Urological cancers why we need to change Stakeholder workshop 14 March 2013
Introduction and welcome Today s event aims to cover: 1. Background, clinical evidence and London Cancer s recommendations Q&As Professor Kathy Pritchard-Jones Chief Medical Officer, London Cancer Mr John Hines Consultant Urological Surgeon 2. Engagement on clinical recommendations and what we ve heard so far Neil Kennett-Brown Programme Director Change Programmes, North and East London Commissioning Support Unit 3. Understanding your views group discussion Led by Neil Kennett-Brown Programme Director Change Programmes, North and East London Commissioning Support Unit 4. Next steps Neil Kennett-Brown
Who s who London Cancer an integrated cancer system that joins up NHS cancer care providers of north east London, north central London and west Essex. London Cancer s aim is to drive superior outcomes and experience for our patients and population of 3.5 million. NHS commissioners are responsible for ensuring that health and social care services meet the needs of the population: NHS Commissioning Board is the future commissioner of specialist cancer services and will make decisions on any proposed changes to urological cancer services. The cluster primary care trusts (PCTs) NHS North East London and the City and NHS North Central London are the current commissioners of the services and are leading this engagement process. Clinical Commissioning Groups are important stakeholders in ensuring the whole pathway, from early diagnosis to high quality after care support, delivers the best patient outcomes. North and East London Commissioning Support Unit is supporting commissioners on this engagement.
Background to London Cancer s review
Drivers for change Pan-London case for change and Model of Care, 2010 Cancer outcomes in London are not good enough Poor patient satisfaction Poor trial recruitment in many tumour types Fragmented training Institutionally focused research at insufficient scale Need to reflect modern practices Can achieve better value for the resources available
What we aim to achieve To deliver services that provide the best outcomes for patients and stand up to international standards Introduce a pathway that starts in the community, ends in the community that is centred around the patient To exceed national, regional, and local care and quality standards For NHS services to work more closely together to provide more cohesive and better care for cancer patients To support and foster cancer research and clinical trials as well as provide excellent training and education To make better use of the urological cancer clinical workforce
London Cancer s recommendations a clinical view
Options considered Two specialist centres three surgeons, on call 1:2.5, 200 operations per annum One specialist centre six surgeons, on call 1:5, 400 operations per annum More surgeons two centre model with four, five or six surgeons
London Cancer s proposals Consolidate complex surgery for bladder and prostate cancer in one specialist centre Consolidate complex surgery for kidney cancer in one specialist centre Continue to provide less complex surgery for urological cancers at local diagnostic and treatment units Improve services at all hospitals providing urological cancer care Improve earlier diagnosis of urological cancers Improve support for people who are living with or beyond cancer Scope: Around two people a day in North East, North Central London and West Essex require complex urological cancer surgery Specialist treatment is only a small part of a urological cancer patient s care. The vast majority of patient care would always take place at local urological units and GP surgeries.
What this means for patients Better treatment, close to home if possible, in a specialist centre when necessary The best chance of controlling cancer and reducing the risk of long-term side effects Increased opportunity to participate in trials and research Enhanced patient and carer experience Some patients may have to travel further estimate around 230 bladder and prostate cancer patients and 270 kidney cancer patients would travel to a different hospital for complex surgery.
Patient pathway bladder and prostate cancer
Patient pathway kidney cancer
Role of local diagnostic and treatment centres A significant role in caring for patients with urological cancers. Most bladder and prostate operations would continue to happen locally. Provide all diagnostic tests, most elements of treatment including some types of surgery, the majority of post-treatment follow-up, and ongoing care and rehabilitation. The first point of contact for early specialist advice required by GPs. High quality medical and nursing care. Doctors would work jointly in both the specialist and local units to make sure that patients experience continuous excellent care. All existing urology units which meet standards of care would continue to provide local services.
