Highland NHS Board 2 June 2009 Item 4.3 BREAST CANCER SERVICES COMPLIANCE AGAINST 31 AND 62 DAY TARGETS Report by Derick MacRae, Cancer Service Manager on behalf of Dr Ian Bashford, Medical Director The Board is asked to: Note the challenges in achieving the 31 day National Target for patients to be treated following referral. Note the measures put in place in 2009 in order to improve capacity within the service. Agree the recommendations, particularly the proposals to minimise governance. issues by establishing the one stop, triple assessment service within the Highland Breast Centre at Raigmore Hospital for all North Highland patients. Agree the recommendation that further work should be commissioned to review the demand, capacity and activity of the NHS Highland breast service. Note the NOSCAN commissioned work. 1 BACKGROUND AND SUMMARY NHS Highland achieves the National 62 Day Target which states that by 2005, the maximum wait from urgent referral to treatment for all cancers will be two months. This is significant progress but meeting the 31 day target continues to be a challenge both locally within NHS Highland and nationally: women who have breast cancer and are referred for urgent treatment will begin that treatment within one month of diagnosis, where clinically appropriate. The target required to be effective from October 2001. Better Cancer Care (2008) has set out new cancer targets which have to be achieved by 2011, and NHS Boards are likely to begin reporting progress toward these new targets from September 2009. 62-day target to treatment for all patients referred urgently with a suspicion of cancer and for screened positive patients. 31-day target from decision to treat to first treatment for all patients diagnosed with cancer irrespective of their route of referral. This report has been produced for the information of Board members following the April 2009 Board meeting, where concerns were noted about the continuing difficulty in meeting the 31 day target for Breast Cancer. It should be noted that the service provided by the NHS Highland breast service in Raigmore Hospital is of an extremely high quality and that the staff have shown dedication and application in providing this service to meet the ever increasing demands and needs of the population and meeting the national targets. The Chetty Report produced by Mr Udi Chetty, as part of the Cancer Performance Support Team established by the Scottish Executive in February 2007, identified a number of issues affecting the delivery of the symptomatic breast service in NHS Highland. The purpose of the Chetty report was to clarify current performance and to review current systems and processes as they are experienced by patients. It should be noted that the Chetty Report did Working with you to make Highland the healthy place to be
not identify any fundamental issues that had not been raised by the breast service staff and did not adequately consider breast services in the periphery. One action resulting from this Report was the lack of adequate managerial input to support the service and an appointment was made to a managerial post. Additional clinics, as recommended by the breast surgeons, were also implemented to augment and expand the capacity of the breast service. The implementation of this report has been monitored locally through the production of an Action Plan, which was most recently updated in March 2009. This paper provides further recommendations on the two outstanding urgent actions within the Chetty Report. These are I. The need for a review of the diagnostic service provided across all sites to ensure that women receive equitable quality of care. II. The development of a timed pathway for a pan Highland Breast Service involving teams in rural general hospitals. The third recommendation required the nomination of a Clinical Lead with a clear remit and accountability to take forward the Chetty Report recommendations. Mr P Walsh, Consultant Breast Surgeon at Raigmore was appointed to this post. Argyll & Bute CHP breast surgery service The current breast service in Argyll & Bute is that all referrals for symptomatic and asymptomatic breast disease are made directly to the breast clinic in the Western Infirmary in Glasgow where triple one stop assessment is undertaken. Subsequent management and treatment is provided by Greater Glasgow & Clyde. It should be noted that there is no assessment diagnosis, management or treatment carried out in the Lorn & Isles District General Hospital in Oban and this service configuration will be maintained. There is participation from Argyll & Bute clinicians in a regular Cancer MDT led by Greater Glasgow & Clyde. NOSCAN There is a further current development emanating from the North of Scotland Cancer Network (NOSCAN) approved by the North of Scotland Regional Planning Group (NoPSG). Real concerns have been raised in NOSCAN with