TOGETHER FOR HEALTH CANCER DELIVERY PLAN VERSION 2.0

TOGETHER FOR HEALTH CANCER DELIVERY PLAN 2016-2017 VERSION 2.0 6 th April 2016

1. BACKGROUND AND CONTEXT Together for Health a Cancer Delivery Plan was published in 2012 and provides a framework for action by health boards and NHS trusts working together with their partners to improve cancer services. It sets out the Welsh Government s expectations of the NHS in Wales to tackle cancer in people of all ages, wherever they live in Wales and whatever their circumstances. The Plan is designed to enable the NHS to deliver on their responsibility to meet the needs of people at risk of cancer or affected by cancer. It sets out: The population outcomes we expect. The outcomes from NHS treatment we expect. How success will be measured and the level of performance we expect. Themes for action by the NHS, together with its partners. 1.1 What do we want to achieve? The Cancer Delivery Plan sets out action to improve outcomes in the following key areas between during 2016/17: Preventing cancer Detecting cancer quickly Delivering fast, effective treatment and care Meeting people s needs Caring at the end of life Improving Information Targeting research Cwm Taf UHB produced its first delivery plan in September 2012 and has subsequently refreshed its plan on annual basis to reflect progress made in implementing the plan and additional or new local priorities. 1.2 The drivers: (SARA) There are clear reasons why cancer remains a top priority for Cwm Taf University Health Board: Cancer Incidence It is estimated around 1 in 3 people in Wales will be diagnosed with cancer before age 75. Around 4 in 10 will be diagnosed with cancer during their lifetime. The incidence rate is increasing. For the period 1995-2009, there was an average of around 16,100 new cases of cancer per year (cancer incidence increased by around 0.6% per year). Over 19,000 2

people were diagnosed with cancer in 2013; 11.5% more than 10 years ago. More people are surviving cancer Cancer survival is improving in Wales. Over 70% of people diagnosed with cancer survive for at least one year and over 50% survive for at least 5 years. Less people are dying from cancer The mortality rate for those aged under 75 has reduced by 14% over the last 10 years. We know there is much more to do to maximise the scope to improve cancer care in Wales, including improving patient outcomes for rarer cancers, preventing cancers developing in the first place, early diagnosis of symptomatic cancers, improved access to treatment and better care for cancer patients and survivors. Late diagnosis We will continue to tackle late diagnoses. Too many people are diagnosed through emergency routes. This will require us to focus upon the hard to diagnose cancers, in particular lung cancer, where survival rates remain lower than other parts of Europe. Improving treatment times Performance against waiting times has been challenging. We have seen a huge increase in referrals, including 56% more urgent GP referrals for suspected cancer than five years ago. However although the targets have not been consistently achieved this year more patients are actually being treated within the target times. It is important to ensure that patients are treated in clinical priority in line within our standards, health boards have developed recovery plans to ensure that this happens. Tackling lifestyle risks There is still a lot to be done to ensure we address the wider lifestyle risks for cancer and there is a need to tackle inequalities in access to cancer services and outcomes for patients. 1.3 Progress during 2015/16 The UHB made significant progress against the plan across all areas of the pathway. Some examples are listed below and further detail can be found in our latest annual report. 3

Person Centre Care: Accredited Connected Advanced Communication Skills Training Course was held in February/March 2016, attendees included Specialist Cancer Nurses, a Consultant and the Macmillan Person Centred Care Project Manager. This course was funded by a Group Grant from Macmillan Cancer Support. A further course is being planned for July 2016 for staff within Cancer Services again being funded by a Group Grant from Macmillan Cancer Support. This course has help improve the confidence of staff when dealing with highly distressed/emotional/anxious or even angry patients who have received a diagnosis of cancer. It has enabled staff to improve on current skills ensuring that patients who have received a diagnosis of cancer feel supported and are given clear information in a relevant way which enables then to make informed decisions. A community based Cancer Services Health & Wellbeing Event was held on the 12 th February 2016 in Abercwmboi which was attended by over 120 people. Many Cwm Taf University Health Board Healthcare Professionals were in attendance including Specialist Cancer Nurses, Specialist Cancer Dieticians, Macmillan Psychologist, Macmillan Relate & Counselling Service, Macmillan Welfare Benefits Service, Macmillan Activity Programme. In addition there were approximately 25 information stands many from the Third Sector available to speak to patients who have received a diagnosis of cancer and their relatives/carers and provide relevant useful information. With the appointment of a Macmillan Person Centred Care Manager in April 2015 we now have the opportunity to improve how patient information is made available to our cancer patients from a range of perspectives. An Information Improvement Action Plan is in place that considers written, verbal, visual and audio information. Information is to continue to be provided to staff in a constructive, organised way via the Cancer Services Intranet Site. Since commencing in post the MPCCPM has worked closely with a number of teams to develop local tools to support them in undertaking Holistic Needs Assessment and Care Planning, relevant to their specific area. Good progress has been made with a number of teams and particularly in identifying how existing software used by the teams can be used to record this information. In order to support local teams the Health Board s intranet site is being used as a tool to support HNA and Care Planning. All HNA tools are uploaded to the site and a signposting section directs staff to appropriate information to support their discussions with patients when specific needs are identified. 4