Specialist surgical centres Bladder and prostate cancer Radical prostatectomies, radical cystectomies and bladder substitution, pelvic lymph node surgery Small number of benign cystectomies 400 operations per annum Kidney cancer Radical nephrectomy, partial nephrectomy, nephro-ureterectomy Benign renal surgery, renal pelvis surgery, ureteric surgery Retroperitoneal lymph node dissection for testicular cancer 400 cases per annum
Surgeons and Clinical Nurse Specialists Surgeons All will work at the specialist surgical centre and at least one local diagnostic and treatment unit Continuity of care for diagnosis, surgery and post-operative care Emergencies will be dealt with in local diagnostic and treatment units Subsequent operations and procedures will be undertaken in local diagnostic and treatment units Clinical Nurse Specialists (CNS) Work across specialist centres and local diagnostic units Main point of contact for patients CNSs will mirror surgeons to maintain patient continuity
Volume-outcome relationship International evidence dating back to 1970s shows that for complex procedures, a higher volume of patients results in fewer complications and better outcomes for patients Rich research showing both a surgeon-volume effect and a hospital-volume effect Some examples: A study from the late 1990s supported the hypothesis that when complex surgical oncological procedures are provided by surgical teams in hospitals with specialty expertise, mortality rates are lower (Begg CB, Cramer LD, Hoskins WJ, Brennan MF) A review of the literature in 2005, noted that high-volume providers have a significantly better outcome for complex cancer surgery (S.D. Killeen, M. J.O Sullivan, J. C. Coffey, W.O. Kirwan and H. P. Redmond)
Example volume-outcome relationship 2593 radical prostatectomies in a single institution 1999-2007 Score Continence: clinical meaning Erectile function: clinical meaning 1 No pads Normal full erections 2 One pad daily Full but diminished erections satisfactory for sexual activity 3 Two or three pads daily Partial erections occasionally satisfactory for sexual activity 4 Four or more pads daily Partial erections unsatisfactory for sexual activity 5 Complete incontinence No erections Vickers et al. Eur Urol 59 2011; 317-322
Return of erectile function by 12 months
Return of continence by 12 months
Volume outcome - function
Volume outcome - cancer control
Individual surgeon feedback - function Vickers et al. Eur Urol 2012; 61: 284-289
Individual surgeon feedback - recurrence Vickers et al. Eur Urol 2012; 61: 284-289
Volume outcome relationship in renal tumours 25,000 patient observational study Complications HR 0.84 for high volume surgeons Death 2% low volume surgeons 0.9% high volume surgeons Partial nephrectomy 11% low volume surgeons 25% high volume surgeons Abouassaly et al. J Urol 2012; 187 (6): 1984-8
Lancet Oncology on line early 17 April 2012
Summary volume-outcome relationship Functional outcomes vary widely between surgeons Continence 64-97% Erectile function 8-49% In order to measure the differences sufficient volumes need to be performed Volume predicted functional return 21% @ 25 cases/year 47% @ 100 cases/year
Video
Recommended providers for specialist surgery
Work with providers during engagement Clinical specification and standards were developed for the care we would expect from local and specialist units Working with trusts to determine how they could work together to implement the proposed model of care Trusts submitted expressions of interest, outlining how they would meet specifications The London Cancer Board is recommending to commissioners that complex bladder and prostate surgery should be based at University College London Hospitals (UCLH) NHS Foundation Trust; and that complex renal cancer surgery should be based at the Royal Free London NHS Foundation Trust. Recommendations are independent of other service reviews currently taking place in London. The requirements for each service will be considered on their own merits, based on improving the outcome and experience of patients. Standards / specification Initial expressions of interest Formal commitment to standards Evaluation of submissions Recommendations to NHS CB
Engagement on clinical recommendations
Indicative engagement process Discuss clinical case for change and recommendations with patients and the public, LINks, councils and other representatives Formally discuss the recommendations with Clinical Commissioning Groups to understand their views Formally discuss the recommendations / requirements for further engagement with Joint Health Overview and Scrutiny Committees Decision making by NHS Commissioning Board taking account views received during engagement Engagement until end of March Discussions with CCGs during Feb/March Discussions with JHOSCs during March and April Following engagement and development of final clinical recommendations, decisions made by NHS CB
Questions?
Understanding your views
Feedback from engagement to date (1/2) Key issues raised to date include: Travel the impact of travel (particularly in outer north east London and West Essex). London Cancer is working with the recommended hosts of specialist centres (Royal Free London and UCLH) to identify solutions to address travel concerns (both for patients and their families/carers). Among the options being considered are improved car parking and taxi services for those in need. Feedback from the engagement to date is informing these discussions. Patient choice while patient choice for specialist surgery would reduce, clinicians believe this would be outweighed by improved patient outcomes. However, specialist surgery is not always necessary. The majority of care, including less complex surgery, would continue to be provided at local urological units and GP surgeries, so patient choice would not be affected
Feedback from engagement to date (2/2) Key issues raised to date include: Support for concentrating specialist surgery, but debate on whether there should be one or two specialist centres London Cancer has published further information on the clinical evidence and produced a video to present the clinical perspective Keeping local skills/training London Cancer has confirmed that clinicians would work across both specialist and local urological units Impact on other services whilst there are some co-dependencies (e.g. interventional radiology and emergency surgery), the recommendations made about urological cancer services are independent of other service reviews currently taking place. The requirements for each service will be considered on their own merits, based on improving the outcome and experience of patients.
Group discussion and feedback Do you agree with the case for centralising specialist urological services? Are there other considerations or concerns that we need to take account of? How could hospitals reduce the impact of additional travel for patients and carers?
Next steps We welcome your active involvement and participation. We are discussing the case for change and recommendations with clinicians, clinical commissioning groups and GPs. During March and April, we are formally presenting the proposals, and the feedback we ve received, to health overview and scrutiny committees. Questions or feedback? Contact Nicole Millane, Communications Lead Transformational Change, North and East London Commissioning Support Unit Email: nicole.millane@elc.nhs.uk Telephone: 020 7683 4251