Annual Report Skin MDT

Transcription

1 Annual Report Skin MDT University Hospitals Bristol NHS Foundation Trust Minicom

2 Agreement and Approval Skin MDT Lead Clinician David DeBerker Date 29/08/2012 Signature Review Date Annual Report Review Date: 01/07/13 Versions Version Date Reason Sign Off /07/2009 Final Version Peer review /09/2010 Final Version for 2010 Peer Review /08/2011 Draft Version for 2011 Peer Review 5.0 April report produced 29/08/ Annual Report - Skin MDT

3 1 Measure Checklist Measure Number Measure Operational Policy 11-2J-101 Lead Clinician and Core Team Membership p10, p J-102 Named Clinical Oncologist p10 Annual Report 11-2J-103 Level 2 Practitioners for Psychological Support p17 p J-104 Support for Level 2 Practitioners p17 p J-105 Team Attendance at NSSG Meetings p7 11-2J-106 MDT Meeting p J J-108 MDT Agreed Cover Arrangements for Core Members Core Member (or Cover) Present for 2/3 of Meetings p10 Work Plan Supporting Information 11-2J-109 Annual meeting to discuss operational policy p14 p4 11-2J-110 Biannual educational/audit meetings p J-111 Policy for all new patients specified as level 4, 5 or 6 care to be reviewed by MDT 11-2J J J-114 Policy for communication of diagnosis to GPs and completed audit of timeliness of diagnosis notification Operational policy for named key worker and its implementation Core Histopathology Member Taking Part in Histopathology EQA 11-2J-115 Core nurse member completed specialist study p12 p10 p13 p7-8 p16 p13 p6 p J-116 Agreed responsibility for core nurse members p J-117 Attendance at national advanced communications skills training programme 11-2J-118 Extended membership of MDT p10 p13 p19 p13 p8 11-2J-122 Patient permanent consultation record p16 p9 11-2J-123 Patient experience exercise p19 p15 p8 11-2J-124 Provision of written patient information p16 p J J J-127 Agree and Record Individual Patient Treatment Plans Network Referral Guidelines Between Named Teams MDT Agreement to Clinical Guidelines for the Management of Skin Cancer p13 p13 p J-128 MDT Agreement to Imaging Guidelines p J-129 MDT Agreement to Pathology Guidelines p J-130 Agreed Collection of Minimum Dataset p19 p J-131 Network Audit p19 p13 p10 p12 p28 Annual Report - Skin MDT 3

4 Measure Number Measure Operational Policy Annual Report 11-2J-132 Agreed List of Approved Trials p19 p16 p J-135 Joint treatment planning for TYAs p15 p9 Locality Measures 11-1D-101j Provision of Clinics for Immunocompromised Patients with Skin Cancer p8 Work Plan Supporting Information 4 Annual Report - Skin MDT

5 2 Contents 1 Measure Checklist Contents Introduction Key Achievements Key Challenges MDT Meetings Team Attendance at Network Site Specific Group Meetings (11-2J-105) MDT Meeting Attendance (11-2J-108) Attendance by Role Individual Attendance Annual Meetings Workload of MDT / Cases discussed TYA patients (11-2J-135) Training Advanced Communications Skills Training Course (11-2J-117) Breaking Bad News Communications Skills Training Course CNS Training and Courses (11-2J-115) Level 2 Psychological Support (11-2J-103,104) Network IOG Action Plan Data Collection (11-2J-130) Audit BCC Follow-Up Audit (NSSG audit) (11-2J-131) Audit of Timeliness of Diagnostic Notification to GPs (11-2J-112) Key Worker Details Audit (11-2J-113) EQA Audit (11-2J-114) Other Audits Patient and Carer Feedback and Involvement (11-2J-123) Research (11-2J-132) Annual Report - Skin MDT 5

