2012/13 NHS STANDARD CONTRACT FOR ACUTE, AMBULANCE, COMMUNITY AND MENTAL HEALTH AND LEARNING DISABILITY SERVICES (MULTILATERAL)

Transcription

1 B3k 2012/13 NHS STANDARD CONTRACT FOR ACUTE, AMBULANCE, COMMUNITY AND MENTAL HEALTH AND LEARNING DISABILITY SERVICES (MULTILATERAL) SECTION B PART 1 - SERVICE SPECIFICATIONS Service Specificatin N. B3k Service Urlgical cancers kidney, bladder and prstate cancer Cmmissiner Lead Prvider Lead Perid 12 mnths Date f Draft Dec 2012 Date f Review Sept Ppulatin Needs 1.1 Natinal cntext and evidence base Natinal cntext Urlgical cancers include a range f tumurs with different presentatins including: Prstate cancer Bladder cancer Kidney cancer Penile cancer* Testicular cancer* (r germ cell tumurs f the testis) NB: * separate service specificatins exist fr specialised testicular cancer services and fr specialised penile cancer services.

2 Prstate cancer is a frm f cancer that develps in the prstate. Advanced prstate cancer can spread t ther parts f the bdy. In 2009, there were nearly 35,000 newly diagnsed cases f prstate cancer in England, with a crude incidence rate f 136 cases per 100,000 ppulatin. One year relative survival estimates in England are very high at 95%. Bladder cancer is any f several types f malignant grwths f the urinary bladder. The mst cmmn type f bladder cancer begins in cells lining the inside f the bladder and is called transitinal cell carcinma. Incidence f bladder cancer is higher in males than in females, with ver 6,400 cases in 2009 in males cmpared t under 2,400 in females. The crude incidence rate per 100,000 ppulatin fr bladder cancer is 25 in men and 9.0 in wmen. One year relative survival estimates fr bladder cancer als differ between males and females at 78% and 64% respectively. Kidney cancer is a frm f cancer that develps in the kidneys. Kidney cancer is ften asymptmatic until an advanced stage. In apprximately ne third f cases, the tumur is detected incidentally during imaging carried ut fr ther reasns. The tw mst cmmn types f kidney cancer, reflecting their lcatin within the kidney, are renal cell carcinma (RCC) and urthelial cell carcinma (UCC) f the renal pelvis. The distinctin between these tw types (RCC and UCC) is imprtant because their prgnsis, staging and management are different. In 2009, there were ver 4,000 cases f kidney cancer in males and ver 2,500 in females. The crude incidence rate per 100,000 ppulatin is 15.9 in men and 9.6 in wmen. Cancer f the renal pelvis is less cmmn with arund 500 cases per year. Relative survival estimates fr kidney (excluding renal pelvis) are similar fr bth sexes at 70 per cent fr males and 68 per cent fr females. There are different levels f care fr urlgical cancers: lcal care, specialised care and supra-netwrk care. This specificatin fcuses n specialised care services. Evidence base This specificatin draws its evidence and ratinale frm a range f dcuments and reviews as listed belw: Department f Health Imprving Outcmes; a Strategy fr Cancer Department f Health (2011) Cancer Cmmissining Guidance - Department f Health (2011) NICE Imprving Outcmes Guidance: Urlgical Cancer NICE (2002) Imprving Supprtive and Palliative Care fr adults with cancer NICE (2004) 2

3 Quality standard fr end f life care fr adults NICE (2011) Quality standard fr patient experience in adult NHS services NICE (2012) Natinal Cancer Peer Review Natinal Cancer Peer Review Handbk NCPR, Natinal Cancer Actin Team (2011) Manual fr Cancer Services: Urlgical Measures (2011) Manual fr Cancer Services Acute Onclgy Measures (April 2011) Manual fr Cancer Services Chemtherapy Measures (June 2011) Other Chemtherapy Services in England. Natinal Chemtherapy Advisry Grup (2009) 2. Scpe 2.1 Aims and bjectives f service The aim f the specialised urlgical cancer service is t deliver high quality hlistic care s as t increase survival while maximising a patient s functinal capability and quality f life and t ensure ready and timely access t apprpriate supprtive care fr patients, their relatives and carers. The service will be delivered thrugh a specialist urlgy multi-disciplinary team. The specialist urlgical cancer multidisciplinary team shuld cver a ppulatin f mre than ne millin and carry ut a cmbined ttal f at least 50 radical prstatectmies and/r ttal cystectmies per year. The service is required t agree the fllwing areas with their lcal cancer netwrks: Service cnfiguratin and ppulatin cverage Referral criteria, clinical prtcls (including referral and management f pleural effusin and emergency prtcls and pathways that enable rapid access fr treatment f infectins), netwrk plicies (including lcal surgical plicies) and treatment pathways Engagement with the lcal netwrk grups and Natinal Cancer Peer Review fr urlgical tumurs The verall bjectives f the services are: T prvide an exemplary and cmprehensive service fr all referred patients 3

