoW Acute Oncology In-Patient 0% PR Salisbury NHS Foundation Trust Acute Oncology In-Patient 0% PR RWST Acute Oncology MDT 0% PR RWST Acute Oncology In-Patient 0% PR Surrey & Sussex Acute Oncology In-Patient 0% PR Princess Royal Hospital Acute Oncology In-Patient 0% PR Eastbourne Acute Oncology MDT 0% PR Eastbourne General Acute Oncology 0% PR Eastbourne Acute Oncology In-Patient 0% PR Hastings Acute Oncology MDT 0% PR Hastings General Acute Oncology 0% PR Hastings Acute Oncology In-Patient 0% PR Worthing & Southlands Acute Oncology MDT 0% PR Worthing & Southlands Acute Oncology In-Patient 0% PR Kent & Canterbury Acute Oncology MDT 0% PR Kent & Canterbury Acute Oncology In-Patient 0% PR Medway NHS Foundation Trust Acute Oncology MDT 0% PR Medway NHS Foundation Trust General Acute Oncology 0% PR Medway NHS Foundation Trust Acute Oncology In-Patient 0% PR 31

32 Team Tumour site / section Compliance Cycle Maidstone Hospital Acute Oncology In-Patient 0% PR The Dudley Group NHS Foundation Trust Acute Oncology MDT 0% PR The Royal Wolverhampton Hospitals Trust Acute Oncology MDT 0% PR Mid Staffordshire NHS Foundation Trust Acute Oncology MDT 0% PR Mid Staffordshire NHS Foundation Trust Acute Oncology In-Patient 0% PR The James Cook University Hospital Acute Oncology MDT 0% PR DMH/BAGH Acute Oncology MDT 0% PR DMH/BAGH Acute Oncology In-Patient 0% PR Gateshead Acute Oncology In-Patient 0% PR South Tyneside Acute Oncology In-Patient 0% PR UHND Acute Oncology MDT 0% PR UHND Acute Oncology In-Patient 0% PR West Cumberland (Whitehaven) Acute Oncology MDT 0% PR West Cumberland (Whitehaven) Acute Oncology In-Patient 0% PR Cumberland Infirmary Carlisle Acute Oncology MDT 0% PR Cumberland Infirmary Carlisle Acute Oncology In-Patient 0% PR FHN Acute Oncology MDT 0% PR Nottingham City Hospital Acute Oncology MDT 0% PR Nottingham City Hospital Acute Oncology In-Patient 0% PR Queens Medical Campus Acute Oncology MDT 0% PR Queens Medical Campus Acute Oncology In-Patient 0% PR Northampton General Hospital NHS Trust Acute Oncology In-Patient 0% PR Kettering Acute Oncology In-Patient 0% PR Leicester General Hospital Acute Oncology In-Patient 0% PR Leicester Royal Infirmary Acute Oncology In-Patient 0% PR Glenfield Hospital Acute Oncology In-Patient 0% PR Grantham Hospital Acute Oncology In-Patient 0% PR Pilgrim Hospital Boston Acute Oncology In-Patient 0% PR RMH Sutton General Acute Oncology 9% PR Freeman Hospital (Newcastle) General Acute Oncology 9% PR Royal Victoria Infirmary (Newcastle) General Acute Oncology 9% PR Rochdale General Acute Oncology 10% PR Oldham General Acute Oncology 10% PR Stockport General Acute Oncology 10% PR Bury General Acute Oncology 10% PR North Manchester General Acute Oncology 10% PR Oldham Acute Oncology MDT 17% PR Wrightington, Wigan And Leigh Acute Oncology MDT 17% PR Mid Cheshire Acute Oncology MDT 17% PR Salford Acute Oncology MDT 17% PR East Cheshire Acute Oncology MDT 17% PR Bury Acute Oncology MDT 17% PR North Manchester Acute Oncology MDT 17% PR St James's Hospital Acute Oncology MDT 17% PR 32

33 Team Tumour site / section Compliance Cycle Scarborough And North East Yorkshire Health Care Acute Oncology MDT 17% PR Barnsley Acute Oncology MDT 17% PR Croydon Acute Oncology MDT 17% PR North Devon Acute Oncology MDT 17% PR Yeovil Acute Oncology MDT 17% PR Horton Hospital Acute Oncology MDT 17% PR IoW Acute Oncology MDT 17% PR Surrey & Sussex Acute Oncology MDT 17% PR Princess Royal Hospital Acute Oncology MDT 17% PR BSUH Acute Oncology MDT 17% PR Maidstone Hospital Acute Oncology MDT 17% PR Royal Shrewsbury Acute Oncology MDT 17% PR Princess Royal Telford Acute Oncology MDT 17% PR West Suffolk Acute Oncology MDT 17% PR Gateshead Acute Oncology MDT 17% PR South Tyneside Acute Oncology MDT 17% PR Derby Hospital Acute Oncology MDT 17% PR Plymouth General Acute Oncology 18% PR Royal Cornwall General Acute Oncology 18% PR Princess Royal Hospital General Acute Oncology 18% PR Maidstone Hospital General Acute Oncology 18% PR West Cumberland (Whitehaven) General Acute Oncology 18% PR Cumberland Infirmary Carlisle General Acute Oncology 18% PR Wrightington, Wigan And Leigh General Acute Oncology 20% PR Bolton General Acute Oncology 20% PR Scarborough And North East Yorkshire Health Care General Acute Oncology 20% PR RWST General Acute Oncology 20% PR Worthing & Southlands General Acute Oncology 20% PR Mid Staffordshire NHS Foundation Trust General Acute Oncology 20% PR Gateshead General Acute Oncology 20% PR Stockport Acute Oncology In-Patient 25% PR Mid Cheshire Acute Oncology In-Patient 25% PR Salford Acute Oncology In-Patient 25% PR Bolton Acute Oncology In-Patient 25% PR Leeds General Infirmary Acute Oncology In-Patient 25% PR St James's Hospital Acute Oncology In-Patient 25% PR Calderdale Acute Oncology In-Patient 25% PR Huddersfield Acute Oncology In-Patient 25% PR Rotherham Acute Oncology In-Patient 25% PR Doncaster Acute Oncology In-Patient 25% PR Bassetlaw Acute Oncology In-Patient 25% PR Walsall Healthcare Acute Oncology In-Patient 25% PR City Hospital Acute Oncology In-Patient 25% PR Sandwell Hospital Acute Oncology In-Patient 25% PR 33

