Improving Cancer Services

in the area served by the Mid Anglia Cancer Network

Urology Cancers Bladder, Kidney and Prostate

Formal Consultation 5th July 2004 to 3rd October 2004

Distributed by the Mid Anglia Cancer Network on behalf of the following NHS Organisations: Central Suffolk PCT Chelmsford PCT Colchester PCT Ipswich PCT Maldon and South Chelmsford PCT Suffolk Coastal PCT Tendring PCT Witham, Braintree and Halstead Care Trust Essex Rivers Healthcare NHS Trust The Ipswich Hospital NHS Trust Mid Essex Hospital Services NHS Trust

Distribution To: Mid Anglia Cancer Network Users Groups Cancer Patient Support Groups Community Voluntary Services PPI Forum Support Organisations Acute Trust Urological Clinical Teams Acute Trust Management Teams Primary Care Trust Chief Executives Primary Care Trust PEC Chairs Local Representative Committees

GP Practices (distribution to GP premises via Primary Care Trusts) County and Borough Councils Local Voluntary Groups PPI Forums Parish Councils Overview & Scrutiny Committees

Strategic Health Authorities Neighbouring Cancer Networks Members of Parliament Social Services Libraries in Essex and East Suffolk Post Offices (for publicity on meetings)

Copies of this document are available from: The MACN Management Team Offices Tel: 01206 288267 Fax: 01206 288270 This element of the consultation process ends on 3rd October 2004

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Contents 1. What are we proposing?………………………………………………………………………..4 2. What does this mean for patients?……………………………………………………………5 3. What are we consulting on?……………………………………………………………………8 4. More detail on the options……………………………………………………………….……11 5. What have people said so far?………….….…………………………..…………...…...…...13 6. Some questions answered…………………………………………………………………….15 7. How to give your views………………………………………………………………………..18

• Writing to us/returning feedback forms • Attending a meeting • Key contacts • Public meetings - timetable

Appendices 1. Mid Anglia Cancer Network Executive Board Membership 25 2. Criteria on which the centre was selected 26 3. The report of the Expert External Review Team 30

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1. What are we proposing? The Mid Anglia Cancer Network is responsible for developing cancer services for people who live in East Suffolk, North and Mid Essex. It is required to put national guidance into action in its area so that cancer services for local people can improve further. The Urology Cancer Centre For some cancers it is known that complex major surgery is best done by specialist units working as larger teams rather than by individual surgeons working alone. The cancer network has already created a specialist centre for gynaecological cancer surgery in Ipswich Hospital, and has planned a centre for cancer of the stomach and gullet in Broomfield Hospital, Chelmsford. Patients will have major operations for these cancers if they are needed at the hospital that specialises in this type of operation. It is now proposing to develop a centre for specialist surgery for cancers of the kidney, prostate and bladder. Most patients who need surgery for these cancers will not need complex major surgery. The local teams will still be doing most urology cancer surgery, and all other treatments such as radiotherapy and chemotherapy, locally as before. The Cancer Network Board invited proposals to create the centre from Colchester and Ipswich (Chelmsford was not able to prepare a proposal). It has identified its ‘preferred option’, which is to site the centre in Ipswich Hospital. To help it reach this conclusion, it sought the views of an independent review panel made up of experts in these cancers. It has also had ‘informal consultations’ with people affected by the change. Many people criticised the informal consultation document previously sent out by the cancer network. It did not provide enough information (especially about the Colchester proposals) to give people a balanced view. We apologise for that, and have tried to correct the problem in this document. Now the cancer network needs your views, to help it make its decision. Why did the cancer network prefer Ipswich? The Expert External Review Team recommended Ipswich because:

• The proposals from Ipswich to create a specialist team for the whole network were more robust.

• It had kidney dialysis on the main hospital site. • Ipswich already had the specialist centre for gynaecological surgery, and the two

specialities often need to work closely together. There is more detail in section 4, and the whole report is attached as appendix 3. Before the Mid Anglia Cancer Network decides where to locate the centre, it needs to know what you think.

The proposal is for Ipswich to become the urology cancer surgery centre for the Mid Anglia Cancer Network.

Most of the diagnosis, all treatment and follow up care, and most cancer surgery, will continue to be carried out at the local hospitals.

Only specialist surgery will be carried out at the centre.

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2. What does this mean for patients? Most patients who have symptoms that suggest cancer of the kidney, bladder or prostate will first see their local family doctor. If the doctor suspects cancer, he will make an urgent referral to the local urology cancer unit in Chelmsford, Colchester or Ipswich. The local unit will do tests to confirm the diagnosis. For some people these tests can be done in their local community hospitals. For most people with these cancers, the best treatment will be limited surgery, radiotherapy, chemotherapy or hormone treatment. These will be done at the local hospital or radiotherapy unit, as they are now. For a few patients, the tests may reveal a cancer that is best treated by complex major surgery. This treatment will be offered at the network surgical centre. They will have their treatment plan discussed at their local hospital first, before they make up their mind. If they agree to have this surgery, the centre will arrange to admit them for the surgery. For most patients this will be the only visit they need to make to the specialist centre. Most will be in hospital for 7-10 days. After the surgery, they can continue follow up treatment and care at their local hospital. What are the benefits of the proposal to create a specialist centre?

• More patients will benefit from specialist care. • Centres of expertise will be available locally within the network, not outside in Cambridge or

London. • Specialist centres will improve standards of care throughout the network.

What are the disadvantages of the proposal to create a specialist centre?

• People may have to travel further than they do now for their operations. • Their families may find it hard to visit. • They may not have as much support from family and friends at a critical time. • The choice of location may be of less advantage to some than to others.

What will happen at the specialist centre? The team at the new centre will have to plan for just under 100 operations every year. These are complex operations so there will be a strong support team in place as well. This will mean some extra staff will be recruited. The cancer network hopes that surgeons who already specialise in these operations in Chelmsford and Colchester will go to operate at Ipswich. By working more closely together, they can develop even greater expertise. There will be additional specialist nurses at both the new centre and the local units, to help patients through this difficult time. The team from the centre will be in regular (weekly) communication with the local teams. That means that everybody who has this type of cancer and needs complex surgery can have their case discussed with the specialist team. If you need kidney dialysis after the operation, Ipswich has a unit on site which can provide this.

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Looking after you and your family in the specialist centre If you need complex surgery at the centre, this will be discussed with you at your local hospital. You will usually be able to discuss this surgery with one of the centre team. Your local specialist will also be able to explain the surgery.

• You will normally be contacted by one of the specialist centre team, often a specialist nurse. They will explain how you and your carers will be looked after.

• If you need transport to get there and back, this will be arranged according to your needs.