End of Life Care: Advance Care Planning our main focus under the Caring at the end of Life theme has been to promote and embed the principles of Advance Care Planning into practice. With Macmillan funding we have benefited from two GP Facilitators, two ACP Clinical Nurse Specialists and an ACP Speech & Language Therapist who have been encouraging and supporting use of universal Advance Care Planning tools within nursing homes and primary care. Patients, carers and staff have reported relief and reassurance at being able to express and understand their preferences and wishes. The Speech & Language Therapist is supporting the ACP nurses in the development and delivery of holistic, safe and dysphagia appropriate care plans for people at the end of life. The S&LT is also providing training for care home staff to help them manage patients with dysphagia competently and safely and help avoid hospital admissions that arise as a result or relating to dysphagia issues. The ACP team link in with the RBID Nurse (Record of Best Interests Decisions) in implementing advance care planning for people without mental capacity, and with the Care Home Support Team established in 2014. Hospice at home One element of advance care planning is identifying the individual s preference for place of care at and around the time of death. Whilst some patients will chose to be cared for and to die in a hospital or hospice setting, others will choose to die at home, or in their care home. With the help of Welsh Government funding and in conjunction with Marie Curie, we have developed a Hospice @Home service which is helping ensure we can support people to be cared for at home where preferred thereby avoiding inappropriate, unplanned hospital admission, and provide a fast-track response to enable prompt hospital discharge. This service complements our existing community based @home and Continuing Health Care services. Care Decisions Tool for Last Days of Life a revised all Wales tool to replace the ICP for the Last Days of Life has been rolled out across Cwm Taf supported by awareness raising and targeted training. Compliance with the new tool will be audited in June 2016. Y Bwthyn Palliative Care Unit following an extensive period of engagement and a Feasibility study undertaken in 2015, proposals are progressing with Macmillan Cancer Support to develop in partnership a new build Palliative Care unit on the Royal Glamorgan Hospital site, to enable the relocation of services from Y Bwthyn. The final design development will commence in April 2016 with final agreement by November 2016 and completion and handover expected in autumn 2018. This will be a flagship unit for 5

both Macmillan and the health board, designed to provide the best possible environment for the provision of inpatient end of life care. Bereavement Survey an online bereavement survey has been piloted and will be rolled out during 2016. 2. DEVELOPMENT OF CWM TAF UNIVERSITY HEALTH BOARD S LOCAL DELIVERY PLAN 2.1 Our Vision: (BECKY) The University Health Board s vision is to: Care for our communities and patients by preventing ill-health, promoting better health, providing excellent services and reducing the need for inpatient care wherever possible through the provision of strengthened home, primary and community care. We will prevent ill health, protect good health and promote better health. We will provide care as locally as possible wherever it is safe and sustainable. Our services will be of the best quality and delivered within efficient, affordable and effective models of care. More care will be delivered in primary and community based settings, reducing the need for hospital inpatient care wherever possible. With a strong sense of corporate social responsibility, we will work with our staff, partners and communities themselves, building on strong local relationships and the solid foundations of the past. We will use our University Health Board status to ensure that working with our academic partners, we bring research, innovation and high quality teaching to support our staff and services. We will ensure a strongly governed system to pay due regard to equality which will underpin everything we do. In respect of cancer services we will work to ensure our population have a minimised risk of developing cancer and, where it does occur, an excellent chance of survival. 2.2 Strategic Objectives The University Health Board has the following five strategic objectives, 6

principally derived from the Institute for Healthcare Improvement (IHI) Triple Aim, which provides a clear framework for our Cancer Local Delivery Plan. These objectives are: To improve quality, safety and patient experience. To protect and improve population health. To ensure that the services provided are accessible and sustainable into the future. To provide strong governance and assurance. To ensure good value based care and treatment for our patients in line with the resources made available to the Health Board. These objectives will govern the planning and development of cancer services within the UHB. 2.3 Prudent Healthcare The University Health Board has been developing its approach to embedding prudent healthcare into, and across the organisation as part of a clinical, value based framework. With the priorities and service changes we have identified within this Local Delivery Plan we will be aiming to embed prudent health care into practice. For example our three year Macmillan funded Acute Oncology Service Project cuts across the 5 principles of prudent health care in the following ways: Ensuring avoidance of unnecessary investigations for cancer patients when admitted as emergencies. Fast tracking cancer patients back to their relevant Multi Disciplinary Teams following emergency admission. Reducing the average length of stay for cancer patients. Identifying patients quickly with symptoms of metastatic spinal cord compression and ensuring they progress on their pathway as a matter of urgency in a co-ordinated approach. Identifying and treating patients with neutropenic sepsis in line with new guidelines and protocols. Ensuring patients with Cancer of unknown primary are fast tracked onto their pathway, avoiding unnecessary investigation and delays. Our work undertaken with all stakeholders to develop and agree our priorities with our Local Delivery Plan since 2012 demonstrates the sense of shared and joint decision making as well as co-production around the implementation of the Welsh Governments Cancer Plan. 2.4 Development of the Plan 7