regard to the sustainability of the breast cancer service in the future. There have been recent surgeon vacancies in the Western Isles Health Board (resignation) and Dr Gray s Hospital, Elgin (retiral) and there is an anticipated number of retirals of the current breast surgeon workforce in the North of Scotland in the near future. NOSCAN has, therefore, commissioned Mr Udi Chetty to review the current configuration and quality of breast services throughout the North of Scotland, consider the profile of the entire clinical workforce and make recommendations on the development of a sustainable service fit for the future. This report is anticipated to be available in approximately four months. Discussions are on-going with NHS Western Isles in order to determine the type of service that could be offered by the Highland Breast Centre (HBC) to their patients as a result of the vacancy there. It is proposed that the model of care would be similar to that offered to the rest of Highland ie patients referred to the HBC for a one stop triple assessment and treatment. 2
2 BREAST SURGERY PROBLEMS AND PROPOSALS Meeting the 31 day and 62 day targets 62 Day Target The overall performance target (for all cancers combined) has been achieved by NHS Highland since Quarter 2 of 2007, and as can be seen at Appendix One, NHS Highland has regularly met this target for Breast Cancer. It is still a challenging target and with only two surgeons available to treat patients, a period of leave for one or limited outpatient and theatre capacity to cope with peaks in referral could risk that target being breached in the future. 31 Day Target Appendix One does highlight the challenges faced by NHS Highland in complying with the 31 Day Target. At the Board s Performance Committee meeting in April 2009 it was reported that only 78 per cent of the Highland Urgent Breast Cancer referrals in the third quarter of 2008 were treated within the 31 day target. This can be compared against the Scottish figure of 83.6 per cent. Only a small increase in the numbers treated would significantly increase the percentage compliance. If only a further three patients were treated days earlier NHS Highland would equal the Scottish average. Again, even though Consultants helpfully plan their leave well in advance with their remaining colleague assessing and treating additional patients, the margins are so narrow that even a small drop in activity or slight increase in referrals can affect the achievement of the target, which is so delicate. The October to December 2008 data are not yet in the public domain given that final validation is required but, unfortunately, this will show that achievement against the target dropped further to 71 per cent for the fourth quarter of 2008. Measures taken to Minimise the Risk of Failure There are a number of bottlenecks in the current system that affect the resources available to assess and treat patients particularly at times of peak referrals. Additional measures were implemented in the spring of 2009 to help manage the demand for services. Referrals for Assessment In January 2009, additional three evening outpatient clinics were held in order to accommodate the increasing number of referrals in the previous two months. An additional outpatient clinic is now held on three out of four weeks in the month by reorganising over committed Job Plans in order to increase capacity and cope with peaks in referrals. Radiologist Availability It is hoped that one of two present Consultant Radiologist vacancies in Raigmore Hospital will be filled by a Radiologist with an interest in Breast Services. This should go some way to minimising the difficulties in staffing a theatre session, when patients requiring wire guided imaging are being treated. This will be in addition to the senior radiographer currently being trained to provide this service. Unfortunately there can be occasions at the moment when theatre slots are available to see patients nearing the end of the pathway, but a radiologist is not available. The means that a patient will breach the target. 3
Theatre Capacity The two breast surgeons in Raigmore Hospital utilise 95 percent of their theatre session time. This is an extremely high rate which makes it is difficult to schedule additional patients at short notice if they are nearing the end of their target time. Further sessions require to be made available as and when required to ensure that patient can be treated timeously towards the end of their pathway. Ideally additional sessions would be planned to allow for such regular peaks in demand. The Department is working with other colleagues in Theatres and other specialties to populate the theatre lists as quickly as possible so that spare capacity can be identified at an early stage and offered to Consultants requiring slots for urgent patients. This method of selective allocation of operating slots was