strength through partnership central south coast cancer network dr richard roope, csccn primary care...
TRANSCRIPT
Strength Through Partnership
Central South Coast Cancer Network
Dr Richard Roope, CSCCN Primary Care Lead
Cancer Early Diagnosis Meeting 8.2.2012
Strength Through Partnership
Central South Coast Cancer Network
Macmillan GP Roles
Strength Through Partnership
Central South Coast Cancer NetworkCSCCN
Central South Coast Cancer Network
Southampton & West(Vacant)
NortheastCharlotte Hutchings
Portsmouth & Southeastern(Vacant)
Isle of WightDavid Issacs
Network Leadership/coordination(RMR)
Strength Through Partnership
Central South Coast Cancer Network
Macmillan GP Roles
•Advert to all practices in SHIP area•Interviews on 20.2.12 & 22.2.12
Strength Through Partnership
Central South Coast Cancer Network
Macmillan GP Roles
Mainland•Awareness and Early Diagnosis -•Survivorship - •End of Life – Charlotte Hutchings
Isle of Wight•Awareness and Early Diagnosis )•Survivorship )David Issacs•End of Life )
Strength Through Partnership
Central South Coast Cancer Network
CCG Engagement
Strength Through Partnership
Central South Coast Cancer Network
CCG Engagement
• Approach made to all CCGs to establish lead for cancer.
• Opportunity to meet up to discuss role of network and work streams
Strength Through Partnership
Central South Coast Cancer Network
RCGP events
•19.1.12 – “Early Detection of Cancer Study Day”
Strength Through Partnership
Central South Coast Cancer Network
RCGP events
•30+ GPs from across SHIP area•Case studies including RAT tool
Strength Through Partnership
Central South Coast Cancer Network
RCGP eventsFeedback•“What actions do you now intend taking?”
•“Talking to my partners re safety netting and circulate the guidelines for urgent referrals”•“Look at practice NCIN profile for cancers”•“Set up a follow up system for patients with symptoms potentially needing referral for cancer”•“Use RAT tool for bowel/lung cancers”•“Share information with partners”•“Teaching for patient group”•“Audit our cancer care”
Strength Through Partnership
Central South Coast Cancer Network
RCGP events
•Next meeting planned for 5.7.12
Strength Through Partnership
Central South Coast Cancer Network
Target events
Strength Through Partnership
Central South Coast Cancer Network
Target events
•Portsmouth 25.1.2012
Strength Through Partnership
Central South Coast Cancer Network
Target events
•Portsmouth 25.1.2012
•Break out groups x2•70 GPs attended•Full feedback not yet collated
Strength Through Partnership
Central South Coast Cancer Network
LMC Event
•Afternoon meeting on 25th April 2012
•E-mailed to all GPs in Wessex LMC patch
Strength Through Partnership
Central South Coast Cancer Network
LMC Event
•Afternoon meeting on 25th April 2012
•“Early cancer diagnosis leads to better outcomes - everything the GP wanted to know but was afraid to ask!”
•E-mailed to all GPs in Wessex LMC patch
Strength Through Partnership
Central South Coast Cancer Network
LMC Event• Avoidable deaths pa if survival in England matched
the best in Europe• Breast ~2000 • Colorectal ~1700 • Lung ~1300 • Oesophagogastric ~950 • Kidney ~700 • Ovary ~500 Brain 225• NHL/HD 370 Melanoma 190• Bladder 290 Cervix 180• Myeloma 250 Oral/Larynx 170• Endometrial 250 Pancreas 75• Leukaemia 240
Strength Through Partnership
Central South Coast Cancer Network
LMC Event
• 54 booked within 2 hours....