• If your family or carer need help with transport or accommodation while you are in hospital,

the centre team will be able to help with these arrangements on an individual basis. Both Ipswich and Colchester Hospitals have hotel accommodation for patients and carers.

• The team will explain to you what to expect.

• The surgery will be done within a month of your agreement to go ahead with this treatment.

Will the local urology cancer team be damaged by this proposal? It is important that people with this type of cancer have as much treatment as possible as close to home as possible. This proposal makes sure of that. The cancer network wants to keep local services as strong as ever. The external review team told the cancer network to introduce the patient pathways pioneered by Colchester for diagnosis and local follow up in Ipswich and Chelmsford, because they were so good for patients’ experience. This will mean developments and investment in local services across the network. Specialist surgery is different – and the external review team thought that Ipswich would make a better base for the specialist surgery, because they had a more robust plan for the specialist and network team. The new centre will not start until the full team is in place. This might mean (under this proposal) a surgeon travelling from Colchester and a surgeon travelling from Chelmsford to take part in the work of the new specialist centre. It might mean appointing a new surgeon to work at the centre.

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The patient pathway for Cancer of the Kidney, Bladder and Prostate This is what might happen to you, under these proposals, if you were a patient with urological cancer Local care is in yellow boxes. Specialist care is in green boxes.

You have symptoms that suggest cancer

of the prostate kidney or bladder

You are referred to the local specialist

team for tests. These tests

confirm the cancer

Your treatment plan is discussed with the specialist

team at a network meeting. The best form of treatment is

agreed between specialists

You agree your treatment plan with the local team, which may include one of the specialist surgeons

You do not need specialist surgery

You have localised surgery, radiotherapy

or chemotherapy, hormonal or other

local treatments. All your treatment remains local

You go to the centre for surgery (7-10 days). All your other treatment (if any) will be local

You need specialist surgery

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3. What are we consulting on? In ths section we explain what we are consulting on. The cancer network has to implement national policy on specialised cancer services. This section explains that policy. National guidance on cancers of the bladder, prostate and kidney The national guidance that forms the basis of this proposal is ‘Improving Outcomes in Urological Cancers’. The guidance shows how treatment outcomes can be improved by creating specialist centres for certain types of cancer, and for some types of cancer surgery such as radical surgery for prostate and bladder cancers. Specialised surgical teams operating on a larger number of patients in larger centres produces better results for the patients – better survival, and fewer complications of surgery. Urological cancers as a whole are common cancers. Prostate cancer is the commonest male cancer, although bladder cancer and kidney cancer are less common. For most patients, treatment will be with surgery, radiotherapy, or hormone treatment. A small number of patients with these cancers (about 15%) will need complex major surgery. National guidance says that specialist teams should treat people who need complex specialist surgery in ‘cancer centres’. We know that more specialisation for complex major cancer surgery will improve survival rates and standards of care. The guidance recommends a minimum number of procedures per year, and a minimum population basis, of about 1 million people. Cancer services that do not meet the guidance will not be accredited. That means they would not be able to treat people with rarer cancers, or who need complex specialist surgery for some cancers such as prostate or bladder cancer. In Mid Anglia we do not have a specialist centre for urological cancers that conforms to the guidance at present. If we do not provide this service on a single site within this network people will have to travel outside of the network area for their treatment, e.g. to London or Cambridge The Board of the Mid Anglia Cancer Network has planned a process to agree the site for specialist centres in the network for rare cancers or for complex major surgery in some commoner cancers. It agreed a programme for evaluating local services in relation to national standards, beginning with gynaecological cancers, then cancers of the stomach and gullet, and now cancers of the bladder kidney and prostate. The Mid Anglia Cancer Network wants to build on local strengths, and it wants to keep services local as far as possible. Not all surgery for these conditions needs to be done in a specialist centre. Only ‘complex major’ surgery for the prostate or bladder, where the whole of the prostate gland or the whole of the bladder is removed, is specialist surgery. Some types of kidney surgery, where part of the kidney is left behind or where the cancer has to be removed from the blood vessels, is also considered specialist surgery. Other types of surgery for these cancers will continue to be done in each of the three local hospitals in the network. Teams of surgeons, oncologists (cancer specialists), specialist nurses and others will be working together across the network in a network multidisciplinary team (MDT) to help plan the most appropriate treatment for each individual.

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Developing specialist cancer surgery All over the country the NHS is working to develop specialist cancer surgery services, so that people with cancer receive the best possible care. The NHS has consulted widely on this, and there is general agreement that this is the best way forward. Specialist cancer surgical centres will have: • A focus on one type of cancer. This is known as ‘site-specialisation’. It means people with

rarer cancers, or people with common cancers who need complex surgery, will be treated at a hospital site serving a population of around 1 million people. This enables the professionals to develop and maintain a special interest and expertise in a particular tumour site or operation.

• Specialist teams. Each individual patient will benefit from having their care planned by a

multi-disciplinary team, by that we mean a dedicated group of doctors, nurses and other health professionals. All of the team will plan diagnostic care, treatment options and supportive care. All members of the team will develop expert skills and knowledge. This will ensure patients receive the best possible care and information – from diagnosis to treatment to follow up care.

When the Mid Anglia Cancer Network was set up in 2000-2001, there was extensive consultation on ‘site specialisation’. Most people then felt that creating specialist teams would be a positive development, even if they had to travel further for treatment. The Cancer Network Board realised that it would be difficult to decide where each centre would be. All choices will disadvantage some people. It decided to develop clear and transparent criteria for selecting the specialist centre. In May 2003 the draft criteria that the Cancer Network Board intended to use to decide the site of the urology cancer surgery centre were sent out to over 50 people for comment. This included health professionals, cancer service users, and health service managers. The Cancer Network Board also asked them to rank the criteria in order of importance to them. The results were then used by the Cancer Network Board to decide what they wanted the external review team to look at in their report in June 2003. These agreed criteria, and their ranking, are included in Appendix 2. What were the choices? The cancer network has to follow national guidance. There could only be one specialist surgery centre for urology in the network. It invited all the hospitals in the network to submit proposals to become the Urology Cancer Centre. Chelmsford decided that it was not able to support a Urology Centre so it supported Colchester in its bid. The choice for the network was therefore between Colchester (supported by Chelmsford) and Ipswich. Once the Cancer Network Board had received the proposals from Ipswich and from Colchester it asked an Expert External Review Team from outside the local area to help it reach a decision. This panel included a patient suffering from a urological cancer. The Cancer Network Board asked the external review team to use the criteria it had set out (see Appendix 2) in reaching its conclusions. The 4 experts spent a day visiting each site, talking to the teams, hearing their proposals, and asking questions.