well described by the management consultants who recently reviewed the Highland management of waiting lists. The Breast Surgeon s theatre utilisation of 95 percent is the highest of all the surgeons in Raigmore Hospital and that the breast surgeons currently provide a very high number of scheduled lists. The 5 percent under-utilisation is usually due to normal turnover between patients or last minute cancellations. A review of extending the theatre working day is being considered to accommodate increased theatre capacity. Capacity It is predicted that the demands on the Breast Service will soon increase in line with: The population living longer and age specific incidence rates of breast cancer show a marked increase with age. Increased detection as a result of two view breast screening: the move from single to two view screening was implemented in 2008, and it is estimated this will result in a five percent increase in the number of referrals and detection. At the same time, the resources available will be under pressure. Like all specialties there is a requirement to comply with the European Working Times Directive (EWTD) and to ensure that the two Consultant breast surgeons work no more than 48 hours per week. Without additional resource there is a risk there will be less direct care clinical sessions being available for patient care. As a result of these expected increases in demand meeting the national targets and European Working Time Directive could be even more of a challenge. Raigmore Hospital is currently developing a business case to evidence the need for an increase in clinical staff. The evidence to date suggests that there may be a requirement for an additional third breast surgeon. Ideally this individual will facilitate the development of sentinel node biopsy treatment and augment the current provision of breast conservation and reconstruction surgery. The Chetty Report The Chetty Report produced in 2007 identified a total of 18 recommendations in order to improve the service within NHS Highland. An Action Plan has been produced since then in order to monitor progress and the most recent update was in March 2009. Following the appointment of Mr Walsh as Lead Clinician for Breast Cancer options to address the two remaining urgent recommendations (the need for a review of the diagnostic service provided across all sites to ensure that women receive equitable quality of care and the development of a timed pathway for a pan Highland Breast Service) were investigated. Options involving shifting some breast care to the Rural General Hospitals or providing an in- 4
reach type service to Raigmore Hospital were piloted. However, for a number of reasons this pilot initiative was not successful. One Stop Triple Assessment The remote and rural geography of the Highlands and the configuration of current services presents real challenges in meeting the National Standards. Initial agreement has now been obtained with colleagues in the North, Mid and South East CHPs to ensure that all symptomatic breast patients are referred directly to the Highland Breast Centre for specialist and timely assessment. The recognised SIGN (Scottish Intercollegiate Guidelines Network No 84) standard for assessment is that all women should have a triple assessment on one visit. This consists of a history and clinical examination, imaging (mammogram/ultrasound) and cytology/histology (tissue sampling using Fine Needle Aspiration or Core Biopsy sometimes guided by imaging) at a single clinic. This will ensure that all patients in North Highland receive the appropriate high quality standard of care consistent and compliant with National Guidance. Local Reasons for Triple One Stop Assessment a) This standard can only be complied with at Raigmore Hospital where there are the necessary imaging facilities including mammography and ultrasound and the appropriately trained and skilled staff who see the annual volume of patients in order to maintain their skills. The guidelines from BASO (Association of Breast Surgery and the British Association of Surgical Oncology) also recommend a minimum caseload of at least 30 newly diagnosed breast cancer cases per consultant per year in order to maximise patient outcome. The number of patients with cancer referred from peripheral areas are relatively small (around 10 cases per year at Caithness General and Belford Hospitals) and are unlikely to meet these minimum caseload numbers if only seen locally. Even if a referral is made to a peripheral consultant clinic and patients are examined, they all require referral to the Highland Breast Centre for mammography and/or ultrasound. Therefore, even if patients undergo triple assessment provided from a number of local facilities they all require to be seen at some stage in the Highland Breast Centre. b) There is a risk that the initial consultation can be with a surgeon who can find