Strength Through Partnership
Central South Coast Cancer Network
Practice Profiles – Dec 2011
Strength Through Partnership
Central South Coast Cancer Network
Practice Profiles – Dec 2011
qqqqqqqqqqqqqqqqqqqqq
Strength Through Partnership
Central South Coast Cancer Network
Index Min Max Range
2ww per 100,000
331 3200 9.67
2ww Age standardised
0.22 2.30 10.45
% 2ww conversion
0% 31.25% ∞% of cancers via 2ww
0% 100% ∞
• Huge variation of practice across SHIP – 2 week wait referrals
CWT 20010/11
Strength Through Partnership
Central South Coast Cancer Network
Index Min Max Range
Emergency presentations per 100,0001
26 1625 62.5
% of cancer presentation via emergency route2
0% 57.14% ∞
• Huge variation of practice across SHIP – Emergency presentation
1. HES 20010/11
2. RtD 2008
Strength Through Partnership
Central South Coast Cancer Network
• Huge variation of practice across SHIP – Emergency presentation
% Emergency Presentation of Cancer - Southampton PCT [Average: 26.2%]
0%
10%
20%
30%
40%
50%
60%
70%
80%
Strength Through Partnership
Central South Coast Cancer Network
• Huge variation of practice across SHIP – Emergency presentation
% Emergency Presentation of Cancer - Hampshire PCT [Average: 21.7%]
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Strength Through Partnership
Central South Coast Cancer Network
• Huge variation of practice across SHIP – Emergency presentation
% Emergency Presentation of Cancer - Isle of Wight PCT [Average: 23.2%]
0%
10%
20%
30%
40%
50%
60%
70%
Strength Through Partnership
Central South Coast Cancer Network
• Huge variation of practice across SHIP – Emergency presentation
% Emergency Presentation of Cancer - Portsmouth PCT [Average: 26.2%]
0%
10%
20%
30%
40%
50%
60%
70%
80%
Strength Through Partnership
Central South Coast Cancer Network
Practice Profiles – Dec 2011
• Variable take up• Isle of Wight 100%• IOW>Portsmouth>Hampshire>Southampton
Strength Through Partnership
Central South Coast Cancer Network
Practice Audit
Strength Through Partnership
Central South Coast Cancer Network
Audit
• A challenge...• Money available• New staff appointed – personal approach
Strength Through Partnership
Central South Coast Cancer Network
Risk Assessment Tool
Strength Through Partnership
Central South Coast Cancer Network
Agenda Item 2.2
Strength Through Partnership
Central South Coast Cancer Network
Agenda Item 2.3
Strength Through Partnership
Central South Coast Cancer Network
• Mousemat and Desk Easel
Risk Assessment Tool
Strength Through Partnership
Central South Coast Cancer Network
Ratmat:
Strength Through Partnership
Central South Coast Cancer Network
Risk Assessment Tool
• Gate keeper role
• UK general practice is regarded by many to be the best in the world• The gatekeeper role has brought many benefits to patients, not
least by ensuring the correct specialist is seen• It has also brought disadvantages, arising from GPs’ desire and
more recently, external pressure to use resources appropriately.• Potential for collusion with patient: “Do I really need to….?”• In cancer this means not investigating the low-risk symptom – and
NICE tells us not to. However this may contribute to poor cancer outcomes in the UK. (cf Denmark)
Strength Through Partnership
Central South Coast Cancer NetworkBackground
How do GPs decide who to refer?• Some is from what has been learnt during training and
CPD• Some from ‘sixth sense’• Some from advice – like NICE• Some from patient pressure• Some from reading up research
Strength Through Partnership
Central South Coast Cancer Network
Risk Assessment Tool
• Colorectal Cancer
• This is one of the four commonest cancers, and possibly the one with most to benefit from improvements in diagnosis.
• Half of patients never have a NICE-qualifying symptom• Only a quarter are diagnosed via 2-week rule clinics• A quarter present as emergencies• Earlier diagnosis may give a stage shift or prevent some of
the emergencies• Duke’s A 93% 5ys: Duke’s D 7% 5ys
Strength Through Partnership
Central South Coast Cancer Network
RAT – Colorectal Cancer
• Implement the Risk Assessment Tool (RAT) Positive predictive value
Strength Through Partnership
Central South Coast Cancer Network
• Patient pathway:Awareness
Presentation
Investigation
Referral
Diagnosis
Strength Through Partnership
Central South Coast Cancer Network
• Helps to decide which patients below the risk level implied by NICE guidance may benefit from urgent investigation
• Uses a combination of symptoms, signs and investigations.• Generates the proportion of patients with the listed symptom(s)who
have that cancer type
Using the RAT tool
Strength Through Partnership
Central South Coast Cancer Network
• Used to supplement NICE guidelines• For patients ≥40• Is used after first and subsequent patient visits
Using the RAT tool
Strength Through Partnership
Central South Coast Cancer Network
RAT – Colorectal Cancer• Implement the Risk Assessment Tool (RAT)
Positive predictive value