6 3 Introduction This Report relates to the operational period April 2011 March This period has seen a number of issues, challenges and successes as outlined below. 3.1 Key Achievements Commencement of consultant training programme in Mohs micrographic surgery Start of nurse excisions below head and neck CNS participation in local radio public awareness opportunities Appointment of new consultant with an interest in skin cancer Increased consultant presence on SSMDT Agreement from commissioners to pay for photophoresis service shared between Dermatology and oncology for patients with skin lymphoma Graft vs Host Disease Improved use of skin cancer excision audit tool Pilot of electronic patient surgery booking process Improvement in patient surgery information leaflet 3.2 Key Challenges Loss of regular attendance at MDT by oncologist and change to oncology support Increased rate of referral through the 2WW system Loss of Dermatology skin cancer CNS time to provide additional service in oncology (for support of patients with malignant melanoma). This is intended to improve the experience of patients with melanoma but does reduce the time available for other duties. 6 Annual Report - Skin MDT

7 4 MDT Meetings 4.1 Team Attendance at Network Site Specific Group Meetings (11-2J- 105) The Skin NSSG held the following meetings during April 2011-March 2012, with the MDT represented as follows. Meeting Date Name Job Title 8 th April 2011 David de Berker Dermatologist and MDT Lead Alison Cameron Oncologist 20 th June 2011 David de Berker Dermatologist and MDT Lead 10 th October 2011 David de Berker Gemma Gregory Overall % Attendance 100 Dermatologist and MDT Lead CNS For further details of the meetings please see the Network Annual Report 4.2 MDT Meeting Attendance (11-2J-108) MDT attendance is recorded using a live data base the Somerset Cancer Register. This process provides a more accurate record than individual sign-in on an attendance form. A full breakdown of the MDT meeting attendance for the year is demonstrated in the below table. There were 48 meetings in the period Attendance by Role Role Lead Clinician 68.75% Dermatologists 100% Histopathology 92% Clinical Nurse Specialist 96% MDT Co-ordinator 96% Individual Attendance Overall attendance Role Agreed Named Lead Attendance Lead Clinician for MDT, Consultant Dermatologist David De Berker 68.75% Consultant Dermatologist Giles Dunnill 66.67% Consultant Dermatologist Adam Bray 92.31% (core from January 2012) Consultant Dermatologist Jane Sansom 60.42% Consultant Dermatologist Shalini Narayan 62.50% Consultant Dermatologist Cameron Kennedy 62.50% Annual Report - Skin MDT 7

8 Consultant Dermatologist Lindsay Shaw % Lead Histopathologist Nidhi Bhatt 81.25% Clinical Nurse Specialist Gemma Gregory 75% MDT Co-ordinator Serena Hodges 91.67% 4.3 Annual Meetings The MDT held its annual general meeting on 16 th December A copy of the actions list is available in the Supporting Information on page 4. In addition a number of the core members (Skin surgeons, CNS, MDT co-ordinator and PCT representation) meet as required throughout the year to discuss current issues and agree work streams, these meetings are extended to all core members and relevant others. The next AGM is planned for 11 th December Workload of MDT / Cases discussed The weekly MDT meeting was held 48 times between April 2011 and March This exceeds the requirement for fortnightly meetings. Four meetings in the period were cancelled due to multiple absences of core MDT members or national holidays. This did not have a detrimental effect upon patient pathways as cancellations were carefully planned and patient cases were discussed the week immediately prior or immediately following the cancelled meetings The following skin MDT statistics apply to the 2011/12 financial year. Two week-wait referrals 1613 Diagnosed cancers - primary 910 Diagnosed cancers - recurrence 8 Diagnosed cancers - metastasis 14 Number of MDT discussions total Average number discussions per meeting Cancer diagnoses by ICD-10 diagnosis code (excludes benign diagnoses) Primary Recurrence Metastases C43 - Malignant melanoma of skin C431 - Malignant melanoma of eyelid, including canthus C432 - Malignant melanoma of ear and ext auricular canal C433 - Malignant melanoma of other and unspecified parts of face C434 - Malignant melanoma of scalp and neck C435 - Malignant melanoma of trunk C436 - Malignant melanoma of upper limb, including shoulder C437 - Malignant melanoma of lower limb, including hip Annual Report - Skin MDT