4 with urlgical cancers. T ensure radilgical, pathlgical and diagnstic facilities are available and t use the mst up-t-date validated diagnstic tls and knwledge in rder t effectively review, diagnse, classify and stage the cancer prir t planning treatment. T advise and undertake investigatins and t prceed t treatment ptins if clinically indicated, including high quality surgical treatment f patients with urlgical cancers. T carry ut effective mnitring f patients t ensure that the treatment is safe and effective. T prvide care that prmtes ptimal functining and quality f life fr each individual cancer patient. T prvide apprpriate fllw-up and surveillance after definitive treatment. T ensure that all aspects f the service are delivered as safely as pssible, cnfrm t natinal standards and published clinical guidelines and are mnitred by bjective audit. T prvide care with a patient and family centred fcus t maximise the patient experience. T supprt lcal healthcare prviders t manage patients with urlgical cancer whenever it is safe t d s and clinically apprpriate within the framewrk f the IOG. T prvide high quality infrmatin fr patients, families and carers in apprpriate and accessible frmats and media. T ensure there is accurate and timely infrmatin given t the patient s General Practitiner. T ensure that there is invlvement f service users and carers in service develpment and review. T ensure there is a cmmitment t cntinual service imprvement. T ensure cmpliance with Peer Review Cancer Measures and with clinical lines f enquiry when they are develped. T ensure cmpliance with Care Quality Cmmissin regulatins. 2.2 Service descriptin/care pathway The specialist urlgical cancer multidisciplinary team shuld treat the less cmmn urlgical cancer r cancers that require cmplex treatment (radical surgery fr prstate r bladder cancer). The specialist urlgical cancer multidisciplinary team will deliver the service in line with the fllwing: There is a weekly multidisciplinary team meeting t discuss the needs f each newly referred patient (and ther patients as required) in detail and review 4

5 ther nn-surgical aspects f their care; patients will be likely t require subsequent additinal review at the multidisciplinary team meeting fr example after treatment r prgressin f the cancer Treatment within the specialist multidisciplinary team shuld be in accrdance with lcally agreed treatment guidelines which shuld be cnsistent with natinally agreed guidelines If surgery is the first planned treatment then effrts shuld be made t give the patient a date fr that surgery at the first visit, and written infrmatin prvided n that surgery. The timing f surgery is agreed n the basis f evidence based treatment prtcls with the lcal cancer netwrk. A written summary f the cnsultatin shuld be ffered t the patient as well as written infrmatin n the relevant type f urlgical cancer. Patients shuld have access t a key wrker - this is nrmally the Clinical Nurse Specialist. Accurate and timely infrmatin shuld be shared with the patients General Practitiner s that they can be in a psitin t supprt and advise the patient. Patients treated as in-patients are reviewed daily n a ward rund supprted by a cnsultant urlgist and nclgical surgen with input frm the cre multidisciplinary team as clinically required. The prviders will hld ther meetings regularly t address clinical, service delivery and gvernance issues. Audit shuld be undertaken as an integral part f imprving the delivery f care t prvide the evidence t imprve and enhance the delivery f the clinical care prvided. Patients shuld be actively invited t participate in clinical trials especially thse apprved by the Natinal Cancer Research Netwrk (NCRN). Members f the specialist urlgical cancer multidisciplinary team Each member f the specialist urlgical cancer team shuld have a specialist interest in urlgical cancer. The specialist urlgical cancer team shuld include ne r mre f each f the fllwing individuals: Urlgical Surgens (at least tw urlgists in the team). Clinical nclgist. Medical nclgist (except where the clinical nclgist has specific expertise in systemic treatment fr urlgical cancers). Radilgist with expertise in urlgical cancers. Histpathlgist with expertise in urlgical cancers. Urlgical - Clinical nurse specialist. Multidisciplinary team c-rdinatr / secretary. 5