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The external review team prepared a report which the Cancer Network Board considered in October 2003. The panel expressed the view that both teams provided high quality services, and both bids were strong, with different strengths and weaknesses. On the basis of this report, the Cancer Network Board decided that its preferred option was to site the centre in Ipswich. The Cancer Network Board has not yet made a decision. It must consider the external review team’s views, the views of the public and those affected by the proposal before it reaches a decision. The cancer network has already undertaken an informal consultation to hear from those most directly affected by the change. It has held a number of meetings and received written submissions. The key themes from this exercise are summarised in Section 5. Many people in their response to the informal consultation asked why the Colchester proposal, which had been supported by Chelmsford was not properly identified as one of the options. The strengths and weaknesses of each proposal were not included. The cancer network recognises it got this wrong and apologises for that. We hope to put this right during the formal consultation. Before the Cancer Network Board makes its decision, it needs to hear from the widest possible range of people. That is why it needs your views. Why did the Expert External Review Team recommend Ipswich? There is more detail from the report in Section 4, but the main areas which the external review team considered to discriminate between the two proposals, are summarised below: • The external review team were impressed with the written proposals and presentations.

It was evident from these that both Trusts provide a service of very high quality. • Ipswich Hospital NHS Trust (IHT) was particularly commended for its focus on the

network dimensions of its proposals. The two options suggested by IHT to address the surgical and multi disciplinary team (MDT) workload issues were considered by the review team to represent a robust and flexible approach to ‘centre’ working which was likely to be successful.

• A urology cancer surgical centre will require dialysis facilities. This is at present only

available in Ipswich or Chelmsford. • Essex Rivers (Colchester) Healthcare Trust (ERHT) was considered by the team to

provide a service that was exceptionally patient focussed, improving the patient pathway by transferring so much activity to a community setting in nurse led units. The external review team were not convinced that ERHT had fully considered the implications of the standards-based requirements of a specialist cancer surgery centre. The focus of its existing service has been the diagnostic and follow up pathway for patients with and without urological cancer. The external review team considered that the proposal from ERHT did not address the requirements of a centre in sufficient detail for the team to be confident that their proposals would deliver effective high quality specialist surgical treatment for urological cancer.

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Both Trusts had the opportunity to present all their information, and there was much else that the external review team considered. In many areas, there was little to choose between the two options. What happens next? When the results of this formal consultation stage are known the Cancer Network Board will consider: • The report of the external review team. • The views of the informal consultation i.e. those most directly affected by the change. • The results of this consultation including responses from the Colchester and Ipswich Hospitals. It will make the final decision in October 2004. 4. More detail on the options Ipswich Hospital Ipswich Hospital presented two options: one where 1 surgeon from the other Trusts in the network joined the specialist team in Ipswich, and one in which Ipswich recruited a new surgeon. The costs of the Ipswich bid were put at just over £500,000. The proposal included the necessary description of activity, research, and capacity. It was able to show how it could accommodate the proposed new service. It referred to the presence of specialist gynaecological cancer surgery and dialysis on the main hospital site. Essex Rivers (Colchester) and Mid Essex Hospitals (Chelmsford) Colchester presented their preferred model of care. They included much detail on their innovative clinical pathways, and their very strong research basis. The proposals included the necessary description of activity and capacity. They were able to show how it could accommodate the proposed new service. They referred to the close physical relationship between gynaecological theatres and the proposed urology centre. Their estimated cost was just under £400,000. Both proposals were very strong on patient information and support. The external review team made some specific recommendations. These are longer quotations to illustrate how they reached their conclusion (The detailed report is attached as Appendix 3). The external review team were not convinced that ERHT had fully considered the implications of the standards-based requirements of a specialist cancer surgery centre. The focus of its existing service has been the diagnostic and follow up pathway for patients with and without urological cancer.

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IHT, because it is geographically at one end of the network, needs to demonstrate that it would be able to provide a service of sufficiently high quality to persuade patients and commissioners that transport and access difficulties would be balanced by the strengths of the proposed service. The review team considered that their proposals did show the required commitment to excellence. Concerns about the available capacity in ICU/HDU (Intensive Care Unit or High Dependency Unit)beds were addressed to the team’s satisfaction by the Chief Executive.’ Does the proposal address the proposed size and composition of the specialist urological team in conformity with outcomes guidance? ERHT Colchester “The sessional commitment of the members of the centre MDT is not clearly defined’…The external review team considered that the network MDT is the essential ‘driver’ for a specialist surgery centre, and that it is unlikely that the network MDT would achieve its objectives without sufficient consultant input. No allowance was made in the proposal for additional oncology input from Ipswich to the network MDT. The proposal elsewhere refers to the important principle that patients should have treatment such as chemotherapy and radiotherapy locally where available, and this would demand the participation of the specialist oncologist from Ipswich. The additional consultant sessional time that would be required was thought to have been significantly underestimated. The additional clinical nurse specialist that was to be recruited by ERHT was said in the presentation to be required (and was to be recruited for) for the local service. The external review team considered that the clinical nurse specialist time required for a specialist cancer surgery centre is likely to have been underestimated’. IHT Ipswich The two options suggested by IHT to address the surgical and MDT workload issues were considered by the external review team to represent a robust and flexible approach to ‘centre’ working which was likely to be successful Has the proposal addressed which associated surgical services (cancer and non cancer) need to be co-located? ERHT Colchester The location of the specialist gynaecological cancer surgery centre in Ipswich is seen by the external review team as a disadvantage, although they recognised that the main benefit of the co-location of gynaecological and urological cancer surgery is to the gynaecological cancer surgery service. A more significant concern was the lack of dialysis facilities on site in Colchester. IHT Ipswich The location of the specialist gynaecological cancer surgery centre in Ipswich is seen by the review team as an advantage. The on site dialysis unit which does treat patients from North Essex is an advantage. Conclusions The external review team has concluded that both proposals have strengths and weaknesses as outlined above. They considered that the proposals from Ipswich represented a clearer vision of the requirements for a specialist urological cancer service for this network. “The innovative clinical pathways described in the ERHT proposals are a model of good practice for the diagnostic and follow up components of the service, and should be adopted throughout the network.”

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5. What have people said so far? The cancer network has already run an Informal Consultation Process lasting from mid February to the end of March 2004. This was designed to seek the views of all those who were most directly affected by the proposals. We prepared a document setting out the proposal, and sent it to staff and patient groups in the network. We also held a series of meetings at different sites within the network. The document we sent them was not very clear or detailed and this in itself has raised a lot of concerns. We have tried to address those concerns in discussion meetings and in written replies, as well as in this document. We have received 175 written responses to the informal consultation, including 2 detailed critiques. Most of the written views have been in favour of the proposal (approximately 160 out of 175). More information on these is available on request. Many people expressed the view that they were satisfied with their local service but understood the need for change. The principal concerns that have been raised include: • Concerns about travel and car parking

Many people have expressed concerns about this. The cancer network, when it makes its final decision will require the successful proposals to include much more detailed information on how they propose to manage this. Some very helpful suggestions have been made – e.g. greater use of voluntary drivers. For most patients, there will just be one visit for surgery. If the local surgeons travel to Ipswich to take part in the specialist team surgery there, follow up and continuity of care will be maintained locally.

