West of Scotland Cancer Network Skin Cancer Managed Clinical Network Activity Report March 2013 February 2014 Dr Girish Gupta Consultant Dermatologist MCN Clinical Lead Tom Kane MCN Manager West of Scotland Cancer Network
CONTENTS EXECUTIVE SUMMARY 3 1. INTRODUCTION 5 2. MCN WORKPLAN AND ACTIVITIES (REPORTING PERIOD 03/2013 TO 02/2014) 5 2.1 CORE OBJECTIVES 5 2.2 INDIVIDUAL MCN OBJECTIVES 6 2.3 OTHER MCN ACTIVITIES 6 3. QUALITY ASSURANCE / SERVICE DEVELOPMENT AND IMPROVEMENT 7 4. KEY PRIORITY AREAS FOR THE MCN IN THE NEXT 12 MONTHS 9 5. CONCLUSION 9 ACKNOWLEDGEMENT 10 West of Scotland Cancer Network 2
Executive Summary Introduction The purpose of this document is to report the Skin Cancer Managed Clinical Network (MCN) activities in respect of: Performance against agreed objectives; Outcomes achieved; and Challenges encountered and actions taken to remedy defined issues. This activity report covers March 2013 to February 2014. It also reports on key audit findings and resultant actions from the 2012 clinical audit, as well as looking forward from March 2014 to February 2015. MCN Objectives The Skin Cancer MCN has made progress and delivered a number of key objectives. Guideline and Protocol Development Development and updating of Clinical Management Guidelines (CMGs) remains a core component of MCN activity. The Squamous Cell Carcinoma (SCC) CMG has been reviewed and updated. The Malignant Melanoma (MM) CMG is nearing completion. Service Mapping A high level map of skin service provision has been collated for all NHS Boards across the region, detailing the points of service delivery and the connections between them. Multi-disciplinary Team (MDT) Working Following the publication of the Lymphoma Quality Performance Indicators (QPIs) the MCN has been working collaboratively with colleagues from the Haemato-oncology MCN to promote implementation of QPI 10 which states that patients with primary cutaneous lymphoma should be discussed at a specialist MDT meeting. Implementation of Regional Follow Up Consensus Guidelines The Follow Up Regional Consensus Guidelines for the three skin cancers was issued to the NHS Boards in October 2011 and is scheduled for review in October 2014. Advisory Board members from across all Boards have confirmed that they are broadly adhering to the guidelines. Quality Performance Indicator Development Quality Performance Indicators (QPIs) for MM are in the development phase with a short list of QPIs agreed by the national group, which has representation by MCN members. Draft indicators are currently being refined ahead of dataset development and engagement. Wide clinical and public engagement commenced in January 2014, with the QPIs expected to be published in summer 2014. Regional Clinical Audit The 2012 clinical audit data report was published in September 2013 and is available on the West of Scotland Cancer Network (WoSCAN) website. Action plans are being monitored through the Advisory Board. West of Scotland Cancer Network 3
Key Priority Areas for the MCN in the next 12 months The MCN work plan has been developed with an emphasis on identifying outcomes that improve the quality of patient care and overall efficiency. A number of objectives will be carried over from this year as guideline and protocol development, service mapping, QPI development and clinical audit continue as priorities in the work plan. New MCN objectives to be progressed in the coming year are listed below: Reviewing the follow up of organ transplant patients who are at a higher risk of skin cancers to ensure equity of care for patients who are followed up in their local NHS Boards Initiate the planning required to undertake the periodic review of the regional consensus guidelines for the follow up of all skin cancers. West of Scotland Cancer Network 4
1. Introduction The Skin Cancer Managed Clinical Network (MCN) was established in 2004 as a means of delivering equitable high quality clinical care to all skin cancer patients across four NHS Boards; Ayrshire & Arran, Forth Valley, Greater Glasgow and Clyde and Lanarkshire covering a population of approximately 2.46 million. The Skin Cancer MCN continues to support and develop the clinical service for skin cancer patients with the three skin cancers (Malignant Melanoma MM, Squamous Cell Carcinoma SCC and Basal Cell Carcinoma BCC). The 2012 West of Scotland Cancer Network (WoSCAN) audit data indicates that the number of MM in that year was 537. The effective management of these patients throughout the region relies on co-ordinated delivery of treatment and care that requires close collaboration of professions from a range of specialties. Predominantly, it is the MM patients who are discussed in the six local and one