6 The multidisciplinary team shuld als have rapid access t: GPs/primary health care teams; Lcal urlgical cancer teams at linked cancer units; Plastic surgen; Clinical geneticist/genetics cunsellr Liaisn psychiatrist; Clinical psychlgist trained in psychtherapy and cgnitive behaviur therapy; Cunsellr with expertise in treating psychsexual prblems; Stma care nurse; Lymphedema specialist; Occupatinal therapist; Scial wrker; Palliative care teams. There shuld be a single named lead clinician fr the specialist urlgical cancer service wh shuld als be a cre team member. A NHS emplyed member f the cre r extended team shuld be nminated as having specific respnsibility fr user issues and infrmatin fr patients and carers. A cre member must be identified as the individual respnsible fr recruitment int clinical trials and ther well designed studies Patient experience The service shuld be patient centred and shuld respnd t patient and carer feedback. Excellent cmmunicatin between prfessinals and patients is particularly imprtant and can avid cmplaints and imprve patient satisfactin. The service shuld be in line with the markers f high quality care set ut in the NICE quality standard fr patient experience in adult NHS services. Patient experience is reprted in the Natinal Cancer Patient Survey. In this survey patients with cntact with a clinical nurse specialist reprted much mre favurably than thse withut, n a range f items related t infrmatin, chice and care. The natinal prgramme fr advanced cmmunicatins skills training prvides the pprtunity fr senir clinicians t imprve cmmunicatins skills and all cre multidisciplinary team members shuld have attended this. Patient infrmatin Every patient and family / carer must receive infrmatin abut their cnditin in an apprpriate frmat. Verbal and written infrmatin shuld be prvided in a way that 6

7 is clearly understd by patients and free frm jargn. The infrmatin must cver: Descriptin f the disease Evidence, effectiveness (risks and benefits) f PSA testing Management f the disease within the scpe f the cmmissined service as described in the specificatin, clinical pathways and service standards Treatment and medicatin (including their side effects) cmmissined in the clinical pathway Pain cntrl Practical and scial supprt Psychlgical supprt Sexual issues and fertility Self-management and care Lcal NHS service and care/treatment ptins Cntact details f the patient s allcated named nurse Pssible benefits and cmpensatin supprt rganisatins r internet resurces recmmended by the clinical team The service must als prvide apprpriate educatin t patients and carers n: Symptms f infectin and management f neutrpenic sepsis and prphylaxis Out f hurs advice/supprt Cntact in case f cncern r emergency The useful reference is the Infrmatin Prescriptin Service (IPS), which allws users, bth prfessinal and public, t create infrmatin prescriptins (IPs) fr lngterm health needs. Referral Prcesses and Surces Referrals t the service will cme frm either primary care r a lcal multidisciplinary team. Steps prir t referral t the specialist team include: The lcal team will already have made a diagnsis, cnfirmed by ultrasund, CT r bipsy The patient will have been infrmed f the diagnsis and given the date f a CT scan The patient will have had staging investigatins The patient will have been discussed at their lcal multidisciplinary team Imaging and pathlgy The service shuld ensure that chest x-ray / ultrasund / CT scanning / MRI shuld be available t the patient as part f the pathway. The service shuld 7

8 agree imaging mdalities and their specific indicatins. The respnsibility fr the scan, its interpretatin and any decisin t infrm treatment lies with the specialist urlgical cancer multidisciplinary team. When symptms r imaging clearly shw that the disease is metastatic r inperable, r the patient is nt sufficiently fit t underg radical treatment, the team is t cnsider the apprpriate palliative treatment. The patient shuld g back t the multidisciplinary team fr a discussin f results befre a decisin is given. Histlgical cnfirmatin f tumur is required befre treatment with chemtherapy r raditherapy. The pathlgy services shuld cmply with Clinical Pathlgy Accreditatin (UK) Ltd (CPA) 1 and the Human Tissue Authrity (HTA). 2 Diagnsis The service shuld develp with primary care, lcal urlgical services and their lcal cancer netwrk agreed guidelines n apprpriate referral fr patients with suspected urlgical cancer int the specialist multidisciplinary team service in line with natinal guidelines. Cmpliance with these guidelines shuld be audited. Prstate assessment clinics and haematuria clinics shuld be prvided in lcal hspitals and staffed accrdingly with members f the lcal/specialist/supranetwrk urlgical multidisciplinary team. Tests shuld be available, including rapid assessments, t determine whether cancer is present in a single visit; range f tests t include ultrasngraphy, digital rectal examinatin (DRE) and prstate specific antigen (PSA) testing, ultrasund (TRUS), needle bipsy, clinical examinatin, urine testing, flexible cystscpy, and rapid access t ultrasund imaging and intravenus urgraphy (IVU) when required. Patients wh present as an emergency n their rute t being diagnsed with cancer have prer survival. In urlgical cancer 10 per cent f prstate cancer patients, 19 per cent f bladder cancer patients and 25 per cent f kidney cancer patients present thrugh an emergency rute s it is imprtant t have gd emergency systems in place. Prviders shuld: Develp an algrithm t supprt decisin-making in A&E r primary care Set up an emergency cmmunicatin alert system service fr GPs/A&E/ Assessment Units/ clinicians t enable rapid specialty assessment and utpatient investigatins Staging Prviders must include staging infrmatin in their cancer registratin dataset (this will becme mandated in the Cancer Outcmes and Services Dataset frm early 2013). Staging data are essential fr directing the ptimum treatment, fr prviding prgnstic infrmatin fr the patient and are als essential t the better 1 CPA, the principal accrediting bdy f clinical pathlgy services and External Quality Assessment (EQA) Schemes in the UK. Mdernising Pathlgy Services. Department f Health (2004) 2 HTA Regulatry bdy fr all matters cncerning the remval, strage, use and dispsal f human tissue. 8