34 Team Tumour site / section Compliance Cycle Solihull Hospital Acute Oncology In-Patient 25% PR Ealing Hospital Acute Oncology In-Patient 25% PR Hillingdon Acute Oncology In-Patient 25% PR Charing Cross Acute Oncology In-Patient 25% PR North Middlesex University Hospital Acute Oncology In-Patient 25% PR University College London Hospitals Acute Oncology In-Patient 25% PR The Princess Alexandra Hospital Acute Oncology In-Patient 25% PR Homerton Acute Oncology In-Patient 25% PR Lewisham Acute Oncology In-Patient 25% PR Epsom & St Helier Acute Oncology In-Patient 25% PR Croydon Acute Oncology In-Patient 25% PR St George's Acute Oncology In-Patient 25% PR Poole Acute Oncology In-Patient 25% PR Dorset County Hospitals Acute Oncology In-Patient 25% PR Yeovil Acute Oncology In-Patient 25% PR Worcestershire Acute Hospitals NHS Trust Acute Oncology In-Patient 25% PR Redditch Acute Oncology In-Patient 25% PR Milton Keynes General Acute Oncology In-Patient 25% PR John Radcliffe Acute Oncology In-Patient 25% PR Horton Hospital Acute Oncology In-Patient 25% PR Basingstoke and North Hampshire Hospital Acute Oncology In-Patient 25% PR Frimley Park Acute Oncology In-Patient 25% PR Dartford & Gravesham Acute Oncology In-Patient 25% PR The Royal Wolverhampton Hospitals Trust Acute Oncology In-Patient 25% PR Royal Shrewsbury Acute Oncology In-Patient 25% PR Princess Royal Telford Acute Oncology In-Patient 25% PR University Hospital North Staffordshire NHS Trust Acute Oncology In-Patient 25% PR Broomfield (Chelmsford) Acute Oncology In-Patient 25% PR North Tees Acute Oncology In-Patient 25% PR Hartlepool Acute Oncology In-Patient 25% PR Derby Hospital Acute Oncology In-Patient 25% PR Burton Hospital Acute Oncology In-Patient 25% PR Lincoln County Hospital Acute Oncology In-Patient 25% PR Salford General Acute Oncology 27% PR North Bristol General Acute Oncology 27% PR UHB General Acute Oncology 27% PR BSUH General Acute Oncology 27% PR Royal Shrewsbury General Acute Oncology 27% PR Princess Royal Telford General Acute Oncology 27% PR The James Cook University Hospital General Acute Oncology 27% PR Nottingham City Hospital General Acute Oncology 27% PR Queens Medical Campus General Acute Oncology 27% PR Yeovil General Acute Oncology 30% PR Buckinghamshire Healthcare NHS Trust General Acute Oncology 30% PR 34

35 Team Tumour site / section Compliance Cycle Royal Hampshire County Hospital General Acute Oncology 30% PR Basingstoke and North Hampshire Hospital General Acute Oncology 30% PR IoW General Acute Oncology 30% PR UHND General Acute Oncology 30% PR Hartlepool General Acute Oncology 30% PR FHN General Acute Oncology 30% PR Rochdale Acute Oncology MDT 33% PR RMH Sutton Acute Oncology In-Patient 33% SA Christie Hospital Specialist Acute Oncology 33% PR Mid Cheshire General Acute Oncology 33% PR Aintree Acute Oncology MDT 33% PR York Acute Oncology MDT 33% PR Leeds General Infirmary Acute Oncology MDT 33% PR RHH Acute Oncology MDT 33% PR WPH Acute Oncology MDT 33% PR City Hospital Acute Oncology MDT 33% PR Sandwell Hospital Acute Oncology MDT 33% PR University Hospital Coventry and Warwickshire Acute Oncology MDT 33% PR Mount Vernon Cancer Centre Acute Oncology MDT 33% PR Ealing Hospital Acute Oncology MDT 33% PR Hillingdon Acute Oncology MDT 33% PR University College London Hospitals Acute Oncology MDT 33% PR Whipps Cross Acute Oncology MDT 33% PR Epsom & St Helier Acute Oncology MDT 33% PR Royal Devon & Exeter Acute Oncology MDT 33% PR Poole Acute Oncology MDT 33% PR Royal Bournemouth and Christchurch Hospitals Acute Oncology MDT 33% PR North Bristol Acute Oncology MDT 33% PR RUH Acute Oncology MDT 33% PR Taunton Acute Oncology MDT 33% PR Heatherwood & Wexham Acute Oncology MDT 33% PR Oxford University Acute Oncology MDT 33% PR Frimley Park Acute Oncology MDT 33% PR University Hospital North Staffordshire NHS Trust Acute Oncology MDT 33% PR Northumbria (North Tyneside) Acute Oncology MDT 33% PR Northumbria (Wansbeck) Acute Oncology MDT 33% PR Northumbria (Hexham) Acute Oncology MDT 33% PR Kettering Acute Oncology MDT 33% PR Lincoln County Hospital Acute Oncology MDT 33% PR Leicester General Hospital Acute Oncology MDT 33% PR Leicester Royal Infirmary Acute Oncology MDT 33% PR Glenfield Hospital Acute Oncology MDT 33% PR Grantham Hospital Acute Oncology MDT 33% PR Pilgrim Hospital Boston Acute Oncology MDT 33% PR 35