it difficult to maintain active breast practice and find it difficult to adhere to standard practice and provide the expected high quality of breast care. A previous model when piloted recommending referral to a single consultant based in a remote and rural location has been discounted due to the difficulty of maintaining their personal skills, maintaining the service at all times and providing a timely and acceptable assessment service. c) Patients referred by a GP to a Rural General Hospital (RGH) can often have a longer interval between referral and completion of triple assessment, by the time they have been seen initially at an RGH, then referred to Raigmore for diagnostic investigation and then referred back to the peripheral clinic to complete the triple assessment over multiple sites. Due to the absence of specialist imaging diagnostics (mammography and ultrasound) it is impossible to provide triple one stop assessment in the RGHs at present. d) This almost inevitably breaches the waiting time for treatment if cancer is diagnosed and is an inefficient pathway of care. 5
e) The alternative for many patients leads to repeated visits to Raigmore for a succession of non-co-ordinated investigations, management and treatment which may lead to increased journey time, duplication, delay and possible confusion. f) It will ensure an equitable level of service throughout Highland, consistent with the Chetty Report. There may be however be a role for surgeons with a breast interest in rural locations to see patients for obvious non cancer referrals but this requires to be agreed throughout NHS Highland. The Specialist Consultants will be working with surgeons to develop breast pathways that could safely and appropriately be managed by those in rural locations and consideration should be given to the diagnostic and imaging facilities that are available in the periphery. The possibility that symptomatic breast disease, however innocuous in presentation, may be malignant must be a primary consideration. It is important than any surgeon treating breast cancer patients should be fully qualified trained and meet the suggested case load minima to maintain skills and provide an appropriate quality service. There are general surgeons in Caithness General Hospital who currently see breast patient referrals and manage some cases, but they are not fully trained breast surgeons. In Belford Hospital, Fort William, there is a qualified breast surgeon appointed to a general surgical role, but with the absence of providing a triple one stop assessment and the small case load, this does not presently meet the suggested standards for breast cancer care. However, further consideration should be given of maximising this potential in an integrated fashion between the Belford Hospital and the Highland Breast Service. The impending NOSCAN review by Mr Chetty may help clarify this issue. Further work is required to develop and agree guidelines and pathways which can clarify the role of the surgeons in RGHs in order to minimise the patient journey for cases which are potentially less serious but ensuring that appropriate care is given. It will also be important to develop pathways which formalise and enhance the role of Nurse Specialists working within the multi-disciplinary team especially in the area of ongoing care and follow up, potentially freeing up consultants to see new and urgent referrals. However, it should be noted that surgeons will still require to see a significant proportion of follow up patients supported by specialist nurses and other healthcare professionals. Multi-Disciplinary Team (MDT) Meetings The present MDT held in the Highland Breast Centre is off extremely high quality and functions very efficiently. It is important that this MDT should be available on a pan Highland (old Highland) basis so that all appropriate stakeholders are able to participate to ensure integration and continuity of care. 3 CONTRIBUTION TO BOARD OBJECTIVES Meeting with the recommendations contained within the report a. will go some way to minimise the delays experienced by some patients being treated; b. and provide equitable care consistent with good practice and Clinical Governance Standards throughout NHS Highland. They will help achieve the targets set out within the Local Delivery Plan 2009-10 ie A9.1 The maximum wait from urgent referral with a suspicion of cancer to treatment is 62 Days 6