9 C438 - Malignant melanoma of skin C439 - Malignant melanoma of skin, unsp C44 - Other malignant neoplasms of skin C440 - Other malignant neoplasms of skin of lip C441 - Other malignant neoplasms of skin of eyelid, incl canthus C442 - Oth malignant neoplasms of skin of ear & ext auricular canal C443 - Oth malignant neoplasm of skin of oth & unsp parts of face C444 - Other malignant neoplasms of skin of scalp and neck C445 - Other malignant neoplasms of skin of trunk C446 - Oth malignant neoplasms of skin of upper limb, incl shoulder C447 - Other malignant neoplasms of skin of lower limb, incl hip C448 - Other malignant neoplasms, overlapping lesion of skin C449 - Other malignant neoplasms of skin, unspecified C770 - Sec & uns malig neoplasm of lymph nodes of head, face & neck C773 - Sec & uns malig neoplasm of axillary & upp limb lymph nodes C792 - Secondary malignant neoplasm of skin C798 - Secondary malignant neoplasm of other specified sites C829 - Follicular lymphoma, unspecified D033 - Melanoma in situ of other and unspecified parts of face D034 - Melanoma in situ of scalp and neck D035 - Melanoma in situ of trunk D036 - Melanoma in situ of upper limb, including shoulder D037 - Melanoma in situ of lower limb, including hip D042 - Carcinoma in situ of skin of ear & external auricular canal D043 - Carcinoma in situ of skin of other & unsp parts of face D045 - Carcinoma in situ of skin of trunk D489 - Neoplasm of uncertain or unknown behaviour, unspecified TOTAL TYA patients (11-2J-135) The MDT discussed one patient in the review period who fell into the TYA age range (15-24 years). The patient was referred to the TYA MDaT as per the protocol for agreement of the treatment decision. A second patient in the age range had a BCC excised but this was not reviewed by the MDT as per policy for low level, completely excised cases. There was therefore no treatment decision to agree. The patient was already receiving support from TYA MDaT for a separate cancer diagnosis. Annual Report - Skin MDT 9

10 5 Training 5.1 Advanced Communications Skills Training Course (11-2J-117) The following core MDT members with direct patient clinical contact have attended the national Advanced Communications Skills Training: David de Berker 7 th -9 th December 2011 Jane Sansom, nd September 2011 Giles Dunnill, th September 2011 Cameron Kennedy, th February 2012 Shalini Narayan, th February 2012 Gemma Gregory, th June 2009 The other relevant members intend to attend as soon as possible and are waiting for further courses to become available. There are currently no accredited community skin cancer clinicians and the PCTs have not made any request for us to help commission a service. 5.2 Breaking Bad News Communications Skills Training Course The MDT s Clinical Nurse Specialist, Gemma Gregory, has completed the Trust s Breaking Bad News course and also delivers nurse training sessions as part of this programme. 5.3 CNS Training and Courses (11-2J-115) Gemma Gregory participates in the Network s programme of media and educational sessions to raise public awareness on sun safety. Gemma also teaches on the Bristol Primary Care Aging Skin educational session. Gemma has undertaken the following training specific to her role in skin cancer: A four day course in Minor Surgery For Nurses (Ninewells Hospital, Dundee) Physical Assessment and Clinical Reasoning For Nurse Led Clinics (University of West of England) 5.4 Level 2 Psychological Support (11-2J-103,104) Gemma Gregory has undertaken the Trust s Network approved training to provide psychological support for patients and carers at level 2. Gemma attended the course on 3 rd and 4 th January The Trust is has recently secured funding for CNSs to undergo monthly clinical supervision with a clinical psychologist with respect to this aspect of their role. 10 Annual Report - Skin MDT

11 6 Network IOG Action Plan There is a network implementation plan for the Improving Outcomes Guidance. Areas to be addressed across the network over the three year service delivery plan include: Provision of Mohs Surgery Provision of Total Skin Electron Beam therapy Provision of Sentinel Node Biopsy service Explore options for provision of photophoresis Develop service for immunocompromised patients Develop service so that patients have surgical treatment as locally as possible with full support of specialist team Phase 1: Unified and centralised dermatology and plastic surgery service in Bristol. The MDT is working with the NSSG on these issues. Annual Report - Skin MDT 11