9 understanding f the reasns behind the UK s pr cancer survival rates. Cancer stage is best captured electrnically at multidisciplinary team meetings and transferred directly t cancer registries. Staging and ther pathlgical data can als be extracted direct frm pathlgy reprts and sent t cancer registries. Treatment Treatment delivered by the specialist urlgy multidisciplinary team includes: Fr kidney cancer Prcedures which shuld nly be carried ut in the hst hspital f the specialist team: Resectin f primary tumurs which have r are suspected t have invaded renal vein, vena cava r heart. Resectin f metastatic disease. Resectin f bth primary and assciated metastatic disease. Resectin f bilateral primaries. Resectin f any primary where it is predicted that the patient will subsequently require dialysis. Surgical management f patients with vn Hippel-Lindau disease r hereditary papillary tumurs. Resectin f urthelial cancers f the upper urlgy tract. Resectin by nephrn-sparing surgery. Resectin f nn-renal cell kidney cancer, excluding transitinal cell carcinma f the kidney, treated by nephr-ureterectmy. Prcedures and treatments where the site f delivery is determined by agreement in the netwrk's guidelines Adjuvant chemtherapy. Bilgical therapy. Nn-surgical management f nn-renal cell kidney cancer. Fr bladder cancer Prcedures which shuld nly be carried ut in the hst hspital f the specialist team: Management f high risk superficial cancer the rles f the lcal urlgy multidisciplinary team and the specialist urlgy multidisciplinary team shuld be explicitly defined in the agreed netwrk guidelines Radical surgery (cystectmy). Bladder recnstructin. 9

10 Surgery fr urinary diversin. Resectin f urethral cancer. Resectin f squamus r adencarcinma. Partial cystectmy (indicated nly fr adencarcinma in the dme f the bladder). Prcedures and treatments where the site f delivery is determined by agreement in the netwrk's guidelines Radical external beam raditherapy. Adjuvant chemtherapy. Ne-adjuvant raditherapy.* Ne-adjuvant chemtherapy.* * Recmmended nly as part f the clinical trial Fr prstate cancer Prcedures which shuld nly be carried ut in the hst hspital f the specialist team: Radical prstatectmy. Prcedures and treatments where the site f delivery is determined by agreement in the netwrk's guidelines Radical external beam raditherapy. Radical brachytherapy. This is nly available in a few netwrks. Many patients will need referring utside their wn netwrk fr this therapy. Fr testicular cancer By agreement with the netwrk urlgy site-specific grup, sme named specialist teams may carry ut: Raditherapy fr seminma (fr specified categries f patients) Chemtherapy fr germ cell cancer; fr stage I and 'gd prgnsis' metastatic cases. Fr penile cancer Resectin (except in cases needing penile recnstructin r lymph nde resectin). All resectins shuld be carried ut in the hst hspital f the team. Raditherapy and chemtherapy. The site(s) where this is carried ut shuld be agreed in the netwrk guidelines. All pssible management ptins shuld be discussed with the patient. The treatment each patient receives shuld be tailred t fit their individual values and 10

11 situatin, s it is essential that patients are actively invlved in decisin-making. This requires that they receive adequate and accurate infrmatin, bth thrugh meetings with members f the multidisciplinary team, and in published frms that they can study at hme. Patients shuld be given sufficient time t cnsider all the ptins available t them. Each individual surgen must perfrm mre than five radical prstatectmies r cystectmies per annum. The cmbined ttal f radical prstatectmies and/r ttal cystectmies, recrded and perfrmed under the care f the multidisciplinary team, shuld be 50 r mre. The service shuld develp rapid access t diagnsis and treatment fr patients wh culd be at risk f fracture r spinal crd cmpressin. Sperm strage (crypreservatin) shuld be ffered t all patients wh may wish t father children. This shuld be available befre chemtherapy r raditherapy t the cntralateral testis. An Enhanced Recvery apprach t elective surgery shuld be adpted by all urlgical cancer teams. Enhanced recvery has been shwn t shrten lengths f stay, facilitate early detectin and management f cmplicatins, as well as imprve patient experience with n increase in readmissins. Surveillance The netwrk urlgical cancer site-specific grup shuld agree, as part f their referral guidelines, in cnsultatin with the relevant supra-netwrk testicular team, a list f named specialist teams wh may carry ut surveillance and fr which specific categries f patients. Otherwise it shuld be carried ut by the supra-netwrk team. The netwrk may agree that surveillance shuld nly be carried ut by the supranetwrk team. Als, surveillance which might therwise be carried ut by an agreed specialist team, may be undertaken by the supra-netwrk team if desired and agreed by the patient and relevant cnsultants. Chemtherapy and raditherapy Chemtherapy and raditherapy are imprtant cmpnents f the treatment f sme patients and shuld be carried ut at designated centres by apprpriate specialists as recmmended by a specialist urlgical cancer multidisciplinary team. There shuld be a frmal relatinship between the urlgical cancer service and the prvider f nn-surgical nclgy services that is characterised by agreed netwrk prtcls, gd cmmunicatin, and well-defined referral pathways. This relatinship shuld be defined in writing and apprved by the cancer netwrk directr and the lead clinician in the specialist urlgical cancer multidisciplinary team. Audits f cmpliance with agreed prtcls will need t be demnstrated. Refer t the fllwing dcuments fr mre detailed descriptin f these services: Adult Systemic Anti-Cancer Therapy (SACT/ chemtherapy) service 11

