Briefing Paper. Single Cancer Pathway

Transcription

1 Briefing Paper Single Cancer Pathway Author: Tom Crosby, Clinical Director, Wales Cancer Network Owner: Wales Cancer Network Date: 27 th November 2017 Version: 1.0 Publication/ Distribution: Wales Cancer Network Health Boards in Wales via Cancer Exec Leads, Cancer Clinical Leads and Cancer Managers WG Cancer Implementation Group Cancer Site Groups Cancer CNS & AHP Teams Macmillan Framework for Cancer Wales Cancer Alliance Purpose and Summary of Document: Briefing Paper providing context and current plans to adopt a Single Cancer Pathway for all NHS organisations across Wales. Colleagues are asked to: Approve Endorse Discuss Note * Consider

2 Single Suspected Cancer Pathway Briefing 27 th November 2017 This briefing paper is intended to provide an overview of the context and current plans for the Single Cancer Pathway, for all NHS organisations across Wales. Further information can be sought from: Dana Knoyle a specialist cancer nurse (lung) and clinical lead for this in the Cancer Network. Damian Heron is the Director for the Network and Dr Tom Crosby is Medical Director for the Network. They would all be delighted to receive any questions or comments you may have. 1. Background The current cancer waiting times (CWT) which has been a Welsh Government performance target for approximately 10 years is incorporated within the NHS outcomes Framework. Rather than just measuring time to first appointment or treatment waiting times as with previous measures, they attempted to measure the whole pathway from referral to the start of the first definitive treatment (FDT). The 2 current targets are: Urgent suspected cancer (USC): Patients referred from primary care as suspected cancer, fulfilling specific criteria, and accepted as suspected cancer, should start treatment within 62 days of the receipt of the original referral. It has a compliance target of 95% Not Urgent Suspected Cancer (nusc): This is for all patients diagnosed with cancer by other referral routes e.g. via A+E, a surprise finding on an investigation for something else etc. The original target was meant to be for 31 days from the date of diagnosis, but this was considered too hard to define and it is currently measured from the time the patient accepts their treatment plan. It has a compliance target of 98% Both targets allow for the suspension of patients for both clinical and non-clinical reasons; although clinical suspensions are for a few limited issues. The conversion rate is the number of USC referrals who actually have cancer. It varies between ~ 3-20% between different cancers. The detection rate is the proportion of all cancers diagnosed via the USC pathway. It is usually ~ 40%, i.e. the majority of cancers are diagnosed via the nusc route. Health Boards have systems in place to track USC patients through their pathway via Patient Tracker Lists (PTL) that are submitted to WG monthly. Health Boards in Wales have not been compliant with the 62 day USC pathway for many years. Over recent years there have been improvements in the numbers of patients treated within target, although the compliance with the target remains around 88%. The number of USC referrals has increased by 46% over 5 years. Earlier this year all HBs except 2 P a g e

3 one were at ~90% compliance, with the other HB approaching 80%. The principal waits are usually with urology, lower GI, gynae and upper GI. Compliance with the 31 day target has customarily been over 98%. However over the last two years some health boards have struggled to achieve this target. This has improved over the last quarter. The only cause for breaches within this target is waiting times for treatment being over 31 days. England have similar targets. They have 2 week waits compared to our USCs, where as well as 62 days to first definitive treatment, patients must be first seen within 2 weeks of referral. Their compliance target for these patients is 85% but they don t include suspensions. Their performance has fallen below their target of 85% as a result of diagnostic pressures. About 6-7 years ago it appeared that despite a long and complicated diagnostic and cancer staging pathway for patients with oesophago-gastric cancers the system was reporting near 100% compliance with the nusc pathway and also a high proportion of patients (up to 70/80% in some Health Boards) coming through this pathway. Whilst the original Welsh Health Circular described the 31 days to be measured from diagnosis, even when the tumour was seen at endoscopy and the patient then had waits for CT scan, CT-PET scans, endoscopic ultrasounds and MDT decisions, the CWT clock only started when the patient accepted the treatment plan, usually just before treatment. Through the then National Service Advisory Groups (NSAGs) it was confirmed that in fact patients with upper GI, lower GI, lung and gynaecological cancers were waiting on average 60 days from diagnosis. It was clear therefore that the system was: Not accurately reporting the actual patient experience Not accurately reporting the pressures in the diagnostic system. Not driving improved performance through improving the causes of delays At the then Health Minsters request the clinical community was asked via the NSAG to consider what the best measure of cancer waiting times is and whether some low risk or indolent cancers should be excluded from CWT reports. Their response was that waiting times were important (delays adversely affect patient outcomes and experience), that 62 days should be the longest time any patients should wait and that the number of patients with low risk disease who would then have to be monitored separately should not be excluded. Patient focus groups said they wanted information on how long they would be expected to wait and they wanted assurance that they would not come to harm through waiting. 2. Single Cancer Pathway A case was made that accurately recording the median and 95 th centile waiting times for all cancer would reveal where the longest waits were, and we could then tackle the causes of these. The waits could also be captured by tumour site. This is important to capture as some cancers should not need to wait more than 28 days for what are shorter diagnostic pathways. Whilst a single target of 62 days as a high level maximum waiting time measure is straightforward, it is also rather blunt as a driver of service improvement. 3 P a g e