12 7 Data Collection (11-2J-130) The MDT has agreed the minimum dataset as defined by the NSSG and endeavours to collect this. Processes are in place to capture both the national cancer waiting time standards and the national data items. The Somerset Cancer Register is used to collect data and several members of the core team have access to add data relevant to them. There is no national audit at present for skin cancer but within the Trust work is ongoing to improve the availability of staging data and histopathology information, along with other key data fields. In 2011/12, patients who completed a 62-day pathway in skin had the following data completeness: TNM staging 62% Pathology report on cancer register 80% Histology code (SNOMED) on cancer register 96% Treatment intent 99.4% Primary procedure name 32% (whole year) improving to 78% quarter 4 12 Annual Report - Skin MDT

13 8 Audit 8.1 BCC Follow-Up Audit (NSSG audit) (11-2J-131) This was the official NSSG audit, and covered five Networks. The results were presented at the April 2011 meeting of the NSSG. The audit showed low recurrence rates of 8% for completely excised cancers and 22% for incompletely excised, with most recurrence within 3 years of excision. It highlighted discrepancies between the number of patients able to self-examine and the number of patient reported tumours. The NSSG plans to produce a patient questionnaire to follow on from the audit to obtain patient views on follow-up. 8.2 Audit of Timeliness of Diagnostic Notification to GPs (11-2J-112) 20 sets of notes were chosen at random and reviewed to see if there was a record of the GP being informed within 24 hours of a patient being given a cancer diagnosis. 14 (70%) met the standard. Of those not meeting the standard, three were instances where the CNS was on leave. Action: Nurse identified to cover this when CNS is on leave 8.3 Key Worker Details Audit (11-2J-113) 20 sets of notes were chosen at random and reviewed to see if the key worker s name and contact details had been clearly recorded within the notes. 15 (75%) met the standard. Of those not meeting the standard, three were instances where the CNS was on leave. Action: Nurse identified to cover this when CNS is on leave 8.4 EQA Audit (11-2J-114) Pathology services within UH Bristol have full CPA accreditation across the laboratory department. The core histopathologist for the MDT, Nidhi Bhatt, participates in the Skin EQA and the General EQA, evidence of which is available in the supporting information on page Other Audits The team has undertaken a number of audits, including: Report on wait for surgery for patients with basal cell carcinoma at different stages in the pathway 22 consecutive cases were examined from referral dates of September The mean wait for surgery from the outpatient consultation was 8.2 weeks with a range of 0 to 18 weeks. Two patients, one follow-up and one Choose and Book, were operated on the same day as the appointment for the clinical diagnosis. Patients with Basal cell carcinoma on the head and neck waited 8.8 (0-11) weeks for surgery with those at other sites waited 5.7 weeks. The mean wait for all patients from the point of initial referral (or follow-up detection of basal cell cancer) was 12.7 (0-24) weeks. Skin Cancer Histological Complete Excision Rates Annual Report - Skin MDT 13

14 Annual repeat of previously carried out audit. All Consultants and Associate Specialists treating skin cancer in the Dermatology service (cases done at either BRI, SMH, or FY) invited to submit data for excisions over 2 month period or approximately cases each during May/June Eight doctors out of a possible nine contributed data (89% - 100% standard not met). 1 of the 8 did no surgery during the audit period. Complete excision rates were broadly good (93% for all skin cancers); some exceeded the audit standards, but others did not meet the standards. The overall complete excision rates had reduced from the previous year (2010), but the amount was not statistically significant due to the relatively small sample size relative to the number of tumours observed to be incompletely excised. Longer data collection periods (preferably all year long) are needed. Improvement Needed BCC complete excision rate 90% (standard 92%). The lack of Mohs micrographic surgery availability locally is a key factor contributing to the BCC standard not being met. Data returns: not all doctors responded. Good Points No incompletely excised SCC (100% complete excision rate exceeded audit standard of 96%; improved from 89% in 2010). No tumours were incompletely excised at their deep margins (a crucial clinical point predicting likelihood of problematic recurrence; improved from 2010). Complete excision rate for MM (inc. in situ) 100% (standard 98%). Action Taken Distributed new MS Excel surgical log collection tool to facilitate easier data collection and analysis. Plan to make complete excision rates submission part of annual ARCP for juniors, and appraisal for seniors. Develop and bid for commissioning new Mohs Micrographic Surgery service. 14 Annual Report - Skin MDT