• Concerns about support for families and carers In Ipswich there is access to patient accommodation which can be used for relatives/carers. Again the cancer network will require the successful proposal to explain in detail how this will be provided. Some patients from Chelmsford have recently had this type of surgery at Ipswich and were very supportive of the service there.

• Concerns about the continued viability of local services

Many staff and other health professionals were concerned that moving specialised urology cancer services to Ipswich will make it much more difficult to recruit and retain staff in Colchester. This has not happened elsewhere in the country where these proposals are being implemented, and only a very small amount of patient work is being transferred. Colchester remains in the forefront of pioneering work for diagnostic and local care pathways for urology cancer and for research. It is a strong cancer centre for radiotherapy and chemotherapy, and due for a massive investment in new facilities soon.

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• Concerns about the process used by the Mid Anglia Cancer Network to select the site for specialist urological cancer surgery

• People were concerned that the criteria had been changed after they had been agreed by the Cancer Network Board. This did not happen.

The criteria that were discussed and then adopted with modifications by the full Mid Anglia Cancer Network Board on 19th June 2003 were exactly those sent to the external review team before their assessment. These are set out in Appendix 2.

They were designed to ensure that the chosen criteria reflected local circumstances in the Mid Anglia Cancer Network. Other cancer networks use different processes to reflect their own local circumstances.

• People were concerned there was a ‘secret’ verbal report from the external review team

to the Board. This did not happen.

• People were concerned that the consultation was a sham because the decision had been made.

The Mid Anglia Cancer Network has not yet made its final decision. It will not do so until it has considered all three components of the process it set up to help it make this decision. These include the report of the external review team, and the results of the two consultations.

Other points that have been raised included: • Some of the strengths of the Colchester unit were ignored by the external review team. This particularly relates to the strengths in research and innovative patient pathways. These factors were considered by the external review team but they did not consider that they could predict the strengths of a specialist surgical team operating on behalf of the whole network. • The criteria and the report made no reference to clinical outcomes, which are of the

greatest importance in selecting the centre. Outcomes were not finally included in the criteria because information collected from individual Trusts or surgeons cannot predict outcomes from a network centre operating on more patients. The very reason behind the creation of a specialist surgery centre is to improve outcomes. It is also very difficult at the moment to collect reliable outcome data. These could only be used to make valid comparisons between hospitals if there were externally validated, case mix adjusted data available for both Trusts. Unfortunately these are not available. Each Trust provided their own outcome data, without external validation, to the external review team when it visited. It would have been impossible to tell whether any differences between the two Trusts arose by chance, or because of imperfect data collection, or as a result of true performance differences between the two Trusts. The next section answers some questions you may already want answers to.

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6. Some questions answered a. How many people will go to Ipswich for surgery?

About 70-90 people a year. From previous figures we know that it is likely to be around 25 from each of the areas served by the hospitals at Chelmsford, Colchester and Ipswich. b. What about travelling? A key part of the detailed planning process over the next months will be to ensure that appropriate transport arrangements are made. People who need hospital transport will have this arranged in the normal way. Transport for relatives/carers will also be considered as part of the detailed planning process. Car parking at Ipswich has to be paid for, but this is the case now in all NHS hospitals. However, special arrangements exist for patients requiring regular visits for cancer treatment and this is likely to be extended to next of kin for visiting purposes where the relative has to travel long distances. These arrangements include special passes and reduced parking rates for limited time periods. Information on how to get to the hospital by road and public transport will also be published for relatives and patients, as will car parking charges and details. c. Family support can be very important. Won’t this be more difficult for those who have to travel? The plans for specialist urology cancer surgery at Ipswich will include some accommodation for those relatives and carers who need to stay overnight in the hospital. These plans have not yet been finalised. The importance of family support is recognised and arrangements will be looked at very closely in the detailed planning stage which will involve patients and carers. Your views and ideas on this will be taken into account. The Ipswich Hospital Trust proposals said:

‘The Ipswich Hospital NHS Trust has learnt from its experience and success, in arranging transport and accommodation for patients and their carers/families previously. In particular for the urological cancer patients from mid Essex who received specialist surgical care at The Ipswich Hospital NHS Trust from August 2002 until August 2003. Transport and accommodation will be provided, if required, and will be tailored individually dependent on patient choice and need, to reduce the stress involved in what is already a physically and emotionally difficult experience’

The Colchester proposal said:

‘Access to Colchester General Hospital is already good and set to improve further. Colchester Station is only half a mile away, with frequent bus connections, and a new direct link to the A12 will dramatically improve road access from Chelmsford and Ipswich. Good access is further complimented by the patient services on site; hotel type accommodation, restaurant and café facilities and on-site patient transport centre.’ ‘The hospital already regularly accommodates 10–12 patients/relatives in a patient hotel style accommodation. There is additional capacity, which is being further expanded and

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will be complete by the end of 2004. This will include purpose built and designed patient/relative accommodation adjacent to the main body of the hospital. It is proposed to offer accommodation to relatives of patients undergoing surgery/treatment in the centre at Colchester. This will reduce the burden on travel during the patient’s hospital stay.’

d. What information will be available for patients/carers? Information about the centre will be available for patients. It will also include details of public transport arrangements, car parking, the facilities and other useful information. e. What if the cancer comes back? If the cancer comes back then treatment will be at the local hospital, unless further specialist surgery is required. f. What about re-admission after surgery?

Your local healthcare team will manage your care. However, should you need further specialist surgery you will be referred back to the specialist centre. g. Is this being done to save money? No. Cancer surgery centres are being developed because this is the best way to improve clinical standards and care. In fact more money is required to enable these changes to happen. h. Why does the specialist urology cancer surgery centre need to be developed? National expert teams are responsible for ensuring that services comply with national guidance. Local services are expected to put the guidance into action promptly, so that people receive improvements in care as soon as is possible. The Mid Anglia Cancer Network will be reassessed to see if it has a specialist urology cancer surgery centre in operation, that meets the guidance, in 2 years’ time. Failure to comply would mean that the network would not be accredited. As a result all patients would have to be referred to a specialist centre, outside of the network area, that does meet the guidance standards. i. How will you know that the service is better? An external review of the services will be made in 2 years’ time to ensure it meets national guidance. If the guidance is not met then the service will not be accredited. This would mean that it would be unable to treat patients with the rarer forms of cancer. The national guidance that is driving this work is based on good scientific evidence. It has been written by a group of national cancer experts which include Professor Mike Richards (the National Cancer Director), the NHS Centre for Reviews and Dissemination at York, the Department of Health, patients, cancer nurses, cancer specialists, urology surgeons and GPs. A much wider group which included the voluntary sector and charities was also involved.

