The Single Cancer Pathway

The Single Cancer Pathway

Background and Case for Change

Case for Change (1) Broadly patient experience of cancer services in Wales is good: 93% of patients rate their care as 7/10 or better (WPES) But survival compared to other developed countries is poor (ICBP)

The consistency of this finding suggests this is less related to use of treatment but the way the system is working (ICBP, Eurocare, Concorde) Five year relative survival rate comparisons for Wales 5-year-age-standardised relative survival for adult patients with cancer, diagnosed 2000-07. De Angelis R, Sant M, Coleman MP, et al. Cancer survival in Europe 1999 2007 by country and age: results of EUROCARE-5 a population-based study. The Lancet Oncology 2013

International Cancer Benchmarking Partnership Module 1: Inferior survival likely related in part to late stage presentation (1 year survival surrogate for stage at presentation)

International Cancer Benchmarking Partnership Module 3: GPs in Wales less likely to refer and/or investigate for a given set of signs and symptoms This correlated with worse survival

International Cancer Benchmarking Partnership Module 4: After presentation patients in Wales spend longer in healthcare system before starting treatment than other countries/jurisdictions

State of Diagnostic Services in Wales 9-10% increase in CT, MR, Endoscopy year on year 10-50% posts vacant in Wales, all HBs outsourcing 30% of workforce could retire in next 5 years >50% current workforce >10 (many >12), unable to attract trainees, <50% primary care timely direct access to NICE recommended diagnostics 7 radiologists per 100, 000 compared to European average 12.7 7 CT scanners per million, compared with 35 in Denmark Situation similar or worse across primary care and pathology

30 8 14 18 4

Case of Mr Jones 72 year old previously fit male t0 PS 0 DG 1 72Kg Noticed food sticking in October 17, saw GP, prescribed PPI Rapid access OGD Jan, malignant stricture lower oesophagus Referred to Upper GI team (nusc), seen within 2 weeks CT scan and local MDT 2 weeks EUS (Carmarthen) and PET 3 weeks CPEX in further 2 weeks MDT 10 days after PET, T4N1M0 cancer, refer to oncology Seen within 2 weeks, unable to swallow, referred for a stent t90 PS 1 DG2 68Kg t120 PS 2 DG 3 64Kg

April 2012 May 2012 June 2012 July 2012 August 2012 September 2012 October 2012 November 2012 December 2012 January 2013 February 2013 March 2013 April 2013 May 2013 June 2013 July 2013 August 2013 September 2013 October 2013 November 2013 December 2013 January 2014 February 2014 March 2014 April 2014 May 2014 June 2014 July 2014 August 2014 September 2014 October 2014 November 2014 December 2014 January 2015 February 2015 March 2015 April 2015 May 2015 June 2015 July 2015 August 2015 September 2015 October 2015 November 2015 December 2015 January 2016 February 2016 March 2016 April 2016 May 2016 June 2016 July 2016 August 2016 September 2016 October 2016 November 2016 December 2016 January 2017 February 2017 March 2017 April 2017 May 2017 June 2017 July 2017 August 2017 September 2017 October 2017 November 2017 December 2017 Percentage of people starting treatment within 62 days of referral Percentage of people USC 62 day performance (%) against target in Wales over last 5 years nusc 31 day performance (%) against target in Wales over last 5 years Percent Percentage of people starting treatment within 62 days of USC referral in Wales Apr 2012 - Dec 2017 Percentage of people starting treatment within 31 days of agreeing their plan for all cancer sites in Wales 2013-2017 100% 90% 80% 95% 86% 100% 98% 98% 70% 96% 60% 94% 50% 92% 40% 30% 90% 20% 88% 10% 86% 0% 84% 82% Month 80% 2013 2014 2015 2016 2017 Year Wales Target

Variation in the System

Conversion rates for all cancers by HB in 2017 Detection rates for all cancers by HB in 2017 Conversion Rate for all cancer sites by health board for 2017 Detection Rate for all cancer sites by health board for 2017 12.0% 60% 54.1% 10.0% 8.0% 6.9% 10.2% 7.4% 7.4% 8.2% 8.5% 7.9% 50% 40% 45.3% 44.2% 47.1% 33.1% 44.1% 44.8% 6.0% 30% 4.0% 20% 2.0% 10% 0.0% Betsi Cadwaladr University Health Board Hywel Dda University Health Board Abertawe Bro Morgannwg University Health Board Cwm Taf University Health Board Aneurin Bevan University Health Board Cardiff and Vale University Health Board Wales 0% Betsi Cadwaladr University Health Board Hywel Dda University Health Board Abertawe Bro Morgannwg University Health Board Cwm Taf University Health Board Aneurin Bevan University Health Board Cardiff and Vale University Health Board Wales