In response to the Together for Health A Cancer Delivery Plan (2012), health boards are required, together with their partners, to produce and publish a detailed local service delivery plan to identify, monitor and evaluate action needed within timescales. These plans need to be updated annually and the health board executive leads for cancer will need to report progress formally to their Boards against milestones in these delivery plans and publish these reports on their websites at least annually. The Delivery Plan was developed in line with the University Health Board s three main areas of focus in planning for and monitoring improvements over time: Developing clear long term strategic objectives, which will frame the development of short and medium term service improvement plans. A clear (and rolling) set of priorities for improvement over the next three years. A clear understanding of the steps which are required in the short to medium term (1-3 years) to underpin the successful delivery of the University Health Board s longer term objectives and priorities. 2.5 Monitoring delivery The Cancer Implementation Group is responsible for driving through the change required to deliver our priorities, addressing issues preventing progress and escalating those issues that can t be resolved within that forum. The University Health Board will seek assurance that the Cancer Delivery Plan is being delivered in line with its three year plan, requiring progress reports to be presented to the Executive Board and Board on an annual basis. 3. ORGANISATIONAL PROFILE 3.1 Organisational Overview Cwm Taf University Health Board was established on 1 st October 2009 and provides a full range of hospital and community based services to the resident population of the University Health Board area, estimated to be 295,953 in 2014 1 accounting for 10 per cent of the Welsh population. Cwm Taf is geographically the second smallest Health Board area in Wales, but also the second most densely populated area. 8

Compared to the Wales average there are over three times as many people per square km living in the Health Board area. Within Cwm Taf, 20 per cent of the population lives within the County Borough of Merthyr Tydfil with the remaining population living within Rhondda Cynon Taf. The University Health Board s catchment population increases to over 330,000 when including patient flow from the Upper Rhymney Valley, South Powys, North Cardiff and the Western Vale. In July 2013 Cwm Taf Health Board was awarded University Health Board status by the Health Minister Mark Drakeford. This acknowledges Cwm Taf s commitment to investing in staff, ongoing learning, research and development and our strong links with the communities we work in and serve. It recognises our commitment to excellence in the quality of services we provide and overall performance across the UHB. It is the our belief that University Health Board status will help us in our ongoing drive to reverse the inverse care law and provide high quality responsive care and services for the communities with the greatest need. Cancer services are currently delivered across the whole University Health Board including health promotion, primary care, secondary care, diagnostic and community services, with established links to specialist tertiary care providers. Health Promotion / Prevention Cwm Taf Health Promotion Team supports the University Health Board and its partners in delivering its health promotion and ill-health prevention services. Health promotion messages are reinforced across the whole pathway from primary care, secondary care and tertiary care. Specific services include: Smoking cessation. Community weight management. Flu and Pneumococcal vaccination programmes. Primary Care Primary care provides a wide range of cardiovascular services including risk factor management. Services include: The UHB s Primary Care Delivery Plan sets outs our vision for primary care in the future and details how we intend to strengthen our primary care infrastructure over the next three years. The diagram below sets out the future model for primary and community services in Cwm Taf; the continued implementation of the Cancer delivery plan will be taken forward in the context of this model. 9

17 Secondary Care Tertiary Services 3.2 Performance Profile 3.3 Overview of Local Health Need and Challenges for Cancer Services The Health Board serves the most deprived population in Wales, which is reflected in the lower life expectancy of residents and a consequent greater need for health care. Life expectancy is the lowest of all Health Boards in Wales and our population can expect to have up to six more years of disability than the Welsh average. This poor health means that the Health Board and its partners provide care for a greater proportion of people s lives, that there is a higher incidence of disease and that the prevalence of chronic conditions is higher than in all other Health Boards. At least one-third of all cancer cases are preventable. Prevention offers the most cost-effective long-term strategy for the control of cancer 10

(WHO). Tobacco, obesity and alcohol are all modifiable cancer risk factors. The Welsh Health Survey provides information about the health of people living in Wales, the way they use health services and their health related lifestyle. It is based on a randomly selected sample of people living in private households in Wales and is designed to be representative of the general adult population in Wales. The survey runs all year round and is reported annually in October. The most recent data available (2012/13) is discussed below. Welsh Health Survey 2012/13 Tobacco Tobacco use is the single greatest avoidable risk factor for cancer mortality. The downward trend in smoking prevalence continued in 2012/13, but levels of smoking in Cwm Taf in 2012/13 (24%) and its constituent local authority areas remains higher than the Wales average (22%). The proportion of adults smoking in Merthyr Tydfil dropped by 2% from the previous 2011/12 Welsh Health Survey, and Rhondda Cynon Taf (RCT) by 1% over the same period. Figure 1: Trend in adults reporting smoking (2003-05 to 2011-12) Adults who reported smoking daily or occasionally (%, age-standardised) 2003/05-2012/13 35 30 25 20 15 10 5 Produced by Cwm Taf Public Health Team, using WHS (WG) data 0 2003/5 2004/6 2005/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 Rhondda Cynon Taf Merthyr Tydfil Cwm Taf UHB Wales 11

Obesity There is a link between overweight and obesity to many types of cancer such as oesophagus, colorectum, breast, endometrium and kidney. Obesity in Cwm Taf has remained at 26% for the last three years. This is, however, the highest in Wales. The proportion of the adult population classified as obese (BMI 30+) has risen consistently since 2005/7 and, at 26%, Cwm Taf is statistically significantly higher than the Wales average (23%) and is the highest among health boards in Wales. However, the latest WHS shows a 1% improvement in the obesity figure for Merthyr Tydfil. The figure for RCT has remained static at 25% since 2009/10. Cwm Taf Health Board has the highest proportion of 4/5 year olds who are obese in Wales. However, these figures should be treated with caution until more information for future years becomes available. Figure 2: Trend in reported obesity 12

