Going Further on Cancer WaitsGoing Further on Cancer Waits Early learning/findings Early learning/findings

from the test sitesfrom the test sites

Patricia Morris Patricia Morris Associate Director Associate Director

19/09/2006 19/09/2006

Context Context

Content: Content: Progress to date - Early Learning Progress to date - Early Learning Breast – Patricia Morris - Durham Breast – Patricia Morris - Durham Stretching the goal – Patricia – LutonStretching the goal – Patricia – LutonBowel – Celia Ingram Clark – Whittington Bowel – Celia Ingram Clark – Whittington Other GFCW - David Levy Other GFCW - David Levy

Starting point ………..Starting point ………..

o Test out ‘what’s possible’ to achieveTest out ‘what’s possible’ to achieve

2 weeks for all breast patients2 weeks for all breast patients 2 weeks for all bowel patients2 weeks for all bowel patients

o 3 sites3 sites o 12 weeks initial testing12 weeks initial testing

Test Site Test Site Focus Focus Aims Aims TestingTestingCounty Durham & County Durham & Darlington Acute Darlington Acute Hospital NHS Trust Hospital NHS Trust

Breast Breast -One route for all One route for all breast service breast service patientspatients- Compress targets Compress targets for breast cancer for breast cancer patients to 52 days patients to 52 days

-Process/capacityProcess/capacity-Triage into structured Triage into structured clinicclinic-Ultra sonographer led Ultra sonographer led clinics for under 35 yrs clinics for under 35 yrs

The Whittington The Whittington Hospital NHS Hospital NHS Trust Trust

Bowel Bowel - To achieve a max - To achieve a max 2ww for new patients 2ww for new patients referred with bowel referred with bowel symptoms by testing symptoms by testing new operational new operational models of services to models of services to test what’s possible test what’s possible

- Straight to test based Straight to test based on symptoms on symptoms - One stop clinics One stop clinics - No routine follow up No routine follow up

in bowelin bowel

The Luton & The Luton & Dunstable Dunstable Hospital NHS Hospital NHS Trust Trust

All tumors with All tumors with emphasis on emphasis on urology & urology & Ultrasound Ultrasound

- Streamline Streamline processes and processes and pathways to deliver pathways to deliver max 18 weeks wait for max 18 weeks wait for all all - Stretch the goals for Stretch the goals for cancer patients cancer patients

-How the aims can be How the aims can be achieved by a rapid achieved by a rapid improvement event improvement event and ‘lean’ application and ‘lean’ application

to urology/ultrasoundto urology/ultrasound

What’s the scale of achieving 2 weeks for What’s the scale of achieving 2 weeks for all……all……

0

200

400

600

800

1000

1200

Total Prostate Kidney Bladder Uretal Testis

New ReferralsReferred 2wwNew Referral not via 2ww

Source: Luton data Feb – May 2006

• Referral routes for all patients with suspicion of cancer (regardless of route) recorded

Key Learning from County Durham…….Key Learning from County Durham…….

To be seen

quickly

Value the expertise & Professionalism

of team

Each appointment kept to minimal delay

Patient Perspective

Extend roles/develop

skills (fully supported)

Second nurse practitioner

required

Training time for 2nd practitioner

Nursing Perspective

Durham cont ……Durham cont ……

Willingness to extend US/mammo Willingness to extend US/mammo radiographersradiographers

Need to have > capacity to manage Need to have > capacity to manage variationvariation

Challenges – local aims to be met Challenges – local aims to be met

Luton & DunstableLuton & Dunstable

A different approachA different approach‘‘Stretching the goalsStretching the goals

Foundation for 18 weeks Foundation for 18 weeks

Rapid Improvement Event Rapid Improvement Event 26/27/28 September26/27/28 September

Urology Urology Ultrasound Ultrasound

Collected the dataCollected the dataAnalysed Analysed Distilled Distilled

LearningLearning• Takes senior leadership Takes senior leadership • Need to have the data Need to have the data • Need to involve all the team Need to involve all the team • Need to be clear about outcomes Need to be clear about outcomes • It takes time !It takes time !