4 The single Suspected Cancer Pathway (SCP): A single suspected cancer pathway would measure CWT from the point of suspicion of cancer. For current USC referrals there would be little change except the clock would start at the date the GP referred the patient rather than receipt of referral by secondary care. For current nusc routes to diagnosis the time the clock would start from clinical point of suspicion, with as a minimum the point being the same as NG12 NICE Guidance on Suspected Cancer. It is likely that a target of 62 days will be set with a compliance of 95% The then and current Cabinet Secretaries were understanding of the issue and have been considering whether to recommend a policy change to a single SCP measure of 62 days from the point of suspicion. The challenge here was that audit work then and since suggests the performance against a single SCP target would be ~65-70%. Whilst this is a more accurate reflection of actual waiting times it could be perceived as a fall in performance. The Cancer Implementation Group (CIG, then Chaired by Paul Roberts, now by Tracey Cooper) made working towards an SCP Pathway a priority 2 years ago. Health boards were given some funding to implement Tracker 7 software (or equivalent) with their PAS systems and the SCP pathway was piloted in Cwm Taf. The key to success, and challenge for the SCP pathway, is for secondary care clinicians to trigger the pathway (tell cancer services or the system) that the patient is a suspected cancer and be put on the PTLs. The Cancer Network (WCN) commissioned a piece of work from Cardiff University to evaluate the Cwm Taf pilot and considered what would be required to diagnose all patients by 28 days (accepted to be necessary to treat by 62 days). The findings were that there would need to be about a 20% increase in diagnostic capacity (especially CT/MRI, endoscopy and pathology). However, this alone would not be enough, Pathways would have to remove waits between tests and also focus on regional diagnostic centres to facilitate accelerated pathways. WCN have been internally shadow reporting waiting times from Health Boards, but with other service pressures Health Boards have yet to put systems in place to track nusc patients. Performance is ~65% but this does not include suspensions. The clinical community, the 3 rd sector, CEOs and the Cancer Implementation Group all accept that moving towards a single cancer pathway is the right thing to do as it will: Accurately reflect patient experience Accurately reflect the pressures in the diagnostic system Drive service improvement to address system delays However, the service is wary of the additional burden of tracking these patients. This concern is understandable, not least because the additional number of patients is unknown, although the conversion rates are usually higher in nusc pathways. The Cabinet Secretary recently expressed his frustration that more hadn t been done to prepare for this new pathway and provide him the assurance that such a policy change would not lead a diagnostic system failure. The CIG through the WCN are now working hard with health boards to prepare for this new pathway and to put processes systems in place to achieve 95% compliance by April At some point in the next few months it is expected that performance against the SCP will be formally shadow reported to and monitored by WG. The Cabinet Secretary may be minded to change policy during 4 P a g e

5 2018 but we would hope that we would set incremental compliance targets as we proceed with implementing new service models and addressing any gaps in infrastructure if this is ahead of April 2019 The CIG and WCN have recently received verbal commitment from health board cancer clinical and executive leads that they will work hard internally and together to improve patient pathways, including preparation for the SCP. There are pockets of excellent practice across the country but this is not as consistent as it could be. We have committed to undertaking a cancer pathway peer review workshop on 19 December where we expect key staff from each organisation to attend to share experience, variations in practice, develop a consensus for a set of best practice principles and standards and to determine next steps. Each health board should develop an implementation plan that will be peer reviewed by mid/end January and the Network will develop a National report. There is a core team from the Network, 1000 lives and Delivery Unit with considerable experience in this area with awareness of improvement work in this area in other devolved UK countries. For example if the following are not in place we feel that compliance is less likely: A HB team of nominated cancer clinical and exec leads a focus from performance executives, information support, and improvement support. Identify the range of routes to referral other than the primary care USC pathway and the non-cancer secondary care clinicians involved in these diagnostic routes. Clear engagement from non-cancer secondary care clinicians and cancer MDTs: they ultimately have to agree pathways, where possible with little National variation and they have to care about their performance and inform the system of new suspected cancers and ultimately refer patients to specialist MDTs and PTL systems. An electronic referral and receiving system integrated with HB PAS system. Capacity and demand modelling to ensure adequate outpatient, diagnostic and treatment capacity. A tracking system to track patients prospectively through the pathway but also able to report component waits to target with improvement measures retrospectively. Designated capacity timed to be delivered with the previous steps in pathway e.g. endoscopy to CT. One step leading to the next, known as an intelligent pathway. Avoid fixed point delays wherever possible such as MDT meetings or consultant decisions. Members of the MDT should be empowered to push patients through agreed accelerated pathways. Be prepared to link across organisational boundaries for tertiary diagnostics or treatment or just where capacity may be better than that available locally. 5 P a g e