Conversion Rate Detection Rate Conversion rates for all UGI cancers by HB in 2017 Detection rates for all UGI cancers by HB in 2017 10% USC Conversion rate for Upper Gastrointestinal Cancer by Health Board for 2017 Detection Rate of Cancer via USC pathway by Health Board for 2017 Upper Gastrointestinal Cancer 9% 8.5% 70% 8% 60% 58.4% 7% 6% 5% 4% 3.7% 5.9% 3.4% 4.3% 4.2% 50% 40% 30% 41.4% 35.7% 36.0% 34.3% 35.1% 3% 20% 2% 1% 1.7% 10% 11.1% 0% Betsi Cadwaladr University Health Board Hywel Dda University Health Board Abertawe Bro Morgannwg University Health Board Cwm Taf University Health Board Health board Aneurin Bevan University Health Board Cardiff and Vale University Health Board Wales 0% Betsi Cadwaladr University Health Board Hywel Dda University Health Board Abertawe Bro Morgannwg University Health Board Cwm Taf University Health Board Cancer Site Aneurin Bevan University Health Board Cardiff and Vale University Health Board Wales

Conversion Rate Detection Rate USC conversion rates by cancer site in 2017 Detection rates by cancer site in 2017 25% USC Conversion rate for all Wales by Cancer Site for 2017 Detection Rate of Cancer via USC pathway by Cancer Site for all Wales for 2017 60% 20% 19.8% 50% 46.6% 52.2% 15% 15.2% 40% 35.1% 37.0% 37.1% 30% 10% 7.9% 20% 5% 4.2% 4.7% 10% 0% Upper Gastrointestinal Lower Gastrointestinal Lung Breast Urological Cancer site 0% Upper Gastrointestinal Lower Gastrointestinal Lung Breast Urological Cancer Site

The Single Cancer Pathway

Percentage of people Percentage of people starting treatment in 62 days from referral Cancer Waiting Times (in Wales but similar to England) 100% 90% Percentage of people starting treatment within 62 days of USC referral for all cancer site groups in Wales. 2013-2017 95% 80% 62 day pathway for Urgent Suspected Cancer (USC) primary care referrals from receipt of referral Performance Wales ~ 85-90% 70% 60% 50% 40% 30% 20% 10% 0% 2013 2014 2015 2016 2017 Wales Target Percentage of people starting treatment within 31 days of agreeing their plan for all cancer sites in Wales 2013-2017 100% 31 day pathway for non USC from point patient agrees treatment plan Performance Wales ~ 95-98% 98% 96% 94% 92% 90% 98% 88% 86% 84% 82% 80% 2013 2014 2015 2016 2017 Year Wales Target

USC Pathway 62 day pathway Day 0 Day 62 Point of Suspicion (PoS) Referral Diagnosis Date of Decision to Treat Treatment Time NOT currently captured by CWT ~35-45% of cancers diagnosed via USC pathway Time in system NOT currently captured by CWT ~55-65% of cancers identified via non-usc pathway Key: - These waits will be exposed under the proposed SCP reporting Non-USC Pathway 31 day pathway

Days Patient 1 - Dec-13 Patient 4 - Nov-15 Patient 7 - May-16 Patient 10 - Aug-16 Patient 13 - Sep-16 Patient 16 - Nov-16 Patient 19 - Dec-16 Patient 22 - Jan-17 Patient 25 - Jan-17 Patient 28 - Jan-17 Patient 31 - Feb-17 Patient 34 - Mar-17 Patient 37 - Mar-17 Patient 40 - Mar-17 Patient 43 - Apr-17 Patient 46 - Jun-17 Patient 49 - Jul-17 Patient 52 - Jul-17 Patient 55 - Sep-17 Patient 58 - Sep-17 Patient 61 - Oct-17 Patient 64 - Oct-17 Patient 67 - Nov-17 Patient 70 - Dec-17 Cancer Waiting Times (in Wales but similar to England) Average 70 Median 65 95th Percentile 114.8 The majority (~55-65%) of cancer patients are diagnosed via the nusc pathway Approximately 50% of patients on complex pathways wait > 62 days on nusc pathway from point of suspicion This reporting of this CWT does not reflect patient experience, does not reflect diagnostic capacity challenges and does not drive pathway improvement 350 300 250 200 150 100 50 0 OGD to Rx Median Expected Actual Patient Waiting times for UGI patients from Point of Suspicion i.e. OGD