Physical Activity Current guidelines, introduced in 2011, recommend that an adult undertakes at least 30 minutes of physical activity, of moderate intensity, on five or more days each week. Previous guidelines were slightly less flexible and as such slightly harder to meet. In the most recent survey (2011/12), a smaller percentage of Cwm Taf population reported meeting current physical activity guidelines (27%) than the Wales average (29%). This was higher in Merthyr Tydfil (32%) but significantly lower than the Wales average in Rhondda Cynon Taf (26%). There has been little change in the level of physical activity reported since 2003/5. Figure 3: Trend in Physical Activity 13

35 30 25 20 15 10 Adults who reported being physically active on 5 or more days pre week (%, age-standardised 2003/05-2012/13) 5 Produced by Cwm Taf Public Health Team, using WHS (WG) data 0 2003/5 2004/6 2005/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 Rhondda Cynon Taf Merthyr Tydfil Cwm Taf UHB Wales Alcohol Alcohol use is a risk factor for many cancer types including cancer of the oral cavity, pharynx, larynx, oesophagus, liver, colorectum and breast. Risk of cancer increases with the amount of alcohol consumed. The Welsh Health Survey questions on alcohol consumption changed in 2008. The current question asks all adults (drinkers and non-drinkers) about the most units drunk on any one day in the last seven days. Above guidelines means men drinking more than 4 units a day and women drinking more than 3 units. Binge means men drinking more than 8 units a day and women drinking more than 6 units. In the most recent WHS (2012/13), 43% Cwm Taf population reported a consumption of alcohol above guidelines; Merthyr Tydfil (39%) and Rhondda Cynon Taf (44%). The trend across Wales is flat. There has been a downward trend in Merthyr Tydfil since 2008-09 and this is now below the Wales average. RCT showed a 2% fall in 2012/13 compared with the previous 2011/12 report. Figure 4: Trend in Alcohol consumption 14

In 2012/13, binge drinking in RCT (29%) had fallen by 2% from the previous 2011/12 survey, but was statistically significantly higher than the Wales average (26%). The figure for Merthyr Tydfil (27%) remained the same as the previous year. 3.4 Overview of Cancer Incidence, Mortality and Survival in Cwm Taf UHB 15

Cancer incidence rate This measures how many new cases of cancer are found each year and tells us how well we are doing at preventing cancer in Wales. If we are achieving our objectives, we would expect to see over time: A slower rise in the rate of increase compared with what might be expected to happen in line with past experience. A reduced gap between the most and least deprived areas of our region. Incidence rates comparable with the best in Europe 1. Cancer incidence (excluding non melanoma skin cancer) in Cwm Taf UHB has been higher than the all Wales average in 12 out of the last 18 years. In 2011 (Figure A), cancer incidence in Cwm Taf was equal to the Wales average. It has increased in 2012, whilst the Wales rate has gone down. Figure A Cwm Taf All Wales 1995 374 394 1996 446 391 1997 425 396 1998 391 389 1999 410 405 2000 403 405 2001 406 407 2002 432 407 2003 453 414 2004 413 422 2005 422 414 2006 439 426 2007 421 424 2008 431 427 2009 446 416 2010 433 422 2011 418 418 2012 432 409 Source: Welsh Cancer Intelligence & Surveillance Unit June 2014 In 2012, Cwm Taf had the highest European age standardised cancer incidence rate (excluding non melanoma skin cancer) in Wales at 431.9 per 100,000 population (Figure B). The rate was particularly high in men (475.3 per 100,000). 16

Figure B showing age-standardised cancer incidence rate per 100,000 population 2012 in Wales (excluding non melanoma skin cancer) Source: Welsh Cancer Intelligence & Surveillance Unit September 2014 Site-specific cancer incidence Compared to the Wales average, figures for 2010-12 show that Cwm Taf has statistically higher incidence rates of lung and cervical cancer in women. There is a statistically lower incidence of melanoma cancer in men and women combined. The rates for men and women combined can be seen in Figure C. Figure C showing European Age-standardised cancer incidence rate per 100,000 population 2010-12 for Cwm Taf Source: Welsh Cancer Intelligence & Surveillance Unit September 2014 Cancer mortality rate 17

Although higher than the Wales average, deaths from cancer in Cwm Taf are falling. It appears that, in the last three years the Wales average rate has reached a plateau at 111 deaths per 100,000 population under 75 (excluding non melanoma skin cancer). It is too early to assess, as shown in Figure D, whether this is also the case for the Cwm Taf population rate. Figure D Cwm Taf All Wales 1995 168 149 1996 169 144 1997 161 141 1998 151 142 1999 156 138 2000 134 132 2001 135 133 2002 138 132 2003 136 126 2004 133 126 2005 132 124 2006 141 125 2007 147 125 2008 127 120 2009 130 116 2010 124 112 2011 121 111 2012 117 111 Source: Welsh Cancer Intelligence & Surveillance Unit June 2014 Figure E shows the age-standardised cancer mortality rate for Cwm Taf compared to other health board areas. Cwm Taf has the highest rate at 184.8 per 100,000 population in 2012 (excluding non melanoma skin cancer). The difference is particularly pronounced in males. Figure E showing European Age Standardised Mortality Rates from all malignancies (excluding non-melanoma skin cancer) per 100,000 for Cwm Taf 2012 compared to Welsh Health Boards. 18