36 Team Tumour site / section Compliance Cycle Northern General General Acute Oncology 36% PR RHH General Acute Oncology 36% PR WPH General Acute Oncology 36% PR Lister General Acute Oncology 36% PR Portsmouth General Acute Oncology 36% PR Kent & Canterbury General Acute Oncology 36% PR The Royal Wolverhampton Hospitals Trust General Acute Oncology 36% PR Lincoln County Hospital General Acute Oncology 36% PR Grantham Hospital General Acute Oncology 36% PR Pilgrim Hospital Boston General Acute Oncology 36% PR East Cheshire General Acute Oncology 40% PR Whipps Cross General Acute Oncology 40% PR North Devon General Acute Oncology 40% PR Weston General Acute Oncology 40% PR Stoke Mandeville General Acute Oncology 40% PR The Dudley Group NHS Foundation Trust General Acute Oncology 40% PR West Suffolk General Acute Oncology 40% PR DMH/BAGH General Acute Oncology 40% PR Sunderland General Acute Oncology 40% PR South Tyneside General Acute Oncology 40% PR Northumbria (North Tyneside) General Acute Oncology 40% PR Northumbria (Wansbeck) General Acute Oncology 40% PR Northumbria (Hexham) General Acute Oncology 40% PR Barnsley General Acute Oncology 44% PR Royal Liverpool & Broadgreen General Acute Oncology 45% PR University College London Hospitals General Acute Oncology 45% PR Queen's General Acute Oncology 45% PR King George General Acute Oncology 45% PR St George's General Acute Oncology 45% PR Southend General Acute Oncology 45% PR North Tees General Acute Oncology 45% PR Derby Hospital General Acute Oncology 45% PR Leicester General Hospital General Acute Oncology 45% PR Leicester Royal Infirmary General Acute Oncology 45% PR Glenfield Hospital General Acute Oncology 45% PR Blackpool Teaching Hospitals Trust Acute Oncology MDT 50% PR Countess of Chester Acute Oncology MDT 50% PR Royal Liverpool & Broadgreen Acute Oncology MDT 50% PR Southport & Ormskirk Acute Oncology MDT 50% PR Wirral Acute Oncology MDT 50% PR Royal Victoria Infirmary (Newcastle) Acute Oncology MDT 50% PR Dewsbury Acute Oncology MDT 50% PR Pinderfields Acute Oncology MDT 50% PR Pontefract Acute Oncology MDT 50% PR 36

37 Team Tumour site / section Compliance Cycle Hull Royal Infirmary Acute Oncology MDT 50% PR DPofW Acute Oncology MDT 50% PR SGH Acute Oncology MDT 50% PR George Eliot Acute Oncology MDT 50% PR Sherwood Forest Hospitals Acute Oncology MDT 50% PR Northampton General Hospital NHS Trust Acute Oncology MDT 50% PR James Paget Acute Oncology MDT 50% PR Addenbrookes Acute Oncology MDT 50% PR Peterborough Acute Oncology MDT 50% PR The Princess Alexandra Hospital Acute Oncology MDT 50% PR Broomfield (Chelmsford) Acute Oncology MDT 50% PR Southend Acute Oncology MDT 50% PR Lister Acute Oncology MDT 50% PR Bradford Acute Oncology MDT 50% PR Queen's Acute Oncology MDT 50% PR King George Acute Oncology MDT 50% PR The Royal London Hospital Acute Oncology MDT 50% PR Lewisham Acute Oncology MDT 50% PR St George's Acute Oncology MDT 50% PR South Devon Acute Oncology MDT 50% PR Dorset County Hospitals Acute Oncology MDT 50% PR Hereford Hospital Acute Oncology MDT 50% PR Worcestershire Acute Hospitals NHS Trust Acute Oncology MDT 50% PR Redditch Acute Oncology MDT 50% PR Milton Keynes General Acute Oncology MDT 50% PR John Radcliffe Acute Oncology MDT 50% PR Salisbury NHS Foundation Trust Acute Oncology MDT 50% PR University Hospitals Southampton Acute Oncology MDT 50% PR St Peters Acute Oncology MDT 50% PR PRUH Acute Oncology MDT 50% PR QEW Acute Oncology MDT 50% PR Charing Cross Acute Oncology MDT 50% PR Royal Hampshire County Hospital Acute Oncology MDT 50% PR Basingstoke and North Hampshire Hospital Acute Oncology MDT 50% PR Preston Acute Oncology In-Patient 50% PR Chorley Acute Oncology In-Patient 50% PR Furness General Hospital Acute Oncology In-Patient 50% PR Aintree Acute Oncology In-Patient 50% PR Countess of Chester Acute Oncology In-Patient 50% PR Royal Liverpool & Broadgreen Acute Oncology In-Patient 50% PR Sunderland Acute Oncology In-Patient 50% PR Northumbria (North Tyneside) Acute Oncology In-Patient 50% PR Northumbria (Wansbeck) Acute Oncology In-Patient 50% PR Northumbria (Hexham) Acute Oncology In-Patient 50% PR 37