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The Mid Anglia Cancer Network is also working hard in supporting its User Network so that it can seek the views of users, relatives and carers on a regular basis. Users and carers will also know where things could be better and if there are gaps, for example – not enough information, poor communication. j. What about other cancers? People with common cancers such as breast, colorectal and lung cancers make up approximately 50% of all cancer cases. These will continue to be treated at the local hospitals in Colchester, Chelmsford and Ipswich. For rarer cancers, patients will have their operation at the hospital selected to specialise in them. Determining the location of these involves - an independent expert review to measure the existing services against national guidance and consultation and discussions with local people and clinicians.

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7. Next steps and why we need your views The Mid Anglia Cancer Network has completed an ‘informal’ consultation programme in which it sought the views of those most directly affected by this proposal. The views expressed, and responses to these, are outlined in section 5. The formal part of the consultation process is designed to enable anyone or any organisation that may have an interest in, or be affected by, the proposed changes to consider and then comment on them. This formal stage of the consultation period will finish on 3rd October 2004. There will then be a full analysis of the results of the consultation. The Cancer Network Board, which has the delegated authority, will make its final decision on the proposed centre in October 2004, and must take into account the results of both consultations. Some of the concerns raised in the external review team report, in particular the co-location of kidney dialysis, may have changed since the review. The formal consultation process also gives Colchester and Ipswich Hospital Trusts and other NHS organisations a chance to respond to any concerns that have been raised, either from the external review team’s teport or in the informal consultation. With this document is a form enabling written comments to be made. You may also wish to attend a meeting to question representatives from the cancer network. There will also be several locality based ‘open’ forums (public meetings) to allow you the opportunity to find out more about this proposal and to raise issues you may have with it. Details of these meetings are attached below. If you would like any more information, including more details of the written responses to the first part of the consultation sent to the network please contact the network management team. Contact details below.

How to give your views a. Written views and/or the enclosed feedback form should be sent to: Dr David Blainey - Lead Clinician Mid Anglia Cancer Network Mid Anglia Cancer Network 659/662 The Crescent Colchester Business Park Colchester Essex C04 9YQ Tel: 01206 288267 Fax: 01206 288270 E-mail contact: pauline.stone@colchester-pct.nhs.uk b. Attending a meeting If you would like to attend one of the meetings below, you don’t have to book – just turn up. It would help us, though, if you could let us know you were coming. Just phone Pauline Stone on 01206 288267, or email pauline.stone@colchester-pct.nhs.uk, or write to any of us at:

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Mid Anglia Cancer Network 659/662 The Crescent Colchester Business Park Colchester Essex C04 9YQ c. Key Contacts Dr David Blainey - Lead Clinician, Mid Anglia Cancer Network Tel: 01206 288261 Jo Tonkin - Lead Nurse, Mid Anglia Cancer Network Tel: 01206 288262 Details of public meetings:

Venue Date Time Ipswich Hospital Seminar Room 2 PGMC Heath Road

Ipswich Suffolk IP4 5PD

26 July

11:30 – 13:00

Halstead Hospital Speech Therapy Room 78 Hedingham Road

Halstead Essex C09 2DL

27 July

12:00 – 14:00

Harwich and District Hospital Meeting Room 417 Main Road Dovercourt

Harwich Essex C012 4EX

28 July

12:00 – 14:00

St Michael’s Day Hospital Physiotherapy Gym 142 Rayne Road

Braintree Essex CM7 2LJ

29 July

12:00 – 14:00

Clacton and District Hospital Meeting Room Tower Road

Clacton on Sea Essex C015 1LH

3 August

12:00 – 14:00

Aldeburgh and District Community Hospital Seminar Room Park Road

Aldeburgh Suffolk IP15 3ES

12 August

18:30 – 20:00

Broomfield Hospital Nash Room Court Road Broomfield

Chelmsford Essex CM1 7ET

13 August

13:00 – 14:30

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Colchester PCT Large Conference Room Health Offices Turner Road

Colchester Essex C04 5JR

19 August

12:00 – 14:00

St Peter’s Hospital Social Hall Spital Road

Maldon Essex CM9 6EG

23 August

18:30 – 20:00

Clacton and District Hospital Tower Road

Clacton on Sea Essex C015 1LH

6 September

18:30 – 20:30

Ipswich Hospital Seminar Room 2 Post Graduate Medical Centre Heath Road

Ipswich Suffolk IP4 5PD

16 September

18:30 – 20:00

Colchester General Hospital Lecture Theatre Post Graduate Medical Centre Turner Road

Colchester Essex C04 5JL

20 September

18:30 – 20:30

Broomfield Hospital Lecture Theatre Medical Academic Unit Court Road Broomfield

Chelmsford Essex CM1 7ET

22 September

18:30 – 20:00

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Feedback Form Formal consultation period to 3rd October 2004 Improving Cancer Services for People with Cancer in the area served by the Mid Anglia Cancer Network

Urology Cancer

How you can influence this part of the consultation process Thank you for taking the time to contribute to this consultation process. Feel free to respond to all or just some of the questions below, but please complete the following details: Town/village where you live……………………………………………………………………. Are you Patient Relative/Carer (please tick whichever apply) Primary care clinician/manager Other Job/organisation/group (if relevant)…………………… Name (optional)…………………………………………… Address (optional)………………………………………… ---------------------------------------------------------------------- Cancer services need to change as a result of nation The guidance says that people with some types ohave their operation in specialist centres. These shoaround 1million people. Evidence shows that this wi The proposal is that Ipswich Hospital should be devesurgery centre for people in south Suffolk, mid and nto mean a 7-10 day hospital stay in Ipswich. The majority of services such as outpatient visits, chwill continue to be provided from the local hospitals a

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Secondary care clinician/manager

………………………………………

……………………………….……

………………………………….…

----------------------------------------------

al guidance that aims to improve serv

f cancer requiring specialised surgeuld be large enough to serve a pop

ll improve survival rates.

loped to become the specialist urologorth east Essex. For most people th

emotherapy, and surgery for commont Colchester, Chelmsford and Ipswich

ices.

ry should ulation of

y cancer is is likely

cancers .

Question a. Do you have any views, comments or ideas regarding this proposal? Question b. What do you think are the most important issues for patients?

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Question c What do you think are the most important issues for staff? Question d. Do you have any ideas or views on improvements that would benefit people using urology cancer services? Question e. Any other comments?

