PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM) Network Organisation (Trust) Team DCN POOLE Poole THYROID ONLY MDT (11-2I-2) - 2011/12 Peer Review Visit Date 18th August 2011 Compliance THYROID ONLY MDT Zonal Statement Completed By Job Title Self Assessment 96.8% (30/31) Anna Eccleston Assistant Quality Manager Peer Review 93.6% (29/31) Date Completed 7th October 2011 Agreed By (Clinical Lead/Quality Director) Cathy Regan Date Agreed 10th October 2011 Key Themes Structure and function of the service The Thyroid Multi-Disciplinary Team (MDT), also referred to as the Endocrine MDT locally is hosted by Poole Hospital NHS Foundation Trust and comprises membership from clinicians at the Trust as well as from clinicians at the Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust and Dorset County Hospital NHS Foundation Trust. Due to the small size of the Dorset Cancer Network and the existence of only one MDT, the MDT also acts as the Endocrine (Thyroid) Network Site Specific Group (NSSG). In light of this, it emerged that the NSSG meetings were used as the forum for operational MDT discussions, which occur three times a year. One meeting is specifically allocated as the annual operational policy meeting and the review team would encourage the MDT Lead to ensure that all MDT members are at this meeting to allow full discussion and agreement of the operational policy. It would also be beneficial to specifically label this meeting as such to ensure clarity of purpose. It was evident during the review that there have been challenges to establishing the Endocrine MDT and NSSG as distinct entities from the Head and Neck Cancer MDT and NSSG. It was PEER REVIEW VISIT REPORT for Poole - THYROID ONLY MDT (published: 10th October 2011) Page: 1/5
clear that differences of opinion still existed, however, good progress had been made on the functioning and constitution of the Endocrine MDT. There has been improvement since the last internal validation in 2010 and the MDT now has sufficient clinical oncology attendance. Clinical Nurse Specialist (CNS) capacity has been greatly affected due to difficulties with long term sickness. The review team was assured that this issue would be addressed imminently and the Trust needs to ensure this is the case as patient care will be compromised in the longer term and this would need to be escalated to a serious concern. The CNSs have access to psychological support and this is provided at an appropriate level. The MDT manages approximately 18 to 20 patients a year and the review team would encourage that this activity is directed to a select number of surgeons to ensure the best quality outcomes for patients. In addition, the MDT described a predominantly elderly demographic of patients over 85, with all patients treated appropriately based on performance status. It was interesting to note the high incidence of thyroid cancers locally based on the information provided by the MDT which indicated approximately 16 new cases diagnosed on an annual basis for the last several years. The two week wait from General Practitioner (GP) referral to first clinic appointment for thyroid cancers is currently recorded as part of the head and neck cancer fast track referrals and this information on waiting times was not made available for the review. This is a vital part of the cancer waiting times data and should be made available to the clinicians to allow for any improvements necessary. The 31 day target from diagnosis to treatment for first, second and subsequent treatments was met at 100% compliance and the 62 day target which applied to only two cases was not met. This was due to repeat non-attendance and a complicated patient pathway. Coordination of care/patient pathways The Endocrine MDT/NSSG has approved and adopted the British Thyroid Association guidelines for the Management of Thyroid Cancer (2007) with some locally approved amendments. In addition, there has been early review of the local guidelines for the investigation of thyroid nodules based on the American Thyroid Association guidelines (2010). Referral pathways have been developed for thyroid lumps, radio-iodine and thyroid cancer follow up, however the neck lump pathway has not yet been agreed by both the Thyroid and Head and Neck MDTs/NSSGs. It was clear from the reviews of both NSSGs that there are clinical differences in opinion on an appropriate neck lump pathway. Both MDTs/NSSGs, with the support of the Network, need to work together in the interest of patients to resolve this to ensure they are accessing the appropriate pathway in a timely manner. Although the MDT operates as a single MDT across the three hospital trusts in the Network, there are two separate diagnostic pathways into the MDT. For example, Poole Hospital NHS Foundation Trust and Bournemouth and Christchurch Hospitals NHS Foundation Trust have a weekly dedicated thyroid clinic, whilst Dorset County Hospital NHS Foundation Trust has a combined lump and thyroid clinic. In light of this, the MDT should regularly monitor that there is equity in patient access to pathways across the three hospital sites. The MDT uses the Royal College of Pathologists' guidelines for thyroid cancer and though these are appropriate to use, they need to be supplemented with local information to make the PEER REVIEW VISIT REPORT for Poole - THYROID ONLY MDT (published: 10th October 2011) Page: 2/5