38 Team Tumour site / section Compliance Cycle Royal Victoria Infirmary (Newcastle) Acute Oncology In-Patient 50% PR York Acute Oncology In-Patient 50% PR DPofW Acute Oncology In-Patient 50% PR SGH Acute Oncology In-Patient 50% PR Scarborough And North East Yorkshire Health Care Acute Oncology In-Patient 50% PR George Eliot Acute Oncology In-Patient 50% PR S Warwickshire General Acute Oncology In-Patient 50% PR Sherwood Forest Hospitals Acute Oncology In-Patient 50% PR James Paget Acute Oncology In-Patient 50% PR Norfolk & Norwich Acute Oncology In-Patient 50% PR East Cheshire Acute Oncology In-Patient 50% PR Kings Lynn Acute Oncology In-Patient 50% PR Colchester Hospital University NHS Foundation Trust Acute Oncology In-Patient 50% PR Ipswich Acute Oncology In-Patient 50% PR Southend Acute Oncology In-Patient 50% PR Northwick Park Hospital Acute Oncology In-Patient 50% PR Watford General Hospital Acute Oncology In-Patient 50% PR Kingston Acute Oncology In-Patient 50% PR West Middlesex Acute Oncology In-Patient 50% PR Royal Free Hampstead NHS Trust Acute Oncology In-Patient 50% PR Chelsea & Westminster Acute Oncology In-Patient 50% PR RUH Acute Oncology In-Patient 50% PR UHB Acute Oncology In-Patient 50% PR Heatherwood & Wexham Acute Oncology In-Patient 50% PR Royal Berkshire Acute Oncology In-Patient 50% PR BSUH Acute Oncology In-Patient 50% PR Royal Hampshire County Hospital Acute Oncology In-Patient 50% PR North Bristol Onc. Pharmacy Serv. MDT 50% PR Kent & Canterbury Onc. Pharmacy Serv. MDT 50% PR University Hospital of South Manchester General Acute Oncology 50% PR Countess of Chester General Acute Oncology 50% PR Kettering General Acute Oncology 50% PR Luton & Dunstable General Acute Oncology 50% PR West Middlesex General Acute Oncology 50% PR Newham Healthcare General Acute Oncology 50% PR South Devon General Acute Oncology 50% PR Royal Bournemouth and Christchurch Hospitals General Acute Oncology 50% PR Salisbury NHS Foundation Trust General Acute Oncology 50% PR PRUH General Acute Oncology 50% PR QEW General Acute Oncology 50% PR Colchester Hospital University NHS Foundation Trust Rad Brachytherapy 50% SA 38

39 The CQC has been notified of all teams whose compliance falls below 50% along with Chief Executives of the trusts concerned, requesting remedial action. 4.3 Good Practice Throughout the 2012/2013 round of peer review, reviewers found examples of good practice in almost every team and organisation that was reviewed. Particular areas of good practice noted throughout the cross cutting teams were: Expansion of high and low dose radiotherapy delivery of brachytherapy treatments across the country. Appointments of radiotherapy medical physics staff and role extensions of radiographers in advanced practice. Completed equipment replacement programmes. Increased capacity in image guided radiotherapy treatments. Innovative and comprehensive training methods with the development of e-learning packages. Strong AOS nurse groups with consistent engagement, collaboration and delivery. Enthusiasm of all stakeholders to implement the AOS for patient benefit. Regular audit of length of stay, time to first antibiotic, MSCC pathways. On-going development of outreach services for the safe administration of appropriate chemotherapy closer to home. Development of telephone assessment clinics to avoid additional journeys. Establishment of pre-assessment sessions. Steady progress to implement full e-prescribing. Work to establish devolved models of chemotherapy ensuring patients have access to chemotherapy closer to home where appropriate. Good progress on establishing network wide agreed treatment algorithms. Many teams had built on the comments from previous reviews to achieve good practice in those areas in 2012/2013. Further details of these good practices can be found in the individual peer review reports and on the CQuINS database. They include many examples of excellent leadership and clinical engagement. Three key areas of good practice identified in relation to the internal validation process were where the internal validation panel included one or more of the following: Trust Executive Director Commissioner Patient / Carer (Users) The inclusion of these members improved focus and status of the panel. In relation to quantitative findings, this report shows that 526 (42%) of the 1260 cross cutting services achieved over 90% compliance with the measures and 412 (33%) achieved 100% compliance with the measures. 4.4 Immediate Risks and Serious Concerns A key feature of National peer review programme is the identification of immediate risks (IRs) and serious concerns (SCs). Peer review is unlike other quality assurance programmes in the NHS, in that if an immediate risk is identified the service is asked for it to be resolved within two weeks. The majority of the immediate risks identified have now been resolved. An immediate risk is an issue that is likely to result in harm to patients or 39

40 staff or have a direct impact on clinical outcomes and therefore requires immediate action. A serious concern is an issue that, whilst not presenting an immediate risk to patient or staff safety, could seriously compromise the quality or clinical outcomes of patient care, and therefore requires urgent action to resolve. In the table below the green shading shows services where the percentage with immediate risks or serious concerns had decreased since 2011/2012, the red shading indicates where the percentage of services with immediate risks or serious concerns had increased since 2011/2012 and lack of shading that the percentage had remained constant. Table 16: Immediate Risk and Serious Concerns-Cross Cutting Services 2011/12 and 2012/13 Service Radiotherapy Generic IR 11/12 2 (4%) SC 11/12 10 (18%) No. of Teams assessed in 12/13 SA IR IV IR PR IR IR total SA SC IV SC PR SC SC total (4%) (5%) Radiotherapy External Beam 2 (4%) 10 (18%) (4%) (5%) Radiotherapy IMRT 2 (4%) 10 (18%) (4%) (5%) Radiotherapy Brachytherapy 0 (0%) 6 (14%) (2%) (9%) Clinical Chemotherapy 7 (4%) 49 (31%) (23%) (57%) Oncology Pharmacy 6 (4%) 28 (18%) (3%) (14%) Intrathecal Chemotherapy 6 (4%) 18 (12%) (3%) (10%) Acute Oncology (i) 15 (8%) 50 (27%) (17%) (69%) Specialist Acute Oncology (ii) 0 (0%) 3 (21%) (8%) (50%) General Acute Oncology (iii) 15 (8%) 54 (28%) (16%) (68%) Acute Oncology Inpatient Assessment 15 (8%) 52 (27%) (16%) (69%) Total