Percentage USC CWT performance by HB & Cancer Site Sept Dec 17 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 88% Percentage of people starting treatment within 62 days of USC referral for all cancer site groups by health board for Sept - Dec 2017 90% Betsi Cadwaladr Hywel Dda University University Health Board Health Board 86% Abertawe Bro Morgannwg University Health Board 89% 89% 89% 88% Cwm Taf University Health Board Aneurin Bevan Cardiff and Vale University Health Board University Health Board Wales 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percentage of people starting treatment within 62 days of USC referral by Cancer Site in Wales Sept - Dec 2017 79% 75% Upper Gastrointestinal Lower Gastrointestinal Lung Breast Urological 89% Cancer Site Group 94% 89%

April 2012 May 2012 June 2012 July 2012 August 2012 September 2012 October 2012 November 2012 December 2012 January 2013 February 2013 March 2013 April 2013 May 2013 June 2013 July 2013 August 2013 September 2013 October 2013 November 2013 December 2013 January 2014 February 2014 March 2014 April 2014 May 2014 June 2014 July 2014 August 2014 September 2014 October 2014 November 2014 December 2014 January 2015 February 2015 March 2015 April 2015 May 2015 June 2015 July 2015 August 2015 September 2015 October 2015 November 2015 December 2015 January 2016 February 2016 March 2016 April 2016 May 2016 June 2016 July 2016 August 2016 September 2016 October 2016 November 2016 December 2016 January 2017 February 2017 March 2017 April 2017 May 2017 June 2017 July 2017 August 2017 September 2017 October 2017 November 2017 December 2017 USC Referrals USC Referrals Numbers of Total USC referrals in Wales Number of USC Referrals in Wales by year between Jan 2013 - Dec 2017 Measure 10000 Number of USC Referrals in Wales by month between April 2012 - December 2017 100000 9000 8000 80000 7000 6000 6532 60000 5000 4000 40000 3000 2000 1000 20000 0 0 2013 2014 2015 2016 2017 Year Month

2013 2014 2015 2016 2017 USC Referrals USC Referrals UGI numbers 2013-17 USC numbers treated UGI within time per quarter Sept Dec 17 12000 Run Chart: Number of USC Referrals in Wales by year between Jan 2013 - Dec 2017 Upper Gastronintestinal 100% Percentage of people starting treatment within 62 days of USC referral for Sept - Dec 2017 Upper Gastrointestinal 100% 10000 8000 Median 8144 90% 80% 70% 88% 86% 72% 67% 69% 79% 6000 60% 50% 4000 40% 2000 30% 20% 0 10% Year 0% Betsi Cadwaladr University Health Board Hywel Dda University Health Board Abertawe Bro Morgannwg University Health Board Cwm Taf University Health Board Aneurin Bevan University Health Board Cardiff and Vale University Health Board Wales

2013 2014 2015 2016 2017 2013 2014 2015 2016 2017 USC Referrals USC Referrals USC Referrals numbers 2013-17 UGI & LGI Run Chart: Number of USC Referrals in Wales by year between Jan 2013 - Dec 2017 Upper Gastronintestinal Run Chart: Number of USC Referrals in Wales by year between Jan 2013 - Dec 2017 Lower Gastronintestinal 12000 18000 10000 Median 16000 14000 Median 8000 8144 12000 12363 6000 10000 8000 4000 6000 2000 4000 2000 0 0 Year Year

Ministerial and CIG response Pressure on system to comply with current CWT targets 2015 asked for clinical review of CWT targets Clinical view Waiting times important for patients and clinicians System should work better and 62 days max time Not in favour of exclusions 2016/17 WG/Network response Pilot new suspected cancer (SC) pathway starting at PoS (where nec as defined by NG12) Pilot suggested 20% increased demand in diagnostics but requirement for improved pathways and not including required increase for NG12 Autumn 2017 Cabinet secretary indicated support for move to SCP Urged NHS Wales to prepare to be compliant with a 62 day SCP target

Summary Patients have relatively poor survival in Wales with stage at diagnosis a key factor in this Patients are waiting too long in the healthcare system before receiving treatment The current system of CWT reports contains hidden waits, does not reflect patient experience, does not report inadequate diagnostic and treatment capacity and does not drive improvement CEOs, Chairs, CIG, CSG, WCN, HB/Trusts agree: A single suspected cancer pathway that reports waiting times for all patients from the point of suspicion is.. THE RIGHT THING TO DO The benefits should lead to better patient outcomes (survival, experience), better patient support and less costly treatment No one underestimates the challenge but we must work together, share best practice and be open to change