Source: Welsh Cancer Intelligence & Surveillance Unit September 2014 Site-specific cancer mortality For women the mortality rate was statistically higher for cancer of the cervix and for men and women combined, it was significantly higher for lung and stomach cancer in 2010-12. These differences are shown in Figure F. Figure F showing European Age Standardised Mortality Rates per 100,000 for Cwm Taf 2010-12, by site. Source: Welsh Cancer Intelligence & Surveillance Unit September 2014 One and five year survival rate The percentage of adults surviving one year is 67.6% in Cwm Taf compared to 69.9% across Wales as measured in the period 2007-11 (excluding non melanoma skin cancer). This is shown in Figure G. The difference between one year survival in Cwm Taf and the Wales average is decreasing. In 1991-1995 it was 5.8% and in 2007-11 it has reduced to 2.3%. Figure G 19

Cwm Taf All Wales 91-95 50.9 56.7 92-96 51.8 57.2 93-97 52.4 57.5 94-98 53.7 58.3 95-99 54.9 59.5 96-00 56.9 60.5 97-01 58.3 61.5 98-02 60.1 62.6 99-03 62.2 63.9 00-04 63.0 64.8 01-05 63.5 65.7 02-06 63.8 66.4 03-07 63.8 67.2 04-08 64.4 67.9 05-09 65.4 68.6 06-10 66.6 69.2 07-11 67.6 69.9 Source: Welsh Cancer Intelligence & Surveillance Unit June 2014 The percentage surviving at one year is improving, in line with the Wales trend. The one year rate increased from 50.9% during 1991-95 to 67.6% in 2007-11. The relative difference between the one and five year survival rates of health boards is illustrated in Figures H and J. Both Cwm Taf s 1 and 5 year rates are the lowest in Wales (excluding non melanoma skin cancer). The one year survival rate is statistically significantly lower than the Wales average, along with Powys Teaching and Betsi Cadwaladr Health Boards. Figure H One year Survival rates for cancer, by Health Board, 2007-2011, (excluding non melanoma skin cancer). Source: Welsh Cancer Intelligence & Surveillance Unit September 2014 A breakdown of the one year survival rate by cancer site is shown in Figure I. Women have a particularly low survival rate at one year in Cwm Taf, at 68.5%. Figure I showing 1 year cancer survival rate Cwm Taf 2007-11 by site, men and women combined. 20

Source: Welsh Cancer Intelligence & Surveillance Unit September 2014 1 (excluding non melanoma skin cancer) The five year survival rate is statistically significantly lower than the Wales average, along with Cardiff and Vale University and Powys Teaching Health Boards. Figure J Five year survival rates for cancer, by Health Board, 2003-07 (excluding non-melanoma skin cancer) Source: Welsh Cancer Intelligence & Surveillance Unit September 2014 The gap between the Wales and Cwm Taf percentages are narrowing in this 5 year survival measure. In the period 1991-95 it was 6.2% and in 2003-07 it was 4.2%, as illustrated in Figure K. Figure K 21 Cwm Taf All Wales 91-95 34.2 40.4

92-96 34.7 41.1 93-97 35.5 41.5 94-98 37.3 42.4 95-99 38.7 43.7 96-00 41.1 44.8 97-01 42.5 45.9 98-02 44.1 47.3 99-03 46.1 48.7 00-04 46.7 49.6 01-05 46.8 50.5 02-06 47.8 51.5 03-07 48.3 52.5 Source: Welsh Cancer Intelligence & Surveillance Unit June 2014 Site-specific cancer survival The 5 year survival rate is statistically lower in both men and women for all malignancies in 2003-07 (excluding non-melanoma skin cancer). In particular, Cwm Taf is statistically lower than the Wales average for leukaemia and head and neck cancer. This is shown in Figure L. Figure L showing 5 year survival by site of cancer in Cwm Taf 2003-07 Source: Welsh Cancer Intelligence & Surveillance Unit September 2014 1 (excluding non melanoma skin cancer) 22

4. PRIORITIES FOR 2016/17 (SANDEEP/WAYNE/BECKY/MICHELLE/SARA/KURT) The Together for Health Cancer Delivery Plan sets out action to improve outcomes in key areas between now and 2016. For 2016/17 the following national priorities have been agreed: Organisation of cancer support services to ensure improved services, delivery, planning and performance. Primary care oncology. Develop and pilot a single urgent cancer pathway. Patient experience. A National focus on lung cancer. The above priorities will ensure there is a national focus and a clear sense of direction for the next 12 months. Health Boards, Trusts, Welsh Government, Cancer Networks and advisory structures are expected to work together to ensure these priorities are delivered. Cwm Taf UHB will support the implementation of the national priorities by actively participating on national and local networks/forums, project groups, learning events focused on these priorities and ensuring local implementation of actions are achieved. We have identified seven key priority areas which align with the national priorities listed above and the key themes within the national delivery plan. Priority One Preventing Cancer Our priorities for 2016/17 are: Cancer Services and health service use teachable moments to signpost to lifestyle support services. Include as a priority in all strategic action plans affecting the CTUHB population (LSB SIP, IMTP, CF Cluster plans and Primary Care Cluster plans). Extend lifestyle interventions through Make Every Contact Count initiative. Develop services and interventions to identify individuals at risk of cancer due to their lifestyles and signpost to services e.g. Inverse care law programme, Community initiatives. Priority Two - Detecting Cancer Quickly Our priorities for 2016/17 are: 23