12 specificatin Raditherapy service specificatins Brachytherapy service specificatin (t be develped) Fllw-up The Imprving Outcmes Guidance series f dcuments made recmmendatins n fllw-up care. Prviders will need t adhere t cancer specific guidelines fr fllw up agreed thrugh the netwrk site specific grup (NSSG) and ensure patients have a fllw up plan. The cancer specific guidelines will identify that sme patients will need t cntinue receiving fllw up frm the specialised service but it is expected the majrity will be able t receive fllw up lcally. The prvider will need t ensure effective hand ver f care and / r wrk cllabratively with ther agencies t ensure patients have fllw up plans apprpriate t their needs. Rehabilitatin There shuld be apprpriate assessment f patients rehabilitative needs acrss the pathway and the prvider must ensure that high quality rehabilitatin is prvided in line with the netwrk agreed urlgy rehab pathway (in develpment) at: Supprtive and palliative care The prvider will give high quality supprtive and palliative care in line with NICE guidance. The extended team fr the multidisciplinary team includes additinal specialists t achieve this requirement. Patients wh are managed by a specialist urlgical cancer multidisciplinary team will be allcated a key wrker, nrmally the clinical nurse specialist. Patients wh require palliative care will be referred t a palliative care team in the hspital and the team will be invlved early t liaise directly with the cmmunity services. Specialist palliative care advice will be available n a 24 hur, seven days a week basis. Each patient shall be ffered an hlistic needs assessment at key pints in their cancer pathway including at the beginning and end f primary treatment and the beginning f the end f life. A frmal care plan shall be develped. The nurse specialist(s) shall ensure the results f patients' hlistic needs assessment are taken int accunt in the multidisciplinary team decisin making. Survivrship The Natinal Cancer Survivrship Initiative (NCSI) is testing new mdels f care aimed at imprving the health and well being f cancer survivrs. The new mdel stratifies patients n the basis f need including a shift twards supprted self management where apprpriate. In sme circumstances traditinal utpatient fllwup may be replaced by remte mnitring. The mdel als incrprates care 12

13 crdinatin thrugh a treatment summary and written plan f care. It will be imprtant fr cmmissiners t ensure that wrk frm this prgramme is included and develped lcally t supprt patients whse care will return t their mre lcal health prviders nce specialist care is n lnger required. End f life care The prvider shuld prvide end f life care in line with NICE guidance and in particular the markers f high quality care set ut in the NICE quality standard fr end f life care fr adults. Acute Onclgy Service All hspitals with an Accident and Emergency (A&E) department shuld have an acute nclgy service (AOS), bringing tgether relevant staff frm A&E, general medicine, haematlgy and clinical/medical nclgy, nclgy nursing and nclgy pharmacy. This will prvide emergency care nt nly fr cancer patients wh develp cmplicatins fllwing chemtherapy, but als fr patients admitted suffering frm the cnsequences f their cancer. Fr full details n AOS please refer t the service specificatin fr chemtherapy. Care Pathways The lcal care pathway fr kidney, bladder and prstate cancers shuld be cnsistent with the natinal pathways n Map f Medicine. The prcess f prducing the pathways and subsequent updates has been accredited by the Natinal Cancer Actin Team. A pathway fr testicular cancer is in develpment NICE have als develped an evidence based pathway fr prstate cancer Ppulatin cvered The service utlined in this specificatin is fr patients rdinarily resident in England 3 ; r therwise the cmmissining respnsibility f the NHS in England (as defined in Wh pays?: Establishing the respnsible cmmissiner and ther Department f Health guidance relating t patients entitled t NHS care r exempt frm charges). Specifically, this service is fr adults with urlgical cancers requiring specialised interventin and management, as utlined within this specificatin. 3 Nte: fr the purpses f cmmissining health services, this EXCLUDES patients wh, whilst resident in England, are registered with a GP Practice in Wales, but INCLUDES patients resident in Wales wh are registered with a GP Practice in England 13