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Please complete and return to: Mid Anglia Cancer Network, 659/662 The Crescent

Colchester Business Park Colchester

Essex C04 9YQ

Tel: 01206 288267 – Fax: 01206 288270

Deadline for responses: 3rd October 2004 Please Note: Responses may be made public unless confidentiality is specifically requested

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APPENDIX 1 The Mid Anglia Cancer Network Executive Board Membership Brendan Osborne, Chief Executive, Colchester PCT – Chair Lesley Watts, CEO, Ipswich Primary Care Trust Mike Harrison, CEO, Maldon and Sth Chelmsford Primary Care Trust Dr Linda Hastings, Deputy Medical Director/Consultant in Public Health Medicine, Essex Strategic Health Authority Deborah Knight, Head of Clinical Networks, Norfolk, Suffolk and Cambridgeshire Strategic Health Authority Paul Forden, CEO, Ipswich Hospital NHS Trust Andrew Pike, CEO, Mid Essex Hospital NHS Trust Peter Murphy, CEO, Essex Rivers Healthcare NHS Trust Rosy Stamp, CEO, St Helena Hospice In attendance – The network management team: Dr David Blainey, Lead Clinician, Mid Anglia Cancer Network Joanne Tonkin, Lead Nurse/Acting Lead Manager Mid Anglia Cancer Network Lead Manager, Mid Anglia Cancer Network User Representative, Mid Anglia Cancer Network The Mid Anglia Cancer Network Executive Board has responsibility for improving cancer services for the people of south Suffolk, mid and north-east Essex. The Board has senior representatives from local health organisations. It has the delegated authority from Strategic Health Authorities to make decisions on changing services for cancer patients. It must take into account the views of those affected by the change, and the general public.

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APPENDIX 2 Mid Anglia Cancer Network: Process for the centralisation of Intermediate Cancer Surgery – Urology Adopted by the Mid Anglia Cancer Network Board on 19th June 2003 Key principles: 1. The MACN Board has agreed that urological cancer surgery for intermediate cancers will be conducted in one centre within this network in accordance with outcomes guidance. 2. There will be a separate process for rare cancers which involves specialist commissioning. 3. The MACN Board will take the final decision on the recommendations for the location of the surgical centre. The decision making process to determine the location of the centre will be open and transparent and will involve key stakeholders (users, clinicians and the Strategy Board) at all stages. The decision will be based on the agreed criteria and will include external clinical advice. 4. Such recommendations will be subject to public consultation in accordance with Section 11 of the Health and Social Care Act 2001. 5. The network Board will commission appraisal of the applications, which will involve independent financial scrutiny, the views of users, and independent external clinical assessment. The expert clinical assessment will involve a review of the service ‘on the ground’. 6. The Board will use advice from these sources to reach its final decision, which will be made within the timescale agreed by the Board. 7. The Board’s decision will commit commissioners to the financial implications of this decision. 8. A process by which agreement between primary care commissioners regarding their respective contributions to network initiatives must be agreed. 9. The Board has agreed the following template to be provided to those submitting proposals which all applications from Trusts applying to become the centre for Urology surgical cancer services should follow. This will enable a standard approach in setting out cases to be adopted. Any additional information, not contained within the template, which Trusts believe is relevant and gives added value to the quality of their applications should be included. The pro-forma is broken down into sections as follows: 1. Introduction This section should contain a brief summary of the Trust as a whole, including its catchment population and a specific description of the current Urology services provided to its local population as well as the expected catchment area for the proposed centre. 2. Executive Summary Articulate the existing strengths of the Trust, specific to its ability to provide the centre based surgical services for the network population.

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With reference to elements of the criteria, the following need to be included providing confirmation of: � how the service will meet improving outcomes guidance � the costs of providing the centre based service and cost effectiveness analysis � how patients will access the service � the time needed to create the centre � the key staff required to support the centre service � how non malignant activity will managed � how academic links will be developed � and what impact the new service will have on other performance managed targets, for example waiting times. 3. The Centre Service Plan This section is the main element of the application and must reference to the criteria below: (i) Criteria a) How the proposal conforms with ‘Improving Outcomes Guidance’ (IOG) for urological cancer surgery. The main recommendations being: (taken from NICE IOG – The Manual). � All patients with urological cancers should be managed by multidisciplinary urological cancer teams. These teams should function in the context of dedicated specialist services, with working arrangements and protocols agreed throughout each cancer network. Patients should be specifically assured of: � streamlined services, designed to minimise delays � balanced information about management and options for their condition � improved management for progressive and recurrent disease � members of the urological cancer teams should have specialised skills appropriate for their roles at each level of the service. Within each network, multidisciplinary teams should be formed in local hospitals (cancer units); at cancer centres, with the possibility in larger networks of additional specialist teams serving at least populations of one million; and at supra-regional level to provide specialist management for some male genital cancers � radical surgery for prostate and bladder cancer should be provided by teams typically serving populations of one million or more and carrying out a cumulative total of at least 50 such operations per annum. Whilst these teams are being established, surgeons carrying out small numbers (five or fewer per annum) of either operation should make arrangements within their network to pass this work onto more established colleagues � major improvements are required in information and support services for patients and carers. Nurse specialist members of urological cancer teams will have key roles in these services � there are many areas of uncertainty about the optimum form of treatment for patients with urological cancers. High quality research studies should be supported, with encouragement of greater rates of participation in clinical trials b) The size and scope of the proposed centre based on the best available estimates of numbers treated. � how many patients � which procedures � the proposed size and composition of the specialist urological team (see ‘Improving Outcomes Guidance’)

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� what additional recruitment would be required to create the specialist team – link to waiting time performance targets � capacity – additional or existing � links with radiotherapy facilities � links with chemotherapy facilities c) Estimated Costs (include at Section 4) Applications should demonstrate consideration of the cost-effectiveness of the Trust becoming the proposed Centre. There should be evidence within the submission that all Primary Care Organisations (within the local sub-economy) have been involved in the decision-making process in relation to the Trusts’ application to become the Centre. This should include a summary of: � potential cost impact on the local sub-economy as a result of the centralisation of services (i.e. revenue consequences for PCTs) � potential losses of activity (as a result of centralisation of services) � potential activity gains (as a result of centralisation of services) � balance of capacity and demand d) Considerations of access for patients and their carers/families from elsewhere in the Network. � how local patients will be accommodated � how patients from elsewhere within the Network will be accommodated � how patients’ families and carers will be accommodated � how transport links to other parts of the Network will be created � how admission and discharge arrangements will be made e) An Implementation Timetable. f) Which associated surgical services (cancer and non cancer) need to be co-located. g) How national targets, including waiting times and pre-planned and pre-booked care will be achieved within the proposed centre. h) How key staff will be recruited to the proposed centre. i) What are the risks to completion of the project. j) Evidence of support from users and their representatives. k) How non-malignant workloads will be managed. l) How academic links will be developed. (ii) Model of Care A Model of Care should be included in this section clearly demonstrating the patient pathway from units to the centre and vice versa. The model should also be explicit in demonstrating how organisations would be affected by the pathway e.g. PCT’s. This should include diagnosis and referral in primary care, patient centred care including: � diagnosis and assessment in secondary care � treatment and palliative interventions and care � information/psychological/social and dietary support