team fully compliant with the measure. The review team commended the MDT on the practice of centralised review of thyroid cancer pathology prior to MDT meetings which allows for better quality of patient care. The review team strongly supported the MDT/NSSG in its plans to direct thyroid surgery to a select number of surgeons to ensure the best quality outcomes for patients. The MDT, Network and commissioners need to ensure that surgical activity is monitored to ensure competency and quality is maintained. The CNSs work well together across the three trusts to ensure the patient pathway is well coordinated. The review of the patient notes demonstrated implementation of the keyworker and principle clinician policies. There was also clear documentation of MDT outcomes, in addition to the minimum dataset recorded on the MDT proformas in the notes. The MDT is yet to complete an audit of communication with GPs, although it reported no issues with this as there is responsive, electronic transfer of diagnosis information. The review team considered this to be good practice. Patient experience The MDT is committed to obtaining feedback on its services and has developed a specific thyroid questionnaire with the input of patients, after discovering the generic questionnaire used for head and neck cancer services was not suitable. The patient experience survey was carried out amongst patients who received treatment for thyroid cancer during 2010 and a separate questionnaire was created for the three types of treatment including surgery, radiotherapy and radioactive iodine treatment. An action plan is in place, however, it is challenging to identify service improvements required due to the small numbers involved. The review team acknowledge the difficulties this presents and would encourage that a regular ongoing exercise is undertaken to ensure the patient experience is fully captured and drives service improvements. Despite this, it was evident some improvements had been made based on patient feedback, such as the development of a dedicated iodine room for patients on radioactive iodine treatment. There was no information available on the results from the National Patient Experience Survey as thyroid cancer was not included. There is no local thyroid support group and although there is a local head and neck support group, the MDT felt this would not be suitable for thyroid patients. However, there are mechanisms in place to access national support groups such as the Teenage Cancer Trust. The MDT provides patients and carers with local information which is regularly reviewed by the Trust readership committee and involves patient input. Clinical outcomes/indicators The MDT is clearly committed to measuring the quality of care by reporting on clinical outcomes PEER REVIEW VISIT REPORT for Poole - THYROID ONLY MDT (published: 10th October 2011) Page: 3/5
in addition to reviewing feedback on the patient experience. A number of clinical indicators were discussed during the review. These included: the proportion of patients receiving appropriate TSH suppression; laryngeal nerve injury rates; hypo-calcaemia rates post total thyroidectomy; monitoring of thyro-globulin; length of stay; and whether follow up protocols were followed. The lack of clinical trials for thyroid patients nationally clearly impacts on the MDT's ability to recruit to clinical trials. Despite this, it was evident the MDT is committed to actively seeking out appropriate clinical trials for its patients. For example, it was successful in recruiting some patients to the HiLo trial. There was evidence of participation in a number of audits designed to improve management and follow up of patients with thyroid cancer, including the adrenal incidentaloma and thyroid cancer follow up audits. Good Practice Good Practice/Significant Achievements Diagnostic support available to MDT, for example imaging and pathology. Centralised review of pathology for all thyroid cancers. CNS access to psychological supervision. E-letter of diagnosis to GPs. Dedicated iodine treatment room as a result of feedback on patient experience. Concerns Immediate Risks Serious Concerns Concerns Surgical activity should be directed to selected surgeons to ensure competency and quality of care. CNS capacity should be addressed. Lack of agreement between the endocrine and head and neck MDTs/NSSGS on the neck lump pathway. PEER REVIEW VISIT REPORT for Poole - THYROID ONLY MDT (published: 10th October 2011) Page: 4/5
PEER REVIEW VISIT REPORT for Poole - THYROID ONLY MDT (published: 10th October 2011) Page: 5/5