41 Acute oncology services and chemotherapy services were subject to their first round of peer review in 2012/13 with 2011/12 being their first year of self-assessment. The levels of reported concerns have increased due to this higher level of assessment for both services. There are still on-going issues nationally around acute oncology services not being fully established and, where there are services in place, issues with staffing, cover and patient pathways. Clinical chemotherapy services have high reported levels of chemotherapy drug storage and preparation concerns, such as the storage area not being locked or drugs being stored at incorrect temperatures. A more detailed breakdown on compliance and commentary on all cross cutting services can be found in the individual sections. Links to Cross Cutting Reports Tumour site or services Radiotherapy Chemotherapy Acute Oncology Link to report Radiotherapy Report Chemotherapy Report Acute Oncology Report 41

42 National Peer Review Programme Children s and TYA Services Overview 5.1 Overall Compliance A total of 336 children s and TYA teams were reviewed as part of the 2012/2013 peer review programme. 231 (69%) teams were on the self-assessment cycle; 36 (11%) on the internal validation cycle and 25 (7%) were subject to a full peer review assessment. The number of children s and TYA teams achieving 100% compliance with the measures was 62 (18%); the number of children s and TYA teams achieving over 90% compliance with the measures was 169 (50%); the number of children s and TYA teams achieving over 80% compliance with the measures was 242 (72%) and the number of children s and TYA teams achieving over 75% compliance with the measures was 255 (76%). The following figures and tables show a comparison of compliance of teams reviewed in 2010/2011, 2011/2012 and 2012/2013, and the overall national compliances for all teams. Figure 9: Median Comparisons of Children s and TYA 10/11, 11/12 and 12/13 100% Median comparisons 10/11, 11/12 and 12/13 90% 80% 70% 60% 50% 40% 2010/ / / % 20% 10% 0% Children: Principle Treatment Centre (PTC) Core PTC, Late effects MDT PTC, Diagnostic & Treatment MDT Paediatric Oncology Shared Care Unit (POSCU) Level 1 Core Paediatric Oncology Shared Care Unit (POSCU) Level 2 Core Paediatric Oncology Shared Care Unit (POSCU) Level 3 Core POSCU MDT TYA Primary TYA PTC MDT Treatment Centre (PTC) Core Measures TYA designated hospitals 11-1D-1z 42

43 Figure 10: Overall Compliance Ranges Children s and TYA 12/13 100% Overall Compliance Ranges: Childrens and TYA (SA, IV and PR 12/13) 90% 80% 70% 60% 50% 40% 30% x2 x3 x5 20% x2 10% 0% Children: Principle Treatment Centre (PTC) Core PTC, Late effects PTC, Diagnostic MDT & Treatment MDT Paediatric Oncology Shared Care Unit (POSCU) Level 1 Core Red vertical lines: complete range Blue box: inter-quartile range Orange horizontal line: median value Team below 50% (If more than one team, number in brackets) Paediatric Oncology Shared Care Unit (POSCU) Level 2 Core Paediatric Oncology Shared Care Unit (POSCU) Level 3 Core POSCU MDT Figure 11: Overall Compliance Ranges Children s and TYA 11/12 TYA Primary Treatment Centre (PTC) Core Measures TYA PTC MDT TYA designated hospitals 11-1D- 1z 100% Overall Compliance Ranges: Childrens and TYA (SA, IV and PR 11/12) 90% 80% 70% 60% 50% 40% 30% x3 x2 x5 20% 10% x3 0% Children: Principle Treatment Centre (PTC) Core PTC, Late effects PTC, Diagnostic MDT & Treatment MDT Paediatric Oncology Shared Care Unit (POSCU) Level 1 Core Red vertical lines: complete range Blue box: inter-quartile range Orange horizontal line: median value Team below 50% (If more than one team, number in brackets) Paediatric Oncology Shared Care Unit (POSCU) Level 2 Core Paediatric Oncology Shared Care Unit (POSCU) Level 3 Core POSCU MDT TYA Primary Treatment Centre (PTC) Core Measures TYA PTC MDT x3 TYA designated hospitals 11-1D- 1z NB These include SA, IV and PR compliances, depending on the cycle. For those teams with a compliance of below 50%, the specific type of assessment may be found in Section

44 National Peer Review Programme Table 17: Comparison of Overall National Compliances Children s and TYA Services (Mean) , and Children s and TYA Service 2010/2011 Overall National Percentage 2011/12 Overall National Percentage 2012/13 Overall National Percentage Children: PTC Core 88% 88% 95% PTC, Late effects MDT 63% 67% 85% PTC, Diagnostic & Treatment MDT 76% 74% 88% POSCU Level 1 Core 84% 82% 93% POSCU Level 2 Core 84% 88% 96% POSCU Level 3 Core 88% 89% 94% POSCU MDT 75% 77% 91% TYA PTC Core Measures 75% 60% TYA PTC MDT 65% 58% TYA designated hospitals 11-1D-1z 71% 75% Table 18: Comparison of Children s and TYA Teams , and / / /13 Total change in teams Initial assessment to Change in number of teams Children: PTC Core PTC, Late effects MDT PTC, Diagnostic & Treatment MDT POSCU Level 1 Core POSCU Level 2 Core POSCU Level 3 Core POSCU MDT TYA PTC Core Measures TYA PTC MDT TYA designated hospitals 11-1D-1z Total to