GP Cluster Networks to analyse their cancer presentations 2016-2016 QOF year and disseminate lessons learnt and educational needs identified. (Cynon, Taff Ely and Rhondda Cluster Plans). Education on signs and symptoms of Cancers and appropriate use of requesting Tumour Markers (Cynon Cluster Network Plan). Merthyr Tydfil Cluster to engage with the screening services (Merthyr Tydfil Cluster Network Plan). Early detection of Pancreatic Cancer. Raise the awareness of how to diagnosis pancreatic cancer by GP s. (Merthyr Tydfil Cluster Network Plan). Merthyr Tydfil Cluster to raise awareness / create portfolio of all available Rapid Access services (Merthyr Tydfil Cluster Network Plan). Continue to ensure that the uptake across Cwm Taf for National Screening Programmes for bowel, cervical and breast are within national targets. Analyse and address inequalities in cancer screening uptake in particular in relation to areas of deprivation. Establish specific projects that specifically focus on update related to deprivation such as the Tenovus Rapid Access Bowel Clinic, which is a pilot project exploring the feasibility and acceptability of developing a rapid access bowel cancer diagnostic service from a mobile unit where there is poor uptake. This service will run from Merthyr Tydfil Town Centre and Tylorstown. Continue to raise awareness of the early signs and symptoms of cancer. Plans to evaluate the adapted health check during Year 2 of the ABACus project (funded by the CRUK National Awareness and Early Diagnosis Initiative) will involve a before and after, nonrandomised evaluation of the intervention in a range of community and healthcare settings identified during Phase 1. The target population will be adults aged 40+ years and resident in Communities First areas of Wales. The study will enable us to test the feasibility of recruitment in various settings, and to pilot the measurement of outcomes including symptom knowledge, beliefs about cancer, and help-seeking intentions/behaviours in 95 participants assessed at baseline and 1 month follow-up. We will also carry out a process evaluation involving 20 observations of health check usage and qualitative interviews with 30 health check users to understand how the intervention works and whether it is being used in the way that it is designed to be used. Raise GP awareness of symptoms to promote prompt referrals in line with national guidance, local pathways and waiting times standards. Macmillan GP Facilitators to promote the use of and populate the GP portal for all GPs to access. Macmillan GPs work plan includes continuation of work to ensure that GPs are aware of direct access to prompt diagnostics to diagnose cancer. A radiology page to be developed and included 24

on the GP portal, to include information on referral pathways, the means to obtain advice from radiologist and specialist nurses etc. Priority Three - Delivering fast, effective treatment and care Our priorities for 2016/17 are: Further implementation of the Acute Oncology Service to support the needs of people admitted as emergencies. Participate in the Macmillan funded Metastatic Spinal Cord Compression Project and to implement the required service improvements Continue to participate in national and local clinical audits and other quality improvement activities. Continue to participate in peer review and continue to implement and monitor the implementation of peer review action plans. Continue to act on the findings within the National Cancer Patient Experience Survey. Continue to develop the intranet page for Cancer Services. Continue to strive to be 100% compliant against National Cancer Standards. Provide definitive treatment consistently in line with national waiting times targets across all cancer sites. Implement the Single Urgent Cancer Pathway in line with national developments. Priority Four - Meeting people s needs Our priorities for 2016:17 include: Review and improve patient information - clinical and non clinical needs such as accessing financial, emotional support. Continue to provide relevant, accurate and useful information to patients and their relatives/carers who have received a diagnosis of cancer, this will enable patients to make informed choices about their care and wellbeing. Ensure a key worker is associated to each person diagnosed with cancer to coordinate their ongoing care. To implement the new Key Worker Guidance across all specialities. Continue to ensure all cancer sites have a Clinical Nurse Specialist. Support patient participation in cancer patient experience surveys and implement the findings of the National Patient Survey. Implement and role out of the use of holistic needs assessments across specialties. Introduce End of Treatment Summary tools across specialities. Continue to implement the Macmillan Recovery Package within Cwm Taf UHB. 25