regional skin multi-disciplinary team meetings (MDTs) across the West of Scotland (WoS) but where there are concerns with any particular non melanoma skin cancer patients, they will also be taken to the MDTs for discussion. The purpose of this document is to report the Skin MCN activities in respect of: Performance against agreed objectives; Outcomes achieved; Challenges encountered and actions taken to remedy defined issues; and Update on progress of actions identified from the Audit Report. MCN Governance The Advisory Board meets three times per annum with representation from each of the partner NHS Boards and all relevant specialities involved in the management of skin cancers. The Advisory Board is consulted between meetings as required by the lead and manager. Dr Girish Gupta has now stepped down from his role as Clinical Lead following five productive years in office. The position of Skin Cancer MCN Clinical Lead has gone out to advert and an appointment will be made in early 2014. The terms of reference and membership of the Advisory Board will be refreshed to reflect these changes. 2. MCN Workplan and Activities (reporting period 03/2013 to 02/2014) 2.1 Core Objectives Regional Clinical Audit Programme A key area of the Skin Cancer MCN was to effectively utilise audit findings to inform and drive service improvement. A comprehensive clinical audit report of performance against key outcome measures (KOMs) was issued to NHS Boards in September 2013 and is available on the WoSCAN website. Progress against action plans is being discussed on a regular basis at the Advisory Board. The Skin Cancer MCN is encouraged by the performance of individual units against the regionally agreed KOMs with results demonstrating that patients with MM receive a consistent and improving standard of care across all geographical locations. West of Scotland Cancer Network 5
Service Mapping A high level map of skin service provision has been collated for all NHS Boards across the region, detailing the points of service delivery and the connections between them. The mapped information was included in a regional report presented to the Regional Cancer Clinical Leads Group in early October 2013 and subsequently shared with Cancer Managers. The map will be updated annually to maintain a baseline position. 2.2 Individual MCN Objectives Review of Clinical Management Guidelines (CMGs) CMGs ensure the safe and equitable management of patients across the West of Scotland Cancer Network area whilst optimising the effectiveness of treatment and care. The MCN has completed the review of the SCC CMG and is continuing to work on the MM CMG to include a new drug approved by the Scottish Medicines Consortium in December 2013. Multi-disciplinary Team (MDT) Working Following the publication of the Lymphoma Quality Performance Indicators (QPIs) the MCN has been working collaboratively with colleagues from the Haemato-oncology MCN to promote implementation of QPI 10 which states that patients with primary cutaneous lymphoma should be discussed at a specialist MDT meeting. A referral template has been circulated to dermatologists by the MCN and a reminder is circulated monthly by the MDT co-ordinator. Implementation of Regional Follow Up Consensus Guidelines The Follow Up Regional Consensus Guidelines for the three skin cancers was issued to the NHS Boards in October 2011 and is scheduled for review in October 2014. Advisory Board members from across all Boards have confirmed that they are broadly adhering to the guidelines. Quality Performance Indicator Development QPIs for MM have been developed by a national group, which had representation by MCN members. Wide clinical and public engagement commenced in January 2014, with the QPIs expected to be published in summer 2014. 2.3 Other MCN Activities National Institute for Health and Clinical Excellence (NICE NHS England) The Advisory Board reviewed the NICE guidance for the use of Electro-chemotherapy in the treatment of Primary Basal Cell Carcinoma and Primary Squamous Cell Carcinoma within the WoSCAN context. The Advisory Board noted that what evidence there is to support it is poor and agreed that there was not a value in proceeding with it at this time. Merkel Cell Carcinoma (MCC) The MCN is currently supporting colleagues throughout Scotland to complete a Scotland wide audit of MCC presentation and management over the last decade. This audit is scheduled to complete in March 2014. MCC is a rare and aggressive neuro-endocrine skin cancer. Patients with MCC have a median survival of 31 months and this disease carries a greater overall risk of mortality than malignant melanoma. The management of MCC has been noted to be variable across the United Kingdom and this observational study will examine how MCC cases have been managed in Scotland during 2000-2010 and attempt to identify any major prognostic indicators in this cohort. West of Scotland Cancer Network 6