Luton & Dunstable cont …Luton & Dunstable cont …Outcomes from Rapid Improvement Event Outcomes from Rapid Improvement Event

To develop a manual data collection system to record clearly To develop a manual data collection system to record clearly demand for ultrasound; this will transfer to the new system in demand for ultrasound; this will transfer to the new system in November 2006 November 2006

To develop a scheduling system that maximises capacity of To develop a scheduling system that maximises capacity of ultrasound staff and equipment ultrasound staff and equipment

To review the flow of patients, information and staff in the To review the flow of patients, information and staff in the ultrasound department and look for opportunities for improvementultrasound department and look for opportunities for improvement

To develop timed pathways for the “Green Stream” i.e. haematuria, To develop timed pathways for the “Green Stream” i.e. haematuria,

urinary flow symptoms, testicular and prostate.urinary flow symptoms, testicular and prostate. To review protocols for: To review protocols for:

Referral to ultrasound from outpatients Referral to ultrasound from outpatients Urology patientsUrology patients

Key learning from ‘best practice visitsKey learning from ‘best practice visits’’ Strong clinical leadershipStrong clinical leadership Value and utilise team to full potentialValue and utilise team to full potential Streamlined pathwaysStreamlined pathways

DiagnosticsDiagnostics Follow-upFollow-up

Workforce development for allWorkforce development for all Clear visual patient and information Clear visual patient and information

processesprocesses

Emerging Common ThemesEmerging Common Themes o Understanding the data to realise the scale of Understanding the data to realise the scale of

the taskthe tasko Apply solutions to meet local circumstancesApply solutions to meet local circumstances o One size will not fit all!One size will not fit all!o 2 weeks for all will need ‘sign up’ from Royal 2 weeks for all will need ‘sign up’ from Royal

Colleges Colleges o Workforce issues (eg Nurse Practitioner roles) Workforce issues (eg Nurse Practitioner roles)

are important are important o Service Improvement – back to basics approach Service Improvement – back to basics approach

is importantis important o Clinical buy in is key Clinical buy in is key o Primary Care is important to success Primary Care is important to success

Thank you to …..Thank you to …..

o The clinical & managerial leads The clinical & managerial leads o The teams The teams o The DH Policy Leads The DH Policy Leads

We’ll continue with testing !We’ll continue with testing !

NOW……NOW……

Celia & David!Celia & David!

Going Further on Bowel Going Further on Bowel Cancer WaitsCancer Waits

Celia Ingham ClarkCelia Ingham ClarkConsultant surgeon, Whittington Consultant surgeon, Whittington

Hospital and NCL (colorectal) Hospital and NCL (colorectal) CSCIPCSCIP

What are we trying to achieve?What are we trying to achieve? Patients with bowel cancer should get Patients with bowel cancer should get

from referral to treatment as efficiently as from referral to treatment as efficiently as possiblepossible

Patients with bowel symptoms who do not Patients with bowel symptoms who do not have cancer should get from referral to have cancer should get from referral to clear reassurance that they do not have clear reassurance that they do not have cancer as efficiently as possiblecancer as efficiently as possible

Two week wait was designed to achieve Two week wait was designed to achieve thisthis

Has the TWW system worked?Has the TWW system worked? <20% of 2WW bowel patients have cancer<20% of 2WW bowel patients have cancer <20% of bowel cancer patients come via 2WW <20% of bowel cancer patients come via 2WW

routeroute Partly due to inappropriate use of 2WWPartly due to inappropriate use of 2WW Partly because 2WW criteria not robust enough Partly because 2WW criteria not robust enough

to identify all patients with bowel cancerto identify all patients with bowel cancer Partly due to emergency admissions (up to 25% Partly due to emergency admissions (up to 25%

of bowel cancers)of bowel cancers)

What are the numbers?What are the numbers?