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4. Impacts of not being designated as the ‘centre’ Trusts should articulate the impact of not being designated but be clear about service areas that would be significant in supporting the centre. For example, specialised technology already available and specialist skills – surgical/diagnostic. 5. Financial Summary This section should be set out in an Excel spreadsheet format. The presentation of the costings should identify the year one costs, which may need to include a capital element. Pay and non-pay should be based on the full year effect. MACN criteria for the selection of a Urological cancer surgery centre Scoring system 1= highest ranked criteria 11= lowest ranked criteria Criteria can be scored equally

Overall Ranking

Order of importance Overall position total

Overall Ranking

Criteria a – conforming with IOG 6 1 d – access for patients 6 1 h – key staff 13 3 g – waiting times targets 13 3 k – support from users 13 3 i – risks 21 6 c – estimated costs 22 7 m – academic links 25 8 e – timetable 27 9 l – non-malignant work 30 10

Note 1. Criteria b and f are excluded from this process because they simply specify the need to describe the proposed service.

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APPENDIX 3

MID ANGLIA CANCER NETWORK REPORT OF EXTERNAL REVIEW TEAM

UROLOGY CANCER SURGERY CENTRALIATION SEPTEMBER 15TH 2003

Overview The external review team was led by Mr John Anderson, Consultant Urological Surgeon from the Royal Hallamshire Hospital, Sheffield, and included Ms Beverly Baxter, Urology CNS, Derby City Hospital, Tony Harvey, User Representative from South Essex Cancer Network, and Dr Colin Trask, Consultant Oncologist and Lead Clinician, South Essex Cancer Network. The review was conducted by a visit to each site that had submitted proposals (Ipswich Hospitals NHS Trust (IHT) and Essex Rivers, (Colchester) Healthcare NHS Trust (ERHT) for a spoken presentation, a question and answer session and a tour of the site. A financial appraisal of each proposal was provided by Mr Peter Mickelsen, Finance Director at Colchester PCT, and presented to the review team at the conclusion of the visits. The review team were impressed with the written proposals and presentations. It was evident from these that both Trusts provide a service of very high quality. Ipswich Hospital NHS Trust (IHT) was particularly commended for its focus on the network dimensions of its proposals. Essex Rivers (Colchester) Healthcare Trust (ERHT) was considered by the team to provide a service that was exceptionally patient focussed. This Trust has demonstrated its commitment to improving the patient pathway by transferring so much activity to a community setting in nurse led units. The review team were not convinced that ERHT had fully considered the implications of the standards-based requirements of a specialist cancer surgery centre. The focus of its existing service has been the diagnostic and follow up pathway for patients with and without urological cancer. The review team considered that the proposal from ERHT did not address the requirements of a centre in sufficient detail for the team to be confident that their proposals would deliver effective high quality specialist surgical treatment for urological cancer. IHT, because it is geographically at one end of the network, needs to demonstrate that it would be able to provide a service of sufficiently high quality to persuade patients and commissioners that transport and access difficulties would be balanced by the strengths of the proposed service. The review team considered that their proposals did show the required commitment to excellence. Concerns about the available capacity in ITU/HDU beds were addressed to the team’s satisfaction by the Chief Executive. The review team has considered its responses in relation to the specific criteria set out by the Mid Anglia Cancer Network Board. These are detailed below to enable the Board to consider how each service compared. Assessment against specific criteria How many patients are to be treated at the centre in conformity with outcomes guidance? Does the proposal comply with estimates of network activity? ERHT Colchester The proposal is consistent with expected activity.

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IHT Ipswich The proposal is consistent with expected activity. Which procedures are to be undertaken at the centre? Does the proposal identify correctly the procedures to be undertaken in the centre and those in the units in conformity with outcomes guidance? ERHT Colchester The procedures expected to be undertaken at the centre and at the unit are correctly identified. IHT Ipswich The procedures expected to be undertaken at the centre and at the unit are correctly identified. Does the proposal address the proposed size and composition of the specialist urological team in conformity with outcomes guidance? ERHT Colchester The sessional commitment of the members of the centre MDT is not clearly defined in section 3.2 or appendix 1 of the proposal and was not clarified during the presentation. In the financial statement only 68 sessions of consultant time were allocated to the network or centre MDT, with an unspecified additional allocation for consultant sessions of £19.8k. The review team considered that the network MDT is the essential ‘driver’ for a specialist surgery centre, and that it is unlikely that the network MDT would achieve its objectives without sufficient consultant input. No allowance was made in the proposal for additional oncology input from Ipswich to the network MDT. The proposal elsewhere refers to the important principle that patients should have treatment such as chemotherapy and radiotherapy locally where available, and this would demand the participation of the specialist oncologist from Ipswich. The additional consultant sessional time that would be required was thought to have been significantly underestimated. The additional Clinical Nurse specialist that was to be recruited by ERHT was said in the presentation to be required (and was to be recruited for) for the local service. The review team considered that the clinical nurse specialist time required for a specialist cancer surgery centre is likely to have been underestimated. These factors impact on the financial estimates provided by ERHT (see below). IHT Ipswich The two options suggested by IHT to address the surgical and MDT workload issues were considered by the review team to represent a robust and flexible approach to ‘centre’ working which was likely to be successful. What additional recruitment would be required to create the specialist team? ERHT Colchester The proposals from ERHT did not provide the team with a clear understanding of the way in which the surgical team would operate, especially in relation to Ipswich. They did not appear to have considered the issues of sub-specialisation and cross cover within the centre surgical team in sufficient detail. There was a discrepancy between what was understood to have been agreed between Ipswich and Colchester and what was presented at ERHT.