A9.2 The maximum wait from decision to treat to first treatment for all patients diagnosed with cancer will be 31 days from December 2011. 4 GOVERNANCE IMPLICATIONS Patient and Public Involvement Through planned Focus Group discussions during the summer the active involvement of Patient Groups to discuss the necessary pathways derived from the recommendations contained within this paper will take place. This will ensure that the views of the patients and public are integral to further service planning. It is important that NHS Highland engages with patients and others to ensure that the overall service provision has the same quality and access to specialist care regardless of their location and circumstance. NHS Highland s Cancer Steering Group has a wide representation with active and enthusiastic participation from voluntary organisations and they will be fully involved in the roll out of these recommendations. The service is very mindful of the need for patients to have an informed choice about the surgeon treating them and optimum location for their surgery. Clinical Governance The recommendations within this paper are consistent with the actions agreed in the Chetty Report of 2007 and the SIGN Guidelines on the provision of Breast Cancer Services to ensure a high quality effective and sustainable service. Financial Impact If the Board agrees to the further review of Demand, Capacity and Activity it is likely that a business case for additional staff will be submitted. 5 IMPACT ASSESSMENT Further work is required and recommended, through Focus Group discussions and the involvement of Patient Groups to ensure that Equality and Diversity issues are raised and addressed in the implementation of the final recommendations. 6 RECOMMENDATIONS The Board is asked to agree to the following recommendations 6.1 NHS Highland will adopt the recognised assessment standard which is to have one stop triple assessment. This should be carried out at Raigmore Hospital in order to maximise the use of expert staff and specialist equipment, especially within the Highland Breast Centre. 6.2 There should be pan Highland Multi Disciplinary Team (MDT) meeting where all appropriate breast patients are discussed following diagnosis and/or treatment. This will ensure that all appropriate staff and patient groups can participate directly in the decision making process and more especially in the follow up care of patients. 6.3 Where there are suitably qualified and accredited breast surgeons in the other NHS Highland locations consideration must be given to their participation in both the assessment and treatment of patients within the Highland Breast Centre to maximise capacity and provide continuity of care. 7
6.4 Where there are appropriately qualified breast surgeons in any of the RGHs, consideration should be given to maximise their professional expertise and potential capacity within the Rural General Hospital to provide an agreed level of breast surgery, management and follow up consistent with a pan Highland approach and accountability. This will maximise capacity and ensure high quality care in provided as locally as possible. 6.5 Pathways of breast care must be developed to clarify the types of Breast Services that could be appropriately and safely carried out in all locations throughout NHS Highland, especially in the Remote and Rural Hospitals. 6.6 Pathways of breast care should be reviewed and developed to maximise the use of the Nurse Specialists skills within the Multi Disciplinary Team setting, potentially releasing the Consultants to maximise their expertise in seeing new, urgent referrals and the management of cases. 6.7 A final assessment and review should be made of the capacity at Raigmore Hospital and the possible requirement for an additional staff, especially an additional breast surgeon and any current capacity within NHS Highland should be considered. This will be presented to the NHS Highland Planning Group by August 2009. Derick MacRae Cancer Services Manager Raigmore Hospital 22 May 2009 8
Appendix One NHS Highland and Scotland Breast Cancer Performance Against 31 and 62 Day Waiting Times Targets Referrals before exclusions 31 Day Target NHS Highland Number treated in 1 month Number of referrals % Achievement Scotland % Achievement 62 Day Target NHS Highland Oct Dec * 62 52 37 71.2 Jul - Sept 68 59 46 78 83.6 100 Apr Jun 68 60 51 85 83.0 100 Jan Mar 49 44 35 79.5 82.0 100 2008 Total 247 215 169 78.6 Average 62 2007 Oct Dec 60 57 29 50.9 79.4 95.7 Jul Sept 60 51 33 64.7 83.4 100 Apr Jun 47 41 26 63.4 84.3 87.5 Jan Mar 66 61 42 68.9 71.7 91.3 2007 Total 233 210 130 61.9 Average 58 2006 Oct Dec 60 54 34 63.0 83.6 79.2 Jul Sept 55 51 32 62.7 82.7 47.4 Apr Jun 47 45 27 59.1 87.8 77.4 Jan Mar 59 59 47 79.3 83.9 75 2006 Total 221 209 140 67.0 Average 55 * - Unaudited data, not yet in the public domain 9
Appendix 2 BREAST PATIENT PATHWAY SYMPTOMATIC PATIENTS SCREENING PATIENTS PATIENT ( with Symptomatic Breast Problems) PATIENT (If abnormality found) GP (Referral and Management) SCREENING SERVICE (Mammography) Highland Breast Centre (Triple One Stop Assessment & Diagnosis) Highland Breast Centre Assessment Clinic (Assessment & MDT Discharge Back to Primary Care or Follow Up OR TREATMENT ( Usually Surgical/ Infrequently Chemotherapeutic, Radiotherapy before Surgery) Discharge MDT FOLLOW UP ( Short/Long Term) DISCHARGE 10