45 National Peer Review Programme Children s and TYA Teams with compliance of 50% or below There were 31 children s and TYA teams that had compliances of 50% or below. This equates to 9% of those teams, compared with 40 teams (12%) 2011/2012. However, it should be noted that 30 of teams with a compliance of 50% or under in 2012/2013 were subject to their first peer review assessment. Table 19: Children s and TYA Services with 50% or below compliance 2012 /2013 Team Tumour site / section Compliance Cycle Oxford University TYA PTC Core 13% PR Lister TYA Hospitals 17% IV Burton Hospital TYA Hospitals 20% SA Whittington Hospital TYA Hospitals 20% IV University Hospitals Southampton NHS Foundation Trust TYA PTC Core 25% PR Nottingham University Hospitals NHS Trust TYA PTC Core 25% PR Morecambe Bay Hospitals TYA Hospitals 33% IV York TYA Hospitals 33% IV Eastbourne TYA Hospitals 33% IV Shrewsbury & Telford Hospitals TYA Hospitals 33% IV Lincoln County Hospital TYA Hospitals 33% IV Clatterbridge Centre TYA PTC Core 38% PR University Hospitals Birmingham Foundation Trust TYA PTC MDT 38% PR UHB TYA PTC Core 38% PR Oxford University TYA PTC MDT 38% PR University Hospitals Southampton NHS Foundation Trust TYA PTC MDT 38% PR Broomfield (Chelmsford) TYA Hospitals 40% IV The Princess Alexandra Hospital Level 1 Core POSCU 45% SA Lancashire Teaching Hospitals TYA Hospitals 50% IV University Hospital of South Manchester NHS Foundation Trust TYA Hospitals 50% IV Stockport TYA Hospitals 50% IV Gateshead TYA Hospitals 50% IV The James Cook University Hospital TYA Hospitals 50% IV FHN TYA Hospitals 50% IV Colchester Hospital University NHS Foundation Trust TYA Hospitals 50% IV Basildon & Thurrock TYA Hospitals 50% IV Heatherwood & Wexham TYA Hospitals 50% IV Maidstone Hospital TYA Hospitals 50% IV Christie Hospital TYA PTC MDT 50% PR The CQC has been notified of all teams whose compliance falls below 50% along with the Chief Executives of the trusts concerned, requesting remedial action. 45

46 National Peer Review Programme Good Practice Throughout the 2012/2013 round of peer review, reviewers found examples of good practice in almost every team and organisation that was reviewed. Particular areas of good practice noted throughout the cross cutting teams were: Age specific training programmes. Increased levels of staffing from all disciplines and improved representation and attendance at MDT meetings. Gaining patient feedback and service developments as a result such as improvements in parent ward facilities. High levels of recruitment into clinical trials. Development and delivery of training programmes such as Entonox for play specialists and sexual health training for any staff working with TYA patients. PTCs have good communication with shared care units and between specialities. Enhanced electronic data capture during MDT meetings. Comprehensive range of patient information including the use of DVDs. Progress in developing end of treatment summaries. Development of nurse led clinics. Progress and participation in survivorship projects, such as the National Survivorship Programme pilot. Improved levels of attendance at national advanced communication skills training programme. Enhanced pathways including end of life care. Development of treatment pathways for patients admitted with febrile neutropenia. Robust processes for the designation of TYA hospitals. Development of pathways in conjunction with the site specific NSSGs. Audits to assess number of referrals to TYA MDT. Links with universities and schools to support continuing education. Many teams had built on the comments from previous reviews to achieve good practice in those areas in Further details of those good practices can be found in the individual peer review reports and on the CQuINS database. They include many examples of excellent leadership and clinical engagement. Three key areas of good practice identified in relation to the internal validation process were where the internal validation panel included one or more of the following: Trust Executive Director Commissioner Patient / Carer (Users) The inclusion of these members improved focus and status of the panel. In relation to quantitative findings, this report shows that 169 (50%) of the 336 children s and TYA services achieved over 90% compliance with the measures and 62 (18%) achieved 100% compliance with the measures. 46

47 National Peer Review Programme Immediate Risk and Serious Concerns A key feature of the national peer review programme is the identification of immediate risks (IRs) and serious concerns (SCs). Peer review is unlike other quality assurance programmes in the NHS, in that if an immediate risk is identified the service is asked for it to be resolved within two weeks. The majority of the immediate risks identified have now been resolved. An immediate risk is an issue that is likely to result in harm to patients or staff or have a direct impact on clinical outcomes and therefore requires immediate action. A serious concern is an issue that, whilst not presenting an immediate risk to patient or staff safety, could seriously compromise the quality or clinical outcomes of patient care, and therefore requires urgent action to resolve. In the table below the green shading shows tumour sites where the percentage of teams with immediate risks or serious concerns had decreased since 2011/2012, the red shading indicates where the percentage of teams with immediate risks or serious concerns had increased since 2011/2012 and lack of shading that the percentage had remained constant. Table 20: Immediate Risk and Serious Concerns -Children s and TYA Services 2011/12 and 2012/13 Tumour site Children: PTC Core IR 11/12 1 (8%) SC 11/12 6 (46%) No. of Teams assessed in 12/13 SA IR IV IR PR IR IR total SA SC IV SC (0%) PR SC SC total 2 (15%) PTC, Late effects MDT 0 (0%) 2 (15%) (0%) (0%) PTC, Diagnostic & Treatment MDT 0 (0%) 12 (33%) (0%) (8%) POSCU Level 1 Core 13 (23%) 24 (42%) (4%) (4%) POSCU Level 2 Core 3 (23%) 6 (46%) (0%) (8%) POSCU Level 3 Core 1 (8%) 2 (17%) (0%) (8%) POSCU MDT 12 (15%) 27 (33%) (2%) (6%) TYA PTC Core Measures 0 (0%) 2 (15%) (8%) (62%) TYA PTC MDT 0 (0%) 2 (15%) (8%) (62%) TYA designated hospitals 2 (3%) 1 (1%) (1%) (6%) Total A more detailed breakdown on compliance and commentary on all children s and TYA Services can be found in the individual sections. 47

48 National Peer Review Programme Links to Children s and TYA Reports Service Children s TYA Link to report Children s Report TYA Report 48