Achievements to Date Briefing document for Cab Sec and CEOs Suite of best practice Peer review of HB SCP Plans 8 site specific optimum pathways Received and reviewed HB Implementation Plans Worked with NWIS to define PoS, impact assessment for DSCN Worked with DU to determine capacity and demand model Worked with 1000 lines re improvement approach and 5 workshops Meetings with Cab Sec and WG

Plans Meeting with CEOs, Chairs and Cab Sec Oct 22 nd Submit advice re requirement for increased funding for diagnostics and national SCP Programme HB to use C&D to inform IMTPs (meet current gap and forecast demand) Q4 2018 Implement new Tracker 7 and embed in HB PAS systems by May 2019 Likely to publish SCP performance from April/May 2019 Continuous improvement work in 2019? 95% compliance by April 2020

SCP Performance

SCP Upper GI overall monthly average Apr 17-Dec 17 by HB 70%

SCP Lower GI overall monthly average Apr 17-Dec 17 by HB 58% 65% 55% 59% 54% 69%

SCP Urology overall monthly average Apr 17-Dec 17 - by HB

SCP Lung overall monthly average Apr 17-Dec 17 by HB 70% 75% 74% 71% 71% 59%

SCP Gynaecology overall monthly average Apr 17- Dec 17 by HB 70% 54% 50% 50% 57% 24%

SCP Head & Neck overall monthly average Apr 17-Dec 17 by HB 80% 76% 70% 60% 54% 57% 63% 57% 50% 45% 40% 30% 20% 10% 0% AB ABMU BCU CT C&V HD

SCP Breast overall monthly average Apr 17-Dec 17 100% 90% 87% 94% 96% 86% 96% 80% 70% 72% 60% 50% 40% 30% 20% 10% 0% AB ABMU BCU CT C&V HD

New rules.. Single Suspected Cancer Pathway Definitions pathway start date Date: March 2018 Version: 1.2.1 Wales Cancer Owner: Network and Welsh Government Status Published

How do we do this? Best Practice Principles Implementing enabling systems and infrastructure Standardising and improving the whole patient pathway Point of suspicion Tracking Information and Intelligence Capacity and Demand Pathway Improvement Referral/Primary Care PoS to Last Diagnostic <28days DDT to Treatment < 21 days Clinical Engagement Patient Centred Care

Work streams Information and Intelligence Capacity & Demand Communication Primary Care Diagnostic Pathway Treatment Pathway CSG s and Clinical Engagement Patient Centred Care Improvement

Priorities To understand the additional capacity required for the NHS to be able to treat all patients from the PoS within 62 days or 95% of patients to be diagnosed and staged < 28 days and treated < 21 days from decision to treat To understand where capacity required eg OPA, imaging, endoscopy, treatment Understand whether increased capacity due to rising referrals, improved USC performance or accelerated nusc pathway To standardise pathways across Wales consistently using best practice principles such as use of NG12 and entry points into system eg straight to test

Priorities To establish informatics systems to link with HB PAS systems that can receive e-referrals, can be easily started on clinical suspicion of cancer, can make system aware patient on accelerated pathway, track patient and record component and total waiting times To understand better where support systems should be introduced eg patient information, prehabilitation, holistic needs support and research To undertake a set of improvement workshops within HBs and across boundaries in Cancer Site Groups to reduce delays due to decision making in MDTs or weekly clinics or introduce accelerated steps such as same day/next day to CT from endoscopy or CXR

Priorities To establish a set of local and National reports that highlight variation between HBs and Cancer Sites and specific pathway steps, to understand the causes of this variation and share best practice across Wales To compare and contrast HB SCP Delivery Plans to help a local and National understanding of what required to achieve compliance with an SCP (assuming 95% compliance with 62 day target)

Summary Patients have relatively poor survival in Wales with stage at diagnosis a key factor in this Patients are waiting too long in the healthcare system before receiving treatment The current system of CWT reports contains hidden waits, does not reflect patient experience, does not report inadequate diagnostic and treatment capacity and does not drive improvement CEOs, Chairs, CIG, CSG, WCN, HB/Trusts agree: A single suspected cancer pathway that reports waiting times for all patients from the point of suspicion is.. THE RIGHT THING TO DO!

Summary The benefits should lead to better patient outcomes (survival, experience), better patient support and less costly treatment Benefits beyond accelerated pathway, more structured and standardised pathways allow for better information and holistic support, access to research and capacity/demand modelling No one underestimates the challenge but NHS Wales, WG, 3 rd sector and cancer services stakeholders are working together, sharing best practice and are open to change