26 Ensure care plans are in place based on an Holistic Needs Assessment and to role out offering written care plans to all patients. Improve the uptake in clinical trials - currently improving across South East Wales. All MDTs to ensure they are aware of suitable trials. Continue to provide relevant training to staff within Cancer Services, this will enable staff to effectively meet the needs of patients, training includes, Connected Accredited Advanced Communication Skills Training; Spiritual Needs of the Cancer Patient Training; Motiviational Interviewing Training and signposting to relevant services training with Public Health Wales. Continue to maintain the Cancer Services Intranet Page so that it is the infra-structure for signposting and a source of quick easy access information for staff in order to provide information or to refer to other healthcare professionals or Third Sector organisations. Priority Five Caring at the end of life Our priorities for 2016/17 are: Raising public awareness of the need for open conversations about end of life preferences, through social media and other communication channels and public engagement opportunities. Advance Care Planning - we will continue to promote and develop advance care planning in care homes and community hospital settings, and to engage more GPs in undertaking and recording advance care planning. The Macmillan posts were funded on a fixed term basis in order to establish the ACP process in primary, community and care home settings, supported by staff education and training. In 2016/17 we will therefore consider whether and how to resource these posts when the Macmillan funding ceases in 2017. Care Decisions Document we will continue to provide awareness and training time to facilitate the implementation of the new Care Decisions document across all care settings. To ensure the multiprofessional team understand the changes and their responsibilities to complete the documentation with full engagement of the patient and those important to them. Compliance will be audited in June 2016. GP Palliative Care Registers we will continue to focus on increasing the number of patients with palliative care needs who are included on GP Palliative Care Registers, to ensure that their needs are recognised and are being met, Prognostic Indicator Guidelines - we will continue to promote use of the Prognostic Indicator Guidelines. The potential for developing a computer based version is also being explored.

Hospice at home implementation and evaluation of the new Hospice @Home service.. Children & Young People. We will explore options for developing a Hospice @Home service for children and young people, such as training a bank of existing children s nurses to undertake the role as and when required; Y Bwthyn we will continue to progress plans for this development with Macmillan. Staff Awareness and Education we will further develop and roll out an education programme to promote awareness and competencies in end of life care provision in all care settings. Bereavement Survey we will implement the online survey of people who have been recently bereaved to obtain their views on how services could be improved for people being cared for at the end of life and their families; Public/patient info we will further develop the webpage on the Cwm Taf UHB website and other sources of information regarding end of life care; Performance info we will arrange quarterly reporting of key data to the End of Life Care Delivery Group and consider how to build into Executive Board / Board performance dashboard reports. Priority Six Targeting Research Our priorities for 2016/17 include: Develop the Cwm Taf UHB R&D infra-structure in support of Cancer and Palliative care related research across Primary and Secondary care. Develop the partnership with the National Institute of Social Care and Health Research (NISCHR) workforce and cancer specialists and increase support for cancer related studies. Optimise the existing and developing resources (eg. Macmillan unit) for Cwm Taf patients to be given the opportunity to partake in Cancer research studies. Increase the number of Cancer related studies adopted at Cwm Taf UHB by 5% per year. Increase the number of participants recruited onto Cancer research studies by 10% per year. Continue to provide all necessary support for Cancer related research undertaken by specialist centres such as Velindre NHS Trust (eg. laboratory support). Priority Seven - Improving Information Our priorities for 2016/17 are: 27

In order to improve cancer survivorship the Cancer Delivery Plans seeks to monitor the percentage of patients who are diagnosed at each stage. The national target is 90% by 2016. The stage not recorded within Cwm Taf increased from 18.33% in 2012 to 26.35% in 2013. We were disappointed with this results as in previous years our staging data had been well above the Welsh average. We are planning to improve on this position over the coming year. Information to continue to be made available to patients at Cancer Services Health & Wellbeing Events and via Cancer Services staff who have quick easy access to a range of information on the Cancer Services Intranet Site. 5. PERFORMANCE MEASURES/MANAGEMENT (BECKY) Together for Health a Cancer Delivery Plan (2012) contained an outline description of the national metrics that LHBs and other organisations will publish: Outcome indicators which will demonstrate success in delivering positive changes in outcome for the population of Wales. National performance measures which will quantify an organisation s progress with implementing key areas of the delivery plan. Progress with these outcome indicators form the basis of the University Health Board s annual report on cancer. Our next annual report will be published in October 2016. 28

6. ACTION PLAN 2016 2017 (ALL) Sections in yellow to be updated Priority Encourage lifestyles (SARA) healthy Preventing cancer & Detecting Cancer Quickly Actions Required Lead Due Date Expected 2016-17 Outcomes Public On-going Increase referral to Health programmes tackling obesity, smoking, alcohol and substance misuse. Ensure that the uptake across Cwm Taf for National Screening Programmes bowel, cervical and breast are within national targets (SARA) Local Public Health Team & Screening Engagement Team (Public Health Wales) On-going Reduced prevalence of smoking, obesity, excess alcohol and substance misuse Increased uptake of screening particularly in deprived communities. 29

To analyse and address inequalities in cancer incidence, mortality and screening uptake in particular in relation to areas of deprivation (SARA) As 2015/16 Cancer inequalities Group Raise GP awareness of symptoms to promote prompt referrals in line with national guidance, local pathways and waiting times standards. As 2015/16 Macmillan GP Facilitators Work all ready commenced ongoing. (KURT) Macmillan GPs work plan includes continuation of work to ensure that GPs are aware of direct access to prompt diagnostics to diagnose cancer. (KURT) To be completed 2015/16. Macmillan GP Facilitators. Work already commenced: Macmillan GPs liaising with Consultant Radiologists and a plan is in place to develop the GP port radiology page. 30