14 The service must be accessible t all patients with a suspected r established urlgical cancer regardless f sex, race, r gender. Prviders require staff t attend mandatry training n equality and diversity and the facilities prvided ffer apprpriate disabled access fr patients, family and carers. When required the prviders will use translatrs and printed infrmatin available in multiple languages. The prvider has a duty t c-perate with the cmmissiner in undertaking Equality Impact Assessments as a requirement f race, gender, sexual rientatin, religin and disability equality legislatin 2.4 Any acceptance and exclusin criteria The rle f the specialist urlgical cancer service is described in this dcument but the detailed specificatin fr lcal urlgical cancer services is described in a separate dcument as these services are expected t be cmmissined by the clinical cmmissining grups (CCGs). Detailed specificatins fr the specialist supra-netwrk testicular cancer services and supra-netwrk penile cancer services are als described in separate dcuments. 2.5 Interdependencies with ther services The management f urlgical cancer invlves three crss-linked teams: Primary health care team, Urlgical cancer team: Lcal urlgical multidisciplinary teams Specialist urlgical multidisciplinary team Supra-netwrk (penile r testicular cancer) multidisciplinary teams Specialist palliative care team The urlgical cancer service prviders are the leaders in the NHS fr patient care in this area. They prvide a direct surce f advice and supprt when ther clinicians refer patients int the reginal specialist services. This supprt will cntinue until the patient is transferred int the lcal r specialist urlgy centre r it becmes apparent that the patient des nt have a urlgical cancer. The urlgical cancer service prviders als prvide educatin within the NHS t raise and maintain awareness f urlgical cancers and their management. The urlgical cancer service prviders will frm a relatinship with lcal health and scial care prviders t help ptimise any care fr urlgical cancer prvided lcally fr the patient. This may include liaisn with cnsultants, GPs, palliative care teams cmmunity nurses r scial wrkers etc. C-lcated services Intensive/critical care services may be required fr sme patients underging cmplex surgery and prviders will be required t refer t the service specificatin fr critical care. 14

15 Cancer Netwrks There are currently (July 2012) 28 cancer netwrks acrss England. Each cancer netwrk has a NSSG cvering urlgical cancers. This grup is made up f clinicians acrss the netwrk wh specialise in urlgical cancers. It is the primary surce f clinical pinin n issues relating t urlgical cancer within the cancer netwrk and is an advisr t cmmissiners lcally. Each Site Specific multidisciplinary team shuld ensure they fully participate in the cancer netwrk systems fr planning and review f services. This grup is respnsible fr develping referral guidelines, care pathways, standards f care and t share gd practice and innvatin. The specialist and supra-netwrk multidisciplinary teams shuld als cllectively implement NICE Imprving Outcmes Guidance including the use f new technlgies and prcedures as apprpriate and carry ut netwrk and natinal audits. Each cancer netwrk shuld agree an up-t-date list f apprpriate clinical trials and ther well designed studies fr urlgical cancer patients and recrd numbers f patients entered int these trials/studies by each multidisciplinary team. 3. Applicable Service Standards 3.1 Applicable natinal standards e.g. NICE, Ryal Cllege Care delivered by the urlgical cancer service prviders must be f a nature and quality t meet the CQC care standards and the IOG fr urlgical cancers. It is the Trust s respnsibility t ntify the cmmissiner n an exceptinal basis shuld there be any breaches f the care standards. Where there are breaches any cnsequences will be deemed as being the Trust s respnsibility. 15

16 Urlgy cancer services are required t achieve the tw week wait fr all patients where urlgical cancer is suspected. In additin the services are required t meet the fllwing standards fr all urlgy cancer patients, 31 day wait frm diagnsis t first treatment, 31 day wait t subsequent treatment, 62 day wait frm urgent GP referral r screening referral r cnsultant upgrade t first treatment. Teams shuld as a minimum aim t achieve the median value fr cmpliance with the Cancer Peer Review measures, and if a team has immediate risks r serius cncerns identified then remedial actin plans shuld be in place. Further details are available at The prvider must be able t ffer patient chice. This will be bth in the cntext f appintment time and f treatment ptins and facilities including treatments nt available lcally. The service will cmply with the relevant NICE quality standards which defines clinical best practice. 4. Key Service Outcmes The expected clinical utcmes/clinical lines f enquiry are still being agreed but prvider services may wish t mnitr: 1-year and 3-year relative survival, adjusted fr age, type and stage f cancer. Patients quality f life and reductin in symptms Included belw are sme key cmmissining questins frm the cancer cmmissining guidance, which may be f help t service prviders: Prstate cancer Are any radical prstatectmies perfrmed utside a specialist team centre? (There shuld be nne.) What is the number f radical prstatectmies perfrmed fr prstate cancer, cmpared with the number receiving external beam radical raditherapy, 16