49 6 Networks 6.1 Context of Network Changes In the cancer networks had to operate in an environment of change and uncertainty, both in the NHS in general and in particular the transition into Strategic Clinical Networks (SCNs). This was particularly challenging where the boundary of the SCN was different to the existing cancer network. Many networks were unable to retain staff over this period and some cancer networks ceased to exist before the end of the year This resulted in some network site specific groups and crossing cutting network groups failing to complete their peer review assessments. The issue of retaining network site specific groups and cross cutting groups has been the topic of much debate and discussion. While there is a unanimous belief by stakeholders that these groups are necessary and they are identified within the NICE IOG it is unclear who or how these group should be funded. In order for networks to manage this difficult period it was agreed that some network groups namely: Rehabilitation Psychology Complimentary therapy Partnership are to be suspended in cycle and that other network groups would only be required to complete the selfassessment (without required evidence upload) and no peer review visits would take place to these groups during this transition year. 6.2 Network Site Specific Groups (NSSG s) NSSGs are central to the delivery of equitable patient care and robust patient pathways for each tumour site. The graphs in appendix 2 show wide variation in the compliance of NSSGs across the networks and tumour sites. A number of themes emerged during the reviews of the network boards and NSSGs during National audit data needs consistent clinical verification and monitoring to ensure that MDTs are appropriately engaged. Lack of clarity over future support that will be offered for the continuation of NSSGs. Inadequate and incompatible video conferencing facilities across trusts which is affecting the effectiveness of MDTs. Lack of network agreed surgical guidelines e.g. Resection of liver metastases, Configuration issues for the care of localised rectal cancer. Complex surgery pathways not sufficiently robust and being undertaken without network agreed guidelines. Network guidelines becoming out-of-date. Inequity in the provision of psychological services. Wide variation in the collection of staging data which could lead to poor treatment decisions. Surgical workload numbers not meeting minimum numbers required by the IOG. CNS funding is a national issue and single-handed CNSs with very high workloads which is seriously affecting 49

50 National Peer Review Programme the standard of caring being received by patients. Lack of AHP provision and unclear arrangements for the coordination of rehabilitation. 6.3 Network Cross Cutting Groups Network cross cutting groups like NSSGs are central to the delivery of equitable patient care and robust patient pathways for each cross cutting service. Graphs in appendix 3 show the compliance for these groups. Overall Percentage Compliance 6.4 Network Children s and TYA Groups Children s and TYA network coordinating groups are central to the delivery of equitable patient care and robust patient pathways for each children s service Graphs in appendix 4 show the compliance for these groups. 6.5 Other Network Groups Cancer Research Networks All of the 32 cancer research networks were on the self-assessment cycle and were externally verified. Measure series Number of teams or services assessed Overall National Percentage Network Measures for Cancer Research Networks 11-1A % Functions of the Cancer Research Networks: 11-5A % Immediate Risks and Serious Concerns There were no immediate risks or serious concerns relating to cancer research networks Rehabilitation All 28 rehabilitation services were on the self-assessment cycle and were externally verified. Overall Percentage Compliance Measure series Number of teams or services assessed Overall National Percentage Functions of the Network Rehabilitation Group: 11-1E-1v 28 70% Immediate Risks and Concerns Number of teams IR % teams IR Number of teams SC % teams SC Rehab Board & Network Group 0 0% 5 18% 50

51 The serious concerns related to the sustainability of the group due to funding for lead AHP posts coming to an end, uncertainty of rehabilitation agenda due to cancer network restructuring, lack of cancer rehabilitation specialists impacting, or having the potential to impact, on the patient rehabilitation pathway Complementary Therapy (Safeguarding Practice) 160 complementary therapy services were on the self-assessment cycle in 12/13 with 1 team on internal validation. Overall Percentage Compliance Measure series Number of teams or services assessed Overall National Percentage Network Board - Complementary Therapy: 09-1A-3w 28 96% Locality Measures - Complementary Therapy: 09-1D-1w % Immediate Risks and Serious Concerns There were no immediate risks or serious concerns reported for the complementary therapy board measures or for the localities Psychological Support All the psychological support services were subject to self-assessment, following the introduction of the measures in Overall Percentage Compliance Measure series Number of teams or services assessed Overall National Percentage Network Psychological Support Group 11-1E-1x 28 64% Immediate Risks and Concerns Number of teams IR % teams IR Number of teams SC % teams SC Network Psychological Support Group 11-1E-1x 0 0% 7 25% 51

52 National Peer Review Programme The serious concerns related to: The lack of level 3 and 4 provision, and also the availability of supervision for practitioners. Variability and sustainability of funding for psychological services leading to inequities and concerns over future provision Patient Partnership Network Group and Board Overall Percentage Compliance Measure series Number of teams or services assessed Overall National Percentage Partnership Net Group 11-1E-1u 28 64% Partnership Net Board 11-1A-3u 28 75% Immediate Risks and Serious Concerns There were no immediate risks or serious concerns reported for the patient partnership group or board measures. 6.6 Clinical Lines of Enquiry The use of clinical lines of enquiry, the result of the NCPES and, where available, NCIN service profiles in has also served to demonstrate the importance of the NSSGs in both obtaining and discussing clinical and patient outcomes data in order to identify outliers in the MDTs and ensure equity of clinical care across the networks for each tumour site. In addition to the breast and lung CLEs, which had been piloted in 2011/2012, a number of additional CLEs were introduced in 2012/2013. These were gynaecology; head & neck; upper GI and colorectal. A number of general, as well as topic specific, themes emerged during the reviews: There was wide variation in the degree to which MDTs captured and validated data, and also the degree to which the MDTs then considered their outcome data as a means of improving their service. There was also variation in the degree to which NSSGs collated and considered the data from their MDTs in order to address outliers and enhance an equitable service for patients. There were challenges nationally in capturing and recording staging data. Introduction of electronic databases such as Somerset and Infoflex are noted at most trusts. Where trusts queried the validity of their submissions to national audits and registries it prompted local audit to check their own data and in most cases showed that the problem lay with the administration of data capture and entry. MDTs are increasingly reporting the use of real time data entry at MDT meetings. CLEs highlighted the lack of clinical validation of data submissions. There were a number of themes that were common to particular tumour sites, and these will be discussed in the individual tumour sections of the report. 52