For an average DGH per monthFor an average DGH per month- ~ 250 new colorectal referrals- ~ 250 new colorectal referrals

- ~ 200 new gastroenterology - ~ 200 new gastroenterology referralsreferrals - < 50 2WW referrals- < 50 2WW referrals

- ~ 12 new bowel - ~ 12 new bowel cancers cancers

What are the options to improve What are the options to improve efficiency?efficiency?

Identify and Identify and prioritise patients at prioritise patients at highest risk of highest risk of having bowel cancerhaving bowel cancer

Aim to get all referred Aim to get all referred patients through the patients through the pathway as quickly as pathway as quickly as possiblepossible

Prioritising high risk patientsPrioritising high risk patients

2WW2WW Cade patient questionnaire using Selva Cade patient questionnaire using Selva

scorescore - good discriminator but 70 - good discriminator but 70 factorsfactors

G-RAF neural network (Sheffield)G-RAF neural network (Sheffield) Screening with FOBScreening with FOB Consultant triage of lettersConsultant triage of letters Consultant history-taking in OPDConsultant history-taking in OPD

A two tier service?A two tier service?

?Two week wait for all??Two week wait for all?

What works to shorten waits?What works to shorten waits?

Demand management at front endDemand management at front end Pool the queues at all stagesPool the queues at all stages Straight to testStraight to test Clear patient pathwaysClear patient pathways Reduce follow-upsReduce follow-ups Match capacity to demandMatch capacity to demand

Outpatient waiting timesOutpatient waiting times

WhittingtonWhittingtonHospitalHospital

20022002 20062006

ColorectalColorectalurgenturgent

2 weeks2 weeks 2 weeks2 weeks

ColorectalColorectalRoutineRoutine

6 months6 months 7 weeks7 weeks

GastroGastrourgenturgent

2 weeks2 weeks 2 weeks2 weeks

GastroGastroRoutineRoutine

12 months12 months 12 weeks12 weeks

Going further project planGoing further project plan

Collate best known practice from CSCIP Collate best known practice from CSCIP and specialists in the fieldand specialists in the field

Use test site toUse test site toa) survey exact distribution of current a) survey exact distribution of current

outpatient colorectal practice and the work outpatient colorectal practice and the work it generatesit generates

b) test means of shortening waits b) test means of shortening waits using validated techniquesusing validated techniques

CSCIP examples of best practice in CSCIP examples of best practice in shortening colorectal access timesshortening colorectal access times

Streamline pathway – e.g. Blackpool, Mid-Streamline pathway – e.g. Blackpool, Mid-Essex, Good Hope, TauntonEssex, Good Hope, Taunton

Nurse-led clinics – e.g. Homerton, Nurse-led clinics – e.g. Homerton, Durham, Taunton, N and E HertsDurham, Taunton, N and E Herts

Straight to test – e.g. Leicester, Straight to test – e.g. Leicester, Nottingham, GloucesterNottingham, Gloucester

Pool the queues – e.g. Blackpool, Pool the queues – e.g. Blackpool, Durham, LutonDurham, Luton

Test site survey:Test site survey:Whittington Hospital July 2006Whittington Hospital July 2006

4 weeks data collection4 weeks data collection What symptoms?What symptoms? What referral route?What referral route? Who saw the patient?Who saw the patient? What test requested?What test requested? Test result?Test result? Patient outcome?Patient outcome?

Changes being introduced at Changes being introduced at test sitetest site

Demand management work with primary Demand management work with primary care trust and GPscare trust and GPs

Reduction in follow-upReduction in follow-up - after tests- after tests- after first - after first

visitsvisits Pool the queuesPool the queues Straight to testStraight to test

ChallengesChallenges Which patients would be better having a Which patients would be better having a

colonoscopy and which a flexible sigmoidoscopy colonoscopy and which a flexible sigmoidoscopy as their first test?as their first test?

Can you decide this without a specialist taking Can you decide this without a specialist taking the history?the history?