17 brachytherapy, ther surgical treatments (e.g. HIFU, crysurgery) and active surveillance as the first definitive treatment fr early prstate cancer? (A reasnably even distributin between surgery, raditherapy (any type) and active surveillance wuld be expected.) Hw many fractins are used in yur radical raditherapy regime? (Shuld be at least 37.) Are cnfrmal delivery and access t brachytherapy available? What is the median length f stay fr men underging radical prstatectmy? Are enhanced recvery prgrammes established in prviders ffering radical prstatectmy? Is a clinical audit dataset recrded fr prstate surgery? A minimum dataset shuld be an abslute prerequisite fr cmmissining. This shuld include audited recrds f pre-perative PSA, pathlgical stage/ grade, pre- and pstperative Internatinal Index f Erectile Functin (IIEF) and Internatinal Prstate Symptm Scre (IPSS) urinary symptm scres, length f stay, margin psitivity rates, PSAs at three and six mnths, the relative rate f pst-surgical raditherapy t the prstate bed and the rate f artificial sphincter insertin within tw years f surgery. Is there a clinical audit dataset recrded fr prstate raditherapy? Measurements might include mean nadir PSA stage fr stage at ne year rates f PSA failure (American Sciety fr Radiatin Onclgy (ASTRO) definitin f an increase f 2ng/ml abve nadir) ptency rates at 12 mnths referral rates t surgens/physicians fr urinary and bwel txicity use f ne-adjuvant hrmne therapy fr ct3 disease use and duratin f adjuvant hrmne therapy fr ct3 disease. Fr advanced disease: prprtin f patients receiving chemtherapy fr palliatin number f palliative surgical interventins (nephrstmy/transurethral resectin (TUR) channel). What is the prvisin f Bacillus Calmette-Guérin (BCG) ± maintenance as a percentage f the presenting patients within year 1? Invasive Bladder Cancer Are any radical cystectmies perfrmed utside a specialist team centre? (There shuld be nne.) What is the cystectmy rate? What is the number f nebladder recnstructins? (Prcedure shuld be available and, when ffered, be taken up by at least 20%.) What is the use f pelvic nde dissectin? (A bit mre difficult t measure and 17

18 quantify.) What is the length f pst-perative stay? Are enhanced recvery prgrammes established in prviders ffering cystectmy? Kidney Cancer What is the prprtin f nephrn-sparing prcedures fr T1a disease? (Shuld nw be mst cases.) What is the recurrence rate/re-peratin rate fr nephrn sparing? (Shuld be n mre than 2%.) What is the rati f laparscpic vs. pen nephrectmy fr T1b and T2 disease? (The majrity shuld nw be dne laparscpically.) What is the percentage f advanced cases having debulking surgery and immun/targeted therapy? What is the number f cases perfrmed invlving renal vein/inferir vena cava (IVC)? (Shuld nt be carried ut utside a designated and functining specialist urlgical cancer team.) What is the length f pst-perative stay? What is the 30-day mrtality? (Shuld be <2%.) 18

19 Quality and Perfrmance Standards Perfrmanc e Indicatr Quality Indicatr Threshld Methd f Measurement Cnsequence f breach % f cases discussed at multidisciplinary team 100% Reprted within natinal audit reprts Fllw up ratis Other Quality Measures Percentage attendance by individual cre members r their agreed cver at multidisciplinary team TBC 67% Natinal Cancer Peer Review Attendance at advanced cmmunicatin skills curse 100%. Natinal Cancer Peer Review IOG Cmpliance Cmpliance with Peer Review Cmpliance with specified measures Cmpliance with all ther Peer Review measures (ther than where agreed with cmmissiners when the Prvider shuld have an actin plan in place that has been agreed with the Cmmissiner) Cmpliance with specific measures fr tumur site as set ut in IOG dcumentati n Natinal median cmpliance level 19

20 Perfrmanc e Indicatr Indicatr Threshld Methd f Measurement Cnsequence f breach Perfrmanc e and Prductivity The Prvider shuld ensure that these targets are achieved fr the part f the patient pathway that it delivers and that, when the patient pathway crsses utside the lcality brder, apprpriate scheduling f patients/activity supprts achievement f the target by ther prviders in the pathway wherever pssible, except when infrmed patient chice r clinical apprpriateness mitigate against this. Waiting Time Cmpliance Aggregate Measures 62 day wait - % treated in 62 days frm GP referral, cnsultant referral and referral frm screening prgramme 14 day suspected cancer referral standard perfrmance (A20) 31 day first treatment standard perfrmance (A15) 31 day subsequent treatment (Surgery) standard perfrmance (A16) 31 day subsequent treatment (Drugs) standard perfrmance (A16) 31 day subsequent treatment (Raditherapy) standard perfrmance (A17) 31 day subsequent treatment (Other Treatments) standard perfrmance >~86% Reprted n cancer waits database 93% As abve 96% As abve 94% As abve 98% As abve 94% As abve TBC As abve 31 day subsequent treatment (Palliative) standard perfrmance TBC As abve 20