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The review team questions whether it is fully appropriate to employ an associate specialist as an MDT co-ordinator, in what is primarily an administrative role. New recruitment of an administrator would add to the costs of the proposal. IHT Ipswich There needs to be clear agreement between surgeons as to how the sessional time is arranged, and this cannot be left entirely to the network lead clinician to resolve. Is there evidence of a link to performance against waiting time targets? ERHT Colchester - Yes IHT Ipswich - Yes What additional capacity has been identified as required? ERHT Colchester The additional capacity that was identified was 7 additional beds on the urology ward which were to be ringfenced, an additional ringfenced HDU bed staffed by urology nurses with HDU training, and additional surgical and CNS capacity. The latter is described above. IHT Ipswich There are concerns about HDU capacity, which the review team regarded as potentially underprovided, but it was confirmed that this would be addressed, Will effective use be made of existing capacity? ERHT Colchester See above. IHT Ipswich See above. Links with radiotherapy facilities. How will these be addressed in the clinical pathway? ERHT Colchester The non-inclusion of sessional time for the Ipswich and Chelmsford Oncologists in the network MDT raised concerns in the review team about the effectiveness of pathway co-ordination for radiotherapy across the whole network. IHT Ipswich Addressed in the MDT plan. Links with chemotherapy facilities. How will these be addressed in the clinical pathway? ERHT Colchester The non-inclusion of sessional time for the Ipswich and Chelmsford Oncologists in the network MDT raised concerns in the review team about the effectiveness of pathway co-ordination for chemotherapy across the whole network.

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IHT Ipswich Addressed in the network MDT plan. Has the proposal identified the potential cost impact on the local sub-economy as a result of the centralisation of services (i.e. revenue consequences for PCTs) ERHT Colchester ERHT are to be commended for including the impact of introducing funding by financial flows based on HRG tariffs, although these may be revised by the time the service (and financial flows) are introduced, especially for specialist services. The overall cost of the ERHT bid is lower than the IHT bid, but this is mainly because of the lower cost in the ERHT proposal of the network MDT. For the reasons described above, the review team considered this to be a significant underestimate of the clinical time required. ERHT did not identify the impact on individual PCT’s. It was noted by the review team that these estimated costs were a statement of intent, and may not accurately represent the costs to PCT’s. These will require further detailed negotiation. IHT Ipswich This bid is more expensive but this is because of the additional costs of the network MDT, and the project manager. No capital equipping costs were included. It was noted by the review team that these estimated costs were a statement of intent, and may not accurately represent the costs to PCT’s. These will require further detailed negotiation. Has the proposal identified the potential losses of activity (as a result of centralisation of services)? ERHT Colchester -Yes IHT Ipswich -Yes Has the proposal identified the potential activity gains (as a result of centralisation of services)? ERHT Colchester -Yes IHT Ipswich -Yes Have the proposals identified how patients from elsewhere within the Network, and patients’ families and carers be accommodated? ERHT Colchester -Yes IHT Ipswich -Yes Have the proposals identified how transport links to other parts of the Network will be created? ERHT Colchester -Yes IHT Ipswich -Yes

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Have the proposals identified how admission and discharge arrangements will be made? ERHT Colchester -Yes IHT Ipswich -Yes Is the Implementation timetable realistic and consistent with the principles of outcomes guidance? ERHT Colchester -Yes IHT Ipswich -Yes Has the proposal addressed which associated surgical services (cancer and non cancer) need to be co-located? ERHT Colchester The location of the specialist gynaecological cancer surgery centre in Ipswich is seen by the review team as a disadvantage, although they recognised that the main benefit of the co-location of gynaecological and urological cancer surgery is to the gynaecological cancer surgery service. A more significant concern was the lack of dialysis facilities on site in Colchester. It is believed that this will be provided as part of the new PFI but this is unlikely to be before 2008, and may not be on the main hospital site. A urology cancer surgical centre will require dialysis facilities. This is at present only available in Ipswich or Chelmsford. IHT Ipswich The location of the specialist gynaecological cancer surgery centre in Ipswich is seen by the review team as an advantage. The on site dialysis unit which does treat patients from North Essex is an advantage. Has the proposal addressed how national targets, including waiting times and pre-planned and pre-booked care will be achieved within the proposed centre? ERHT Colchester - Yes IHT Ipswich - Yes Has the proposal addressed how key staff will be recruited to the proposed centre? ERHT Colchester Not fully – see above in relation to comments on the network MDT. IHT Ipswich The 2 option plans for consultants and the possibilities for sub specialisation and cross cover are seen by the review team as robust and flexible. Has the proposal considered the risks to completion of the project? ERHT Colchester The main issues are lack of capacity (beds and staff). It is not certain how effective ringfencing will be in the absence of additional capacity for medical outliers. The organisation of the network MDT

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was also considered by the review team to be a risk to completion, in the sense that without an effective sessional commitment the network MDT is unlikely to achieve the required objectives. IHT Ipswich There is concern about the HDU capacity which is a significant risk. Is there evidence of support and participation in the preparation of the proposal from users and their representatives? ERHT Colchester The ERHT urological service is strongly patient focussed and is obviously extremely well supported by its users. IHT Ipswich There is evidence of user support. Has the proposal considered which non-malignant cases are likely to be done in the centre, and how the workloads will be managed. ERHT Colchester - Yes IHT Ipswich – Yes Does the proposal address how academic links will be developed. What evidence is there that patients are offered the opportunity to participate in local/national clinical research? Is there a history of initiating research? ERHT Colchester The review team were presented with evidence of close links with Essex University and the development of shared research projects. Information on participation in NCRN Trials was not presented. IHT Ipswich Links are being developed with Norwich. Information on participation in multicentre trials was presented although it was not clear how many of these were NCRN trials. Does the proposal address information and support services for patients and carers, and the role of nurse specialist members of urological cancer teams in these services? ERHT Colchester Information for patients is clearly identified as a priority for this service and a high standard is achieved. See above for reservations on the proposals for CNS support for the centre. IHT Ipswich Information and support is identified as a priority in the proposal. A new information and support centre adjacent to the radiotherapy and chemotherapy unit is being developed.

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Model of Care Has a Model of Care been included clearly demonstrating the patient pathway from units to the centre and vice versa? The model should also be explicit in demonstrating how organisations would be affected by the pathway e.g. PCT’s. This should include diagnosis and referral in primary care, patient centred care including: � diagnosis and assessment in secondary care � treatment and palliative interventions and care � information/psychological/social and dietary support � Follow-up care � Emergency readmissions ERHT Colchester - Yes IHT Ipswich -Yes Neither clinical pathway addressed the issue of emergency readmissions but it is understood that this is unlikely to be agreed until the different options for surgical cover for the centre have been determined. Conclusions The review team has concluded that both proposals have strengths and weaknesses as outlined above. They considered that the proposals from Ipswich represented a clearer vision of the requirements for a specialist urological cancer service for this network. The innovative clinical pathways described in the ERHT proposals are a model of good practice for the diagnostic and follow up components of the service, and should be adopted throughout the network. On this basis, the review team makes the following recommendations: 1. Ipswich Hospital NHS Trust should be designated as the specialist centre for urological cancer for the Mid Anglia Cancer Network. 2. Immediate steps should be taken to establish a network MDT for patient discussion, and this should be in place before clinical pathways change. 3. The patient focussed pathways developed in ERHT should be used as the basis for diagnostic and follow up services throughout the network.