53 6.7 Improving Outcomes Guidance There has been further progress in implementation of IOG configurations although at the time of the reviews there were still challenges in particular with urology, head and neck services and pathways for HPB patients. Some networks had arrangements which were outside of IOG recommendations, particularly for urology and head & neck, but had the National Cancer Action Team (NCAT) agreement by exception as best serving the needs of a particular population. These will stay under review in terms of numbers and outcomes. Details of the NICE IOG configuration of services can be found in the local area team reports which are published on the CQuINS website. 53

54 7 Future of Peer Review In order to ensure future sustainability of the peer review programme a number of changes have been introduced for the 2013/2014 round which is currently in progress. A new style of measures has been introduced for breast, lung and haematology services. This new style contains significantly fewer measures, some of which however include some previous measures that have been merged together. These measures will be reviewed during 2013/2014 to establish if they should be adopted for all tumour types and services in 2014/ /2014 sees the introduction of measures for Haematology and CUP. The change introduced in 2012/2013 that self-assessment evidence is only required every three years and internal validation is only required every third year will continue in 2013/2014. Table 21: Peer Review Cycle 2013/2014 Peer Review Cycle 2013/2014 Self-Assessment Internal External Validation Validation Breast Yes Yes Lung Yes Yes Colorectal Gynae UGI Urology Yes Yes Head and Neck Yes Yes Skin Brain and CNS Sarcoma Cancer Research Networks Radiotherapy Yes Yes Chemotherapy Acute Oncology Children's Cancer Teenage and Young Adult Haematology Yes Yes CUP Yes Yes The peer review programme will continue to working closely with NCIN and use the service profiles developed by them as and when they become available. The programme will also continue to use the NCPES. This will ensure the move to measuring clinical and patient outcomes is continued. With the appointment of a new clinical director and recent changes to the NHS environment discussions are currently taking place to ensure the peer review programme remains fit for Peer Review Visit Targeted Visits Targeted Visits Targeted Visits purpose. It is likely that the future peer review programme will expand to include other services and the programme will complement the work of the new CIOH, Professor Sir Mike Richards, at CQC. The CIOH has confirmed that it will not be possible for CQC to review all parts of a hospital and he is considering if/how best to make use of the range of accreditation and peer review programmes that currently exist to inform the hospital inspections 54

55 programme. He is considering the possibility of some form of accredit the accreditor' programme. This would be a means to identify those schemes that CQC would consider as a reliable information source for surveillance, and pre-inspection data packs and/or as means of trusted quality assurance in their own right to broaden the scope of the assessment from the core services without the need for additional CQC inspection. The CIOH is supportive of the NPRP and recognises its potential value in supporting his hospital inspection model. It is therefore suggested that a short term aim would be to become accredited by the CQC as soon as such a process is put in place. The national peer review programme will continue to support commissioners and it is planned to formalise arrangements with NHS England s Clinical Director for specialised commissioning to provide information on the implementation of services specification and to inform the work of the Clinical Reference Groups. 55

56 National Peer Review Programme Appendix 1: Background to National Peer Review Programme National Cancer Peer Review Programme 2001 The first national cancer peer review programme was in Although this was a national programme, it was implemented with regional differences which made it difficult to compare the results across the country. The first Manual for Cancer Services which covered standards for the four common cancers breast, lung, colorectal and gynaecology was published in The national evaluation of the programme by Keele University recommended that national consistency was addressed with the establishment of a national team and methodology. National Peer Review Programme In 2004 the second national programme commenced. A new Manual for Cancer Services, which covered measures for six cancer sites (breast, lung, colorectal, gynaecology, upper GI and urology) and six cross cutting services (chemotherapy, radiotherapy, pathology, imaging, specialist palliative care and network user groups) was published to support the programme. Head and neck, haematology and revised colorectal measures were published in All teams/services within a cancer network were asked to complete a self-assessment once in the three year cycle, which was then followed by comprehensive peer review visits. A second national evaluation was undertaken and was also included in the review of national programmes by the Office of Strategic Health Authorities. The continuation of the peer review programme was supported but changes were recommended in order to meet the annual requirements of the national regulator (Healthcare Commission) to encompass the principles of better regulation. National Cancer Peer Review Programme 2009 to 2013 In April 2009 a new methodology for NPRP was introduced. The new methodology has adopted an annual self-assessment process supported by a targeted visit programme. The peer review programme consists of four key stages (see figure 1): Self-assessment (SA) - completion of an annual self-assessment by the team/service who deliver the service. Internally validated selfassessments (IV) - Internal validation of the self- assessment by the host organisation for that service. Externally verified selfassessments (EV) - An external desk top review of internally validated self-assessments by the cancer peer review coordinating teams. Peer review visits (PR) - A targeted schedule of peer review visits. Clinical Lines of Enquiry (CLE) The use of clinical lines of enquiry (CLE) has now been extended to seven tumour types, breast, lung, colorectal, upper GI, gynaecology and head and neck and sarcoma services. This has been received well by clinical teams and has moved the focus of peer review to one of more clinical outcomes. In addition to CLE, peer review has started to use service profiles developed by NCIN. 56

57 These commenced in 2012 with breast and colorectal services. It is the intention to feedback and review these CLE at the National Cancer Intelligence Network (NCIN) Site Specific Clinical Reference Groups (SSCRG) on an annual basis. Further details of the 2012/2013 peer review process can be found in the National Cancer Peer Review Programme Handbook (2011) on the CQuINS website 57