21 Perfrmanc e Indicatr Indicatr Threshld Methd f Measurement 62 day standard frm 14 day referral perfrmance (A18) 62 day standard frm cnsultant upgrade perfrmance (A19) Diagnstic Test Waiting Times 85% As abve TBC TBC As abve Sme natinal data Cnsequence f breach 21

22 Activity Perfrmance Indicatrs Activity Perfrmance Indicatrs Threshld Methd f measurement Cnsequence f breach Annual review cnducted Audits Participatin in Natinal Audits 100% Additinal Audits undertaken N/A Activity Threshld fr number f prcedures Length f stay benchmarking Level f admissins Chice Establish baseline cancer activity data fr :- number f prcedures fr elective, day case, nn elective nn emergency, nn elective emergency, utpatient FA, utpatient FU, utpatient prcedures all by speciality Service User Experience Natinal Cancer Patient Experience survey (ref A46 main cntract) Natinal survey reprt when published If the prvider des nt take part they will be required t meet with the cmmissiners t explain reasns fr nt ding s and activity planned t enable the infrmatin t be captured thrugh alternative mechanisms Imprving Service User Experience Of respnses received 75% shuld express verall satisfactin 22

23 Activity Perfrmance Indicatrs Threshld Methd f measurement Cnsequence f breach with the service.trust t evidence the measures it has taken t imprve service user experience and utcmes achieved and numbers / percentages stratified Addressing Cmplaints Trust t evidence the measures it has taken t address cmplaints and utcmes achieved Patient invlvement Trust t evidence the actins it has taken t engage with patients and demnstrate where this has impacted Staff Survey Staff survey results Trial Activity Recruitment int trials Patients eligible fr an existing clinical trial shuld be ffered the chance t be treated in a clinical trial Outcmes Pst surgery mrtality 30 day mrtality Numbers and percentages baseline t be set in year 1 yr survival 5 yr survival 23

24 Activity Perfrmance Indicatrs Threshld Methd f measurement Cnsequence f breach 30 day readmissin rates fr cancer patients Numbers and percentage baseline t be set in year Data Submissin Registry dataset submissin status DCOs As required by Registry Staging data As required by Registry 24

25 Additinal infrmatin Incidence and survival data within this dcument refers t urlgical cancers classified using the internatinal classificatin f diseases (versin 10 - ICD10) as fllws: C61: Malignant neplasm f prstate - apprximately 35,000 cases per year C64: Malignant neplasm f kidney, except renal pelvis - apprximately 6,500 cases per year C65: Malignant neplasm f renal pelvis - apprximately 500 cases per year C67: Malignant neplasm f bladder - apprximately 8,800 cases per year Incidence data fr patients diagnsed in 2009, England. Surce: UKCIS, data extracted August Emergency presentatin data fr patients diagnsed , surce: NCIN. Cancer waiting times The urlgical cancer grup fr the 31-day reprting categry cmprises f ICD-10 cdes C60-C68. Fr the 31/62-day (referral t treatment) reprting categry, the grup is urlgical (excluding testicular) and cmprises C60-C68, excluding C62. OPCS-4 cdes The fllwing OPCS-4 cdes have been agreed within the NCIN as peratins that, if undertaken n a patient with prstate, bladder and kidney cancer, wuld be a majr surgical resectin: Prstate M611 Ttal / Radical prstatectmy, Ttal excisin f prstate and capsule M614 Perineal prstatectmy M618 Open excisin f prstate, ther specified M619 Prstatectmy NEC. Open excisin f prstate, unspecified Bladder M341 Cystprstatectmy M342 Cysturethrectmy M343 Cystectmy NEC M348 Other specified ttal excisin f bladder M349 Unspecified ttal excisin f bladder 25

26 Kidney M021 Nephrectmy and excisin f perirenal tissue, Nephrureterectmy and excisin f perirenal tissue M022 Nephrureterectmy NEC M023 Bilateral nephrectmy M024 Excisin f half f hrseshe kidney M025 Nephrectmy NEC M028 Ttal excisin f kidney, ther specified M029 Ttal excisin f kidney, unspecified M038 Other specified partial excisin f kidney M039 Partial nephrectmy NEC, Partial excisin f kidney, Unspecified M042 Open excisin f lesin f kidney NEC M104 Endscpic cryablatin f lesin f kidney M181 Ttal ureterectmy, Ureterectmy NEC M182 Excisin f segment f ureter M183 Secndary ureterectmy M252 Open excisin f lesin f ureter NEC 26