Download Achievement of Revised Cancer Waiting Times Standards

Agenda Item 8b
Achievement of Revised Cancer Waiting Times Standards
1.
Introduction
This paper provides an update on performance against the Cancer Waiting Times Standards and the
plan to improve and ensure compliance with the revised waiting times standards in accordance with the
Cancer Reform Strategy as part of “Going further on Cancer Waits”. In particular the paper details the
challenges identified with the implementation of the new standards that came into force from 1st
January 2009, together with the new rules on the measurement of cancer waiting times which change
the way patient choice and deferrals for medical reasons are reflected in the time waited by a patient.
Whilst the definitive thresholds for the new cancer standards and associated changes to waiting times
have not been published, the National Cancer Action Team have provided some benchmarking
information, which are detailed in this paper and are being used as a working standard in the interim.
2.
Background
The NHS Cancer Plan in September 2000 introduced specific cancer waiting times standards. The first
of these standards was the maximum wait of two weeks for patients to be seen by a specialist following
referral by their GP with a suspected cancer (2-week wait). Secondly, where a cancer is diagnosed,
following the urgent referral by a GP, patients should wait no longer than two months (from the date of
the initial decision to refer) for the treatment to commence (62-day target). As not all cancers are
diagnosed via urgent referral for a suspected cancer, the third standard that was introduced in the
Cancer Plan was that all patients should wait no longer than one month following agreement to treat the
cancer, through to the commencement of treatment, irrespective of the initial route into the service, e.g.
as an emergency admission or via a routine outpatient appointment.
2.1.
Changes to the standards from 1st January 2009
In the Cancer Reform Strategy published in 2007, it was recognised that the 2-week wait, 62-day and
31-day target only applied to a limited number of patients in that the standards only applied to first
cancers and for the 2-week wait and 62-day target only included urgent referrals made be GPs. As part
of the Cancer Reform Strategy two significant changes to the cancer waiting times standards came into
effect in January 2009.
1) The first change was to increase the categories of patients included within the 31 and 62-day
standards. From 1st January 2009, any patients who are found to have a suspected or confirmed cancer
identified via any of the three national cancer screening programs (Breast, Bowel and Cervical) should
now receive their first treatment within 62 days of a referral being generated from their initial
investigation within the screening program. In addition consultants working within the organisation can
choose to ‘upgrade’ patients they suspect may have a cancer, so that they are managed along with GP
and screening referrals under the 62-day standard. The scope of the 31-day standard has also been
expanded to include all phases of treatment, for example, where chemotherapy is given ahead of
surgery and also for non primary cancers, i.e. recurrent or metastatic disease. All treatment types will
be included in this 31-day standard. However there is a national recognition that radiotherapy services
will take longer to increase capacity and as such the target does not become operational until December
2010 for those patients receiving radiotherapy other than for first treatment.
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2) The second change to the waiting times standards relates to the way in which we measure the length
of time a patient has waited. This change was made to bring cancer waiting times measurement in line
with the national rules for 18-week Referral to Treatment time measurement. From the 1st January 2009
it is no longer possible to adjust for a patient’s decision to wait longer for an outpatient appointment,
diagnostic test or any treatment carried-out in an outpatient setting. Similarly, time cannot be taken out
of a patients total waiting time to reflect periods when they were not medically fit for treatment (e.g. if
a patient has heart problems and cannot undertake surgery without further management of their
condition). The only permissible adjustments to the waiting times that can now be applied are to
reflect:


3.
The period when a patient was not able to be seen following their failure to attend their first
appointment following a suspected cancer referral (two week wait)
The patient choosing to delay their treatment if being delivered in the inpatient setting (e.g.
choosing to delay the date for their admission for surgery)
How will performance against these new standards be managed by the Healthcare
Commission and Monitor?
As mentioned in the opening part of this paper, the Department of Health has not yet confirmed the
operational thresholds for the 31, 62-day or the 2-week wait waiting times standards. However,
indications have been given that nationally, performance for the three targets is expected to be in the
region of the following:
 93% for 2-week wait (formerly 98%)
 86% for 62-day target (formerly 95%)
 98% for 31-day target (no change from previous threshold)
The Healthcare Commission will assess performance against the 31 and 62-day standards by way of
two indicators: a) performance under the ‘Existing’ standards for quarters 1-3; b) performance against
the new standards with the application of the new rules for waiting times measurement for quarter 4.
Performance against these two indicators will be combined to create a single score which will
determine whether each of the 31 and 62-day targets was ‘achieved’, ‘under-achieved’ or ‘failed’.
Performance figures for each of the ‘Existing’ standards during quarters 1-3 have already been
submitted to the Department of Health. For this part of the combined target the Trust is expected to
have ‘underachieved’ the required standard for the 31 and 62-day targets, although for the 31-day target
this is still subject to confirmation due to lack of clarity over whether the 97.6% performance will be
rounded-up to the required 98%.