Completion 2015/16. Priority Continue to develop an Acute Oncology Service to support the needs of people admitted as an emergency. (MARIE) Delivering fast, effective treatment and care Actions Required Lead Due Date Expected 2016-17 Outcomes Ongoing Lead All posts The management of monitoring and Cancer recruited to by unscheduled evaluation of the Clinician May 2015. presentation of cancer service in line outpatients is with agreed Service launch fundamental in avoiding outcome July 2015. hospital admission and measures. reducing lengths of stay where admissions are necessary. To facilitate the rapid identification and appropriate prompt management of patients that present acutely with complications following their cancer treatment, complications and a consequence of their cancer or who present 31

acutely with previously undiagnosed cancer. To participate in the Macmillan funded Metastatic Spinal Cord compression Project and to implement the required service improvements. Ongoing audit, monitoring, evaluation and education in relation of MSCC patients. Lead Cancer Clinician. Macmillan funded project for a 3 year period. To accelerate coordinate and signpost patients onto the correct pathway and ensure consistent access to oncology expertise, wherever that patient presents. To develop and implement pathways, in line with national guidance and the Macmillan funded Cancer Network project, for patients presenting with spinal cord compression. (MARIE) Ensuring there is education in relation to MSCC for a range of professionals within Cwm Taf. Ensuring easy access to pathways to guide health professionals in 32

To provide definitive treatment consistently in line with national waiting times targets across all cancer sites. As 2015/2016. Cancer Manager/ Lead Cancer Clinician Ongoing. delivering a prompt and timely intervention. Patients referral to first treatment is prompt and is in line with national targets. (WAYNE/DEB) Continue to participate in national and local clinical audits and other quality improvement activities. (SANDEEP) Continue to participate in the National Peer Review Programme. As 2015/2016. As per 2015/2016 Site specific Cancer Leads/ Cancer Lead Clinician Executive Lead for Cancer Ongoing Ensuring service provision. outcomes are monitored. Ongoing. (WAYNE) Continue to act on the findings within the National Patient Experience Survey. Participate in future National Patient Survey for Cancer. Lead Nurse Cancer for Commenced April 2015. A range of service improvements required based on the findings of the survey. 33

(SANDEEP) Continue to develop the intranet page for Cancer Services. Continue to strive to be 100% complaint against National Cancer Standards. To continue to maintain the Cancer Services Intranet Page on an ongoing basis, ensuring that information is up to date and accurate and well organised, giving staff easy access to required information for a range of perspectives and also when undertaking Holistic Needs Assessments/Car Plans or referring on to other professionals or Third Sector organisation. As per 2015/16. Lead Cancer Clinician. Lead Cancer Clinician/ Site Commenced April 2015. To have a source of easy accessible information that is useful to staff within Cancer Services. It also contains significant information for patients who have received a diagnosis of cancer which staff can pass on when relevant. This information includes; relevant Third Sector Organisations, documentation and referral methods to other health care professions, access to useful links, and produced literature, signposting information, training. The Cancer Services Intranet Page will act as the infrastructure of information for undertaking Holistic Needs Assessment & Care Plans. Ongoing Ensuring national standards are met across all cancer specialities. 34

(WAYNE/SANDEEP) Specific Cancer Leads Priority Review and improve patient information - clinical and non clinical needs such as accessing financial, emotional support. (MICHELLE) Actions Required 2016-17 Person Centred Care Manager to take forward this priority through the Information Improvement Action Plan. A full audit of all information provided to patients via Specialist Cancer Nurses was carried out in 2015. As above the Cancer Services Intranet page is a robust source of information for staff. Meeting people s needs Lead Due Date Expected Outcomes Lead Appointee Ensuring patients needs are met Nurse for commenced from a range of perspectives and Cancer role April 2015. ensuring that verbal, written Work information is accurate and programme delivered in an appropriate way being which then enables patients to developed April make informed decisions about their care and wellbeing. 2015. 35

Ensure a key worker is associated to each person diagnosed with cancer to coordinate their ongoing care. To implement the new Key Worker Guidance across all specialities. (MICHELLE) Connected Accredited Advanced Communications Skills Courses to continue to be provided for staff within Cancer Services. CNS Forum to be established within CTUHB to take forward a range of developments. Support provided by the Networks Lead Nurse. A Cwm Taf University Health Board Specialist Cancer Nurse Professional Forum has been established and meets 3 monthly. This forum is Chaired by the Macmillan Person-Centred Care Manager and supported by the Lead Nurse for Cancer/ Assistant Director of Nursing. Forum to be established April 2015. Ensuring a range of service improvements/initiatives are undertaken. 36

Assistant Director of Nursing and the Macmillan Lead Nurse/Cancer Network. Continue to ensure all cancer sites have a Clinical Nurse Specialist. (JASON) Ensuring that all patients who have received a diagnosis of cancer has an allocated Key Worker is a workstream within that Forum. Maintain the Cancer Services Intranet Page on an ongoing basis, ensuring that information is up to date and accurate and well organised, giving staff easy access to required information for a range of perspectives and also when undertaking Holistic Needs Assessments/Car Plans or referring on to other professionals Lead Nurse for Cancer/ Assistant Director of Nursing. To determined. be To have a source of easy accessible information that is useful to staff within Cancer Services. It also contains significant information for patients who have received a diagnosis of cancer which staff can pass on when relevant. This information includes; relevant Third Sector Organisations, documentation and referral methods to other health care professions, access to useful links, and produced literature, signposting information, training. The Cancer Services Intranet Page will act as the infra-structure of information 37