If using straight to test for colonoscopy, how do If using straight to test for colonoscopy, how do you know who is fit enough for the procedure you know who is fit enough for the procedure and how do you take informed consent?and how do you take informed consent?

??

ScreeningScreening

ScreeningScreening

Tackling hidden waitsTackling hidden waits

Fast tracking patients with a high risk of Fast tracking patients with a high risk of cancercancer

Breast Breast 12,00012,000 cancer patientscancer patients Cervix Cervix 3,000 3,000 patientspatients BowelBowel 3,0003,000 cancer patientscancer patients

Bowel CancerBowel Cancer

(2%) positive reading (2%) positive reading T = 0 daysT = 0 days

Nurse clinicNurse clinic < 1 week< 1 week Colonoscopy Colonoscopy < 2 weeks< 2 weeks

Refer to MDT Refer to MDT

TreatmentTreatment

Cervical screeningCervical screening Invasive/Glandular cancer suspected on Invasive/Glandular cancer suspected on

slideslide T=0T=0

Direct referral to colposcopy clinicDirect referral to colposcopy clinic

MDTMMDTM

TreatmentTreatment

Breast screeningBreast screening First report of abnormal mammogramFirst report of abnormal mammogram

T=0T=0

Assessment appointmentAssessment appointment14-21days14-21days

MDTMMDTM 28days28days

TreatmentTreatment 42 days42 days

TestingTesting

5 screening centres5 screening centres

It can be doneIt can be done

Need to clarify definitions Need to clarify definitions

Fast tracking patientsFast tracking patients

Some feedback from national leadsSome feedback from national leads

Sheffield about to pilot some work with Sheffield about to pilot some work with clinicians clinicians

JCCO targets (1993)JCCO targets (1993)

Patient group Patient group Waiting times for radiotherapy Waiting times for radiotherapy

Good practice Good practice Max. acceptable Max. acceptable delay delay

A Urgent A Urgent 24 h 24 h 48 h 48 h

B Radical B Radical 14 days 14 days 28 days 28 days

C Palliative C Palliative 2 days 2 days 14 days 14 days

D Post-operative D Post-operative - - 28 days 28 days

31 day target for subsequent 31 day target for subsequent treatmentstreatments

SurgerySurgery

ChemotherapyChemotherapy

RadiotherapyRadiotherapy

The Sheffield experienceThe Sheffield experience Concerns that "target-eligible" patients fast-Concerns that "target-eligible" patients fast-

tracked at the expense of those with greater tracked at the expense of those with greater clinical need. clinical need.

Only way to address this concern, is to ensure Only way to address this concern, is to ensure that all patients are treated in a timely fashion that all patients are treated in a timely fashion

At Sheffield 90+% success rate of JCCO At Sheffield 90+% success rate of JCCO maximum targets for all radiotherapy patients. maximum targets for all radiotherapy patients.

A key to success has been visionary and A key to success has been visionary and sustained investment by commissioners and sustained investment by commissioners and Trust Trust

The Sheffield experienceThe Sheffield experience Since 1999 Since 1999

4 to 7 linear accelerators 4 to 7 linear accelerators 0.5 to 1.5 CT simulators 0.5 to 1.5 CT simulators 2 expansions of our facility2 expansions of our facility installation of a MRI scanner installation of a MRI scanner

BUT, no doubt that active service BUT, no doubt that active service improvement programme has significantly improvement programme has significantly contributed to success contributed to success

Percentage Achieving Waiting Time Targetsfrom ready-to-start-treatment date to first radiotherapy treatment

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

30 November2002

18 June 2003 04 January 2004 22 July 2004 07 February 2005 26 August 2005 14 March 2006

% Radical Success % Palliative Success % Emergency Success

Percentage Achieving Waiting Time Targetsfrom ready-to-start-treatment date to first radiotherapy treatment

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

30 November2002

18 June 2003 04 January 2004 22 July 2004 07 February 2005 26 August 2005 14 March 2006

% Radical Success % Palliative Success % Emergency Success