However, the time taken to reach the diagnosis is just as crucial for quality of care.

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1 Oxfordshire Clinical Commissioning Group Cancer referrals new lung pathway GPs are in the front line for referrals. The 2015 NICE cancer guidelines were altered to reduce the threshold for making referrals and OCCG has been working with providers towards better pathways for patients to follow, when GPs suspect this diagnosis, to attain a 3% pick up rate i.e. low but safer. However, the time taken to reach the diagnosis is just as crucial for quality of care. In 2017 NHSE introduced new criteria for improving cancer care through best practice guidelines. One of the new criteria is the 28 Day National Faster Diagnosis Standard which is expected to go live nationally in April The actual wording is Patients should be informed of a definitive diagnosis or ruling out of cancer within 28 days of a referral. The target is likely to be set at 95% (current 2WW target 93%). It is expected, but not confirmed, that eventually this will replace the 31 day and 2ww target altogether. This slightly wordy title represents a laudable standard that is not unreasonable. If you thought that you might have cancer, would you wish to wait more than 28 days before being told, one way or the other? I think not. We are slightly ahead of the curve here in Oxfordshire, as we have already streamlined some pathways through the 2ww forms. FIT testing is already in place and suspected prostate cancer referrals are already improved through direct to test MRIs where appropriate. Prostate patients get a much quicker diagnosis as this shaves days off the pathway, provided they come into the system with the correct clinical information. The 2ww referral form is designed to help the GP achieve best practice by providing this. Data reinforces this and as GPs, you should be very proud of the improvements seen here. Partly because of these innovations the OCCG has been given cancer alliance funding to develop better practices in cancer care; more about this will follow soon. The next step towards improved care is the Lung cancer pathway. Lung cancer is the commonest cancer and yet 24% of patients present via A&E. The new standard implements straight to test for lung patients where appropriate. For some time already, an improved referral template has been in circulation, however, our main provider has not had the infrastructure to take advantage of this. This has now been corrected through clinical and IT co-operation across primary and secondary care. Attached to this article you will find a document that explains the new pathway in greater detail, along with the rationale. Please familiarise yourself with the processes and circulate the article to

2 your admin staff and anyone else that may have contact with these patients, so that everyone is up to speed. The only change to the traditional approach is the request for a straight to test CT on ICE at the time of referral. Many of you are already using this approach with good results. However, from the middle of May this approach will be mandatory for all, as we strive toward the new 28 targets through better care. If you have any questions, please the OCCG planned care team as usual. Many thanks. Dr Shelley Hayles Planned care and Cancer clinical lead OCCG.plannedcare@nhs.net April 2018

3 Oxfordshire Clinical Commissioning Group Referral guidance for suspected lung cancer patients All patients referred via the 2-week urgent referral pathway for suspected lung cancer have CT imaging. In order to follow best practice guidance for straight to test, GPs are requested to book the patients for CT scan at the time of 2ww referral by raising a request on ICE. This will flag the referral to the radiologist and allow for a better first outpatient appointment with the relevant test result. The OUH clinicians have undertaken the responsibility to follow up these requests and act on them. This is a very new way of working for clinicians; however, in the last few months the trial run has proven very successful in reducing the time to diagnosis, for patients whose GPs have used this system, with no untoward events so this request will now become mandatory for all lung cancer referrals. Joint Responsibilities in improving outcomes GP referrers Will use the OCCG 2ww Suspected Lung Cancer template to make referrals to the two-week urgent pathway for suspected lung cancer Will generate a request in ICE at the same time for o o a CTPA for patients with unexplained haemoptysis and CT CAP for patients with chest radiograph abnormalities Will confirm this as done, via the mandatory field requiring an electronic request for a CT, on the 2ww Suspected Lung Cancer template. Respiratory Consultants accepting 2 week wait pathway referrals On receipt of the 2 week wait referral Will check there is a CT request, CT appointment booked, or CT scan reported for each patient as a fail-safe mechanism. If there is no CT request, CT appointment or recent (< 1 month) CT chest, the respiratory consultant will request a CT. Will review and take responsibility to act upon the results of the CT requested by the GP as part of the 2 week wait referral process. If an urgent or unexpected finding (other than lung cancer) is identified, the respiratory consultant will take the necessary steps to ensure the patient is investigated and treated appropriately. This may involve contacting the GP and asking him/her to take further action. Radiology consultants Will prioritise reporting the 2 week wait urgent CT scans. They will undertake the delegated practitioner role and are aware of the clinical indications and scan protocols. Will check twice daily for lung cancer 2WW CT referrals as per the agreed Standard Operational Procedure for Radiographer Authorisation of CT in Suspected Lung Cancer (appendix 3).

4 Step-by-step guide to ICE requesting for CT scan in suspected lung cancer: Requesting CT exams in ICE to initiate fast track process for suspected lung cancer patients; to be completed in addition to the 2-week Urgent Referral for suspected Lung Cancer template. Step 1: Select CT Chest/Abdomen and Pelvis button in the CT modality group B: Select CT option on the left hand menu A: Select GP Radiology on top row C: Select CT Chest/Abdomen and Pelvis group Step 2: Select CT Chest/Abdo/pelvis with contrast exam or CT Pulmonary Angiogram in the list of available CT exams, as required by previous findings/test result A: Select CT Chest/abdo/pelvis (CT CAP) B: Select CT Pulmonary Angiogram (CTPA) A: Select CT Chest/Abdo/pelvis with contrast ICE request for CT CAP & CTPA examsv: Draft March 2017 Page 4 of 7

5 Step 3: Identify this CT request to be part of a 2WW clinical referral select Yes Select Yes Step 4: Reminder to complete the 2WW referral proforma in addition to making the CT request Select Yes ICE request for CT CAP & CTPA examsv: Draft March 2017 Page 5 of 7

6 Step 5: Confirm this CT request should be fast tracked to the Lung Cancer Clinic Select Urgent referral for suspected lung cancer Step 6: Complete the hospital location and clinical information required for all CT exams, based on the patient s medical profile. ICE request for CT CAP & CTPA examsv: Draft March 2017 Page 6 of 7

7 Step 7: Identify the urgency for the exam by selecting Cancer 2 week wait (2WW) Select Cancer 2 week wait ICE request for CT CAP & CTPA examsv: Draft March 2017 Page 7 of 7