Scottish Intercollegiate Guidelines Network (SIGN) MCN members are currently working with SIGN to develop guidelines for the management of primary cutaneous SCC. Once the national guidelines are available, the MCN will review the WoSCAN CMG and Follow Up Regional Consensus Guidelines in the light of recommended changes to clinical practice. 3. Quality Assurance / Service Development and Improvement The primary function of the MCN is to facilitate continuous clinical service improvement, supporting delivery of high-quality, equitable, treatment and care to patients with skin cancers in the WoS. The MCN prospective clinical audit programme underpins much of the regional service development and improvement work of the MCN and supports quality assurance (QA) by providing the means for regular assessment and reporting against recognised and agreed measures of service performance and quality. The annual regional quality assurance of service provision utilises six regionally agreed KOMs in addition to basic demographics. The latest report of audit data is based on 537 new cases of MM presenting in 2012, set against results obtained from the previous report. The MCN QA process requires local multi-disciplinary teams to critically review and verify their own results before being collated to provide a regional comparative report of performance against agreed measures and variance between MDTs. The report of the 2012 clinical audit data was published in September 2013 and can be found in the WoSCAN internet site. Regional Audit and Governance Process In accordance with agreed governance procedures, Boards were asked to produce Action/Improvement Plans in response to audit findings and to take forward recommendations set out in the Audit Report. The expectation is that these actions will be progressed and monitored via local governance structures. Plans are expected to be submitted to the Regional Information Manager within two months of publication of the report. An Action/Improvement Plan template is provided to ensure consistency and standardisation across the region. The MCN Manager/Clinical Lead have been reviewing Board Action Plans to identify priorities for co-ordinated regional action and these, along with progress against specific Board actions are monitored throughout the year by the Advisory Board under the standing MCN Work Plan agenda item. Action Plan Progression Recommended actions on the basis of the key findings of the audit report were directed to Boards requesting the development of local plans to address areas of deficiency identified. Skin Cancer Action/Improvement plans have been submitted by each of the NHS Boards. Outlined below is a high level summary of progress on actions required. Service Improvement Ayrshire & Arran is encouraging the use of photo-triage to speed up referrals of suspicions lesions. Forth Valley is continuing to work to improve the knowledge base of primary care clinicians in respect of skin cancers. Greater Glasgow and Clyde and Lanarkshire have written or plan to write to colleagues in primary care to highlight the importance of referring appropriate patients urgently. Ayrshire & Arran and also Greater Glasgow and Clyde have reviewed cases where excisions have been performed in primary care. Ayrshire & Arran indicated that the biopsies were carried out by General Practitioners with a special interest (GPwSI) in skin cancers. They will West of Scotland Cancer Network 7
ensure that the data for GPwSI is entered correctly. Greater Glasgow and Clyde advise that the numbers are small and that they are now requesting feedback from GPs after each specific case. Ayrshire & Arran has reviewed the cases where biopsy was performed prior to surgical treatment, noting that there were four cases and that all were considered clinically appropriate. All NHS Boards have reviewed clinical practice to ensure that further increases in biopsy prior to surgical resection are not observed. Reasons for each of the biopsies that were performed have been noted. Forth Valley has reviewed their surgical techniques in respect of compliance with the SIGN guideline recommendation. Forth Valley noted that three patients failed to meet the standard. Patients will be discussed at the multi-disciplinary team meeting to prevent this occurring. All NHS Boards have reviewed the number of patients undergoing wide local excision to determine if the relatively low numbers are due to a data recording issue or demonstrate a change in clinical practice. Ayrshire & Arran is in the process of identifying a robust process to collect this information for patients treated in Glasgow. Greater Glasgow and Clyde plan to review the 2013 data following Electronic Patient Records (EPR) implementation. Forth Valley noted that the majority of these patients progress to wider excision, which was not being recorded; Forth Valley will change practice accordingly. Lanarkshire noted that the numbers of patients not having a wide local excision was low and itemised the reasons for each patient not having the procedure. Data Quality Improvement Ayrshire & Arran has reviewed case ascertainment. All melanoma related pathology is now sent directly to the lead audit data facilitator and this process has been confirmed by pathology. Ayrshire & Arran is now also crosschecking the list of audit patients with MDT minutes and tracking database to increase case ascertainment. Lanarkshire has reviewed audit data collection processes to ensure complete and accurate data capture for surgical excision margins. Access to the Glasgow Clinical Portal has been granted to all cancer audit staff in Lanarkshire, meaning that operation notes can now be viewed in Lanarkshire which will ensure complete and accurate data capture for surgical margins. Greater Glasgow and Clyde and NHS Lanarkshire have reviewed audit data collection processes. Greater Glasgow and Clyde advise that EPR implementation has significantly improved data capture. Across all Boards all the actions identified in the Board-specific action/improvement plans have been reviewed and a progress/action status provided in line with the governance framework; for those actions that remain ongoing a further update will be requested at the next Advisory Board meeting. The expectation is that all actions would be addressed prior to the onset of the next audit reporting schedule with sign off of the 2013 clinical audit data completed in August 2014. Escalation Process Any service or clinical issue which the Advisory Board considers not to have been adequately addressed will be escalated to the Regional Lead Cancer Clinician and relevant Territorial NHS Board Cancer Clinical Lead by the MCN Clinical Lead. West of Scotland Cancer Network 8
4. Key Priority Areas for the MCN in the next 12 months The MCN work plan is currently being finalised with an emphasis on identifying outcomes that improve the quality of patient care and overall efficiency. The work plan is expected to be published by early May 2014. Below are the objectives to be progressed in the coming year: Core Objectives: Continue to support the regional clinical audit programme and effectively utilise audit findings to inform and drive service improvement. Support delivery of the national cancer QPI development programme. Update the regional service map for skin cancer service provision. Individual MCN Objectives: In addition to guideline development, the Network will also review the follow up of organ transplant patients who are at an increased risk of skin cancers and initiate the planning required to undertake the 3-yearly periodic review of the regional consensus guidelines for the follow up of all skin cancers; this will require engagement with all disciplines involved in the follow up care of patients. 5. Conclusion This has been a productive year and the MCN, with the support of the Advisory Board, has continued to work closely with local and regional clinical and management teams across the WoS to progress the work plan objectives. Ongoing development and update of CMGs and other regional guidance continue to drive consistency of practice and provide improved care for patients with skin cancers in the WoS. Recognising the pressures on clinical time, the MCN is looking at the most time efficient and effective way to engage and involve members in MCN activities to ensure essential clinical input to the ongoing improvement and development of skin cancer services in the WoS. Looking ahead the membership welcomes the opportunity to improve quality of clinical audit data, assess the probable implications of the QPI process and continue to support and improve the treatment pathway and effective patient journey around local and regional services. West of Scotland Cancer Network 9
Acknowledgement This report represents the achievements and challenges progressed across the NHS Boards of the West of Scotland Cancer Network: NHS Ayrshire & Arran NHS Forth Valley NHS Greater Glasgow and Clyde NHS Lanarkshire We would like to thank all members and active participants in the cancer network for their continued support of the Managed Clinical Network, without their efforts this level of progress would not be possible. West of Scotland Cancer Network 10