15 9 Patient and Carer Feedback and Involvement (11-2J-123) A local skin cancer patient experience survey was conducted in September 2010, with 37 patients responding. 97% of patients felt that the reasons for tests were explained to them at least to at least some extent and 98% felt that that the risks and benefits were explained to them to at least some extent. Only a minority (28%) had immediate excision on the first appointment and only 40% were definitely aware this would be the case and a further 27% were only aware to some extent. 73% felt that aftercare was verbally clearly and completely explained, though only 65% agreed that this was totally provided in written format. 73% were told to contact the hospital should problems arise with most of the rest advised to contact their GP. Half (50%) did not need to contact anyone, 24% contacted their GP and 18% contacted the specialist nurse. Of those that did need to contact anyone 94% felt their concern was dealt with in a satisfactory way. Most patients (76%) received their diagnosis from the doctor in person and 89% of patients felt the way they received their diagnosis was completely acceptable. Provision of a written diagnosis and treatment plan was patchy with only 50% being offered and receiving a copy. Only 65% of patients were given details of a key worker and 37% were informed that their case might be discussed in a multidisciplinary team meeting. 76% of patients surveyed were being followed up in a local hospital, 1 was not and the remainder were not being followed up. Provision of information was patchy with clinically related information being provided in most cases verbally and in most instances not backed up with written information. A sizeable minority felt they were not provided with information though the spread of opinion varied by topic. 61% of patients had their treatment in one hospital with those also seen in other locations being seen either in Frenchay or Bristol Haematology and Oncology Centre. Most or all patients felt that in the areas surveyed there were no issues in the transfer between hospitals. As a result of the survey the CNS completed a full review of the written information available to patients. Leaflets explaining the function of MDT meetings have been introduced. The Trust participates in the National Cancer Patient Experience survey and forms action plans in response to the results. In response to the 2010/11 survey actions were implemented including improvements in the information on financial matters/benefits advice available to be patients, appointment of patient/user representatives to the Cancer Board, Macmillan information points placed around the Trust, and establishment of a CNS/AHP forum to share good practice. The 2011/12 survey results were published shortly before the self-assessment. Unfortunately, only five skin cancer patients responded and therefore results have not been provided and the MDT is unable to draw any conclusions. The survey covers only patients with melanomas, although many more patients were diagnosed here with melanoma in the survey period than responded. At the time of preparing the annual report we do not have figures for other Trusts so are unable to compare to see if such low numbers of responses are typical for skin patients. There will be many actions from the 2011/12 survey that are applicable to all areas of cancer, and therefore the results will still be of some use and the MDT will undertake these as appropriate. In light of these results, the MDT will undertake its own patient experience survey tailored to skin cancer patients in the next year. Annual Report - Skin MDT 15

16 10 Research (11-2J-132) The below shows the trials recruitment for 2011/12 and actions to improve recruitment, as presented to the SSG on 18 th May MDT estimate for recruitment (2011/12) Actual MDT recruitment (2011/12) Trial Status (April 12) MDT annual estimate of recruitment for 2012/2013 MDT actions and comments for 2012/13 (endorsed trials) If no actions required please state no actions required. SSG endorsed NCRN trials 11/12: AVAST-M 6 1 Open 0 Trial now closed Melanoma Lifestyle Study 6 3 Open 4 New clinical oncologist to encourage recruitment MDT actions - to be completed at MDT meeting: AVAST-M trial has now closed and there are no new trials in skin cancer likely to open in next few months. Will discuss the melanoma lifestyle study with new clinical oncologist to encourage recruitment. The above actions were agreed by the MDT on 10 th July 2012 in the presence of Dr De Berker 16 Annual Report - Skin MDT