•Amber and red suggests 2WW referral.•Yellow and no colour best managed by review within 1º Care
Strength Through Partnership
Central South Coast Cancer Network
RAT – Lung – Non-smokers
• Implement the Risk Assessment Tool (RAT)
Strength Through Partnership
Central South Coast Cancer Network
RAT – Lung - Smokers
• Implement the Risk Assessment Tool (RAT)
Strength Through Partnership
Central South Coast Cancer Network
Strength Through Partnership
Central South Coast Cancer Network
Risk Assessment Tool
• Embedding in 2WW referral form
• Likely to highlight a learning need. • Likely to change practice. • Likely to engender earlier diagnosis.• Likely to result in more 2WW referrals etc.• Likely to reduce emergency presentations
Strength Through Partnership
Central South Coast Cancer Network
Agenda Item 2.4
Strength Through Partnership
Central South Coast Cancer Network
Primary Care Safety Netting
Strength Through Partnership
Central South Coast Cancer Network
• Safety-netting– Practice system if patient fails to attend for
investigation or clinic?– Practice system if results/correspondence go to
ground?– Not sufficient to say:
“Come back if it doesn’t get better”
Strength Through Partnership
Central South Coast Cancer NetworkSafety-netting
Strength Through Partnership
Central South Coast Cancer NetworkSafety-netting - Screening
• Bowel cancer screening DNA notifications– Enter into computer history– Flag record (computerised post-it) so next
contact with Primary Care Team patient will be reminded
– Letter sent to patient from surgery• may be worth GP signing• To provoke a response may include phrase along
lines of:
Strength Through Partnership
Central South Coast Cancer NetworkSafety-netting - Screening
Dear
We have recently been advised by the National Bowel Screening Programme that you failed to return the test kit for analysis.
The Practice firmly believes that this simple test is a valuable aid in detecting any potential signs of bowel cancer cells, and would
encourage you to reconsider your decision.
You should continue to be aware of any bowel symptoms such as:– A persistent change in bowel habit, especially going to the toilet more often or diarrhoea for several weeks– Bleeding from the back passage without any obvious reason– Abdominal pain especially if it is severe– A lump in your abdomen
Please remember that these symptoms do not necessarily mean that you have bowel cancer, but if you have one or more of these symptoms for four to six weeks, you should see your GP.
Should you no longer have the test kit and now wish to take part, you can call the Screening freephone number 0800 707 6060 and ask for another.
If, after careful consideration, you decide not to take part, please would you let us know by returning the slip below. Your decision will have no impact on any future medical services provided by the Practice.Yours Sincerely,
Main and Branch Surgeries
I do not wish to take part in bowel cancer screening, and am aware this may delay the diagnosis of bowel cancer were I to develop it.
(signed)…………………………………………………
Strength Through Partnership
Central South Coast Cancer NetworkSafety-netting - Screening
I do not wish to take part in bowel cancer screening, and am aware this may delay the diagnosis of bowel cancer were I to develop it.
(signed)…………………………………………………
Strength Through Partnership
Central South Coast Cancer Network
Safety-netting – Investigations if cancer is on differential diagnosis
• Blood tests (if checking for tiredness, shortness of breath)
• CXR• USS for ?ovarian cancer
• Systems in practice so if result not received can be followed up.
Strength Through Partnership
Central South Coast Cancer NetworkSafety-netting – 2ww referrals
• A surprising number of 2ww referral patients who fail to attend/postpone
• Make sure patient understands that referral is to exclude the possibility of cancer
• Have system to follow up/flag up any DNAs at 2ww appointments (similar to screening DNAs)
• May be regarded as good practice to ask patient to have GP follow up 4 weeks after referral to 2ww, as by then the diagnosis is likely to have been met.
Strength Through Partnership
Central South Coast Cancer Network
Other elements of safety-netting include:
• Communicating the existence of uncertainty • Outlining exactly what the patient needs to look out for • How to seek further help and • What to expect about time course
Strength Through Partnership
Central South Coast Cancer Network
Patient Pathway: LAEDI - 2012 - Summary
Awareness
Presentation
Investigation
Referral
Diagnosis
New Practice Profiles:•Target Meetings•RCGP/LMC Meetings•Practice visitsSafety netting
National Bowel cancer awareness: Jan 2012•Nationwide•Multiple Media•Primary Care
RAT launch January 2012
Pan network 2ww referral forms
Lung Cancer Education Day 21.3.12
Engaging with CCGs
Summer 2012“Be Clear on Cancer”Lung cancer
Strength Through Partnership
Central South Coast Cancer NetworkCSCCN LAEDI Programme:
• Any questions?