Within Monitor’s Compliance Framework there are two sets of targets for both the 31 and 62-day
targets, with the new standards replacing the ‘Existing’ from the 1st January 2009.
4.
Operational Challenges
During the first three quarters of 2008/2009 the Trust encountered difficulties in achieving the former
(‘Existing’) 31 and 62-day standards. However, the change to the standards and the way waiting times
are measured has brought new challenges which need to be identified and managed afresh. Analysis
has therefore been undertaken of the first month of data (i.e. January 2009. From this some common
themes are emerging, some of which where previously present for the Existing standards and for which
actions have already been taken, some of which are new. It appears at this stage though that the main
challenges are limited to a small number of specialties and are not spread across the whole range of
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tumour sites for which the trusts provides cancer services.
4.1
Analysis of performance against the new standards under the new rules
1) Two-week wait - No patient should wait longer than two weeks to be seen for their first
appointment following referral from their GP
Old Threshold for
‘Existing’ standards
Expected
Threshold
Quarter 1 – 3
performance under
‘Existing’ standards
January 2009
performance
98%
93%
99.7%
89.9%
Figure 1 – Reasons for patients waiting longer than the 2-week to be first seen by a specialist during
January 2009
40
30
20
10
0
Did not attend first
appointment
Patient choice to delay first
appointment
Internal delay
During January, 396 suspected cancer referrals were received from GPs, of which 34 patients choose
an appointment outside of the 14 days to which an adjustment to the waiting times can no longer be
applied. This adversely affected performance reducing performance to 89.9%. During the same month
there were 2 breaches resulting from internal delays, i.e. lack of capacity for an appointment to be
offered within 14 days. Under the ‘old’ rules performance would have exceeded 99%.
2) 31-day standard – No patient should wait longer than 31 days for treatment following the decision
to treat
Old Threshold for
‘Existing’
standards
Expected
Threshold
Quarter 1 – 3
performance under
‘Existing’ standards
January 2009
performance
98%
98%
97.6%
97.2%
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Figure 2 – Reasons for patients waiting longer than the 31 days for treatment, following the decision to
treat, during January 2009
6
5
4
3
2
1
0
Other
Lack of theatre capacity
Medical deferral
During January, 213 patients received treatment (165 for first definitive; 48 for subsequent treatment)
against the new 31-day standard. Of these, 6 patients received their treatment outside of the 31-day
standard, 1 of which for medical reasons, which could not be adjusted for, and 4 due to lack of theatre
capacity. One further reason for breach is under review. Performance is currently close to the expected
required standard of 98%.
3) 62-day standard - No patient should wait longer than 62 day following an urgent GP referral,
consultant upgrade or referral via a national screening program
Old Threshold for
‘Existing’
standards
Expected
Threshold
Quarter 1 – 3
performance under
‘Existing’ standards
January 2009
performance
95%
86%
93.4%
82.3%
During January 70.51 patients received treatment against the 62 day standard, of these 12.5 (15 cases)
received their treatment outside of the standard. Delays caused by the Trust included the inability to
offer an outpatients appointment in a timely manner, to enable onward planning of treatment, and the
inability to schedule surgery within the target time. In addition to these internal delays, 5 patients could
have been treated within target but chose to wait for later dates for outpatient appointments and
diagnostic tests. As it currently stands the threshold for this standard is such that avoidable delays have
to almost be eliminated in order to consistently achieve the 86% target, due to the volume of patients
that choose to wait longer or are not fit to proceed to treatment, which previously we could have made
adjustments to the waiting times to account for.
1
Under national ‘accountability’ rules patient referred from other trusts for treatment are count as 0.5 patients in the
total treated and total breaches, reflecting the role the referring trusts should play in the management of the pathway to
the national standards.
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6
5
4
3
2
1
0
Previously
Lack of outpatient Lack of outpatient Late referral from
adjustable waiting
capacity
then theatre
other trust
time (e.g. patient
capacity
choice, medical
deferral)
4.
Diagnostic test
delay
Key actions to achieve improvement and sustainability:
It is clear that whilst the changes to the waiting times measurement and the inclusion of more patients
under the 31 and 62-day standards has had a significant negative impact on the reported performance,
there are still underlying themes which were present during the first three quarters if the year.
Throughout the year, work has been undertaken to improve performance against the ‘Existing’ cancer
standards, including changes to the management of beds to improve the throughput of thoracic (lung)
capacity, and improvements to the management of pathways for patients with skin cancer. These
changes have begun to have an effect and will continue to reduce the breaches of standard over coming
months. However, the Trust has also developed a comprehensive action plan to support specifically the
delivery of these new cancer standards, recognising that challenges remain and have been added to by
the changes in the waiting times measurement rules. The table below identifies deliverables and time
scales for the high impact actions within the action plan.
1.
2.
3
Action
Impact
Delivery date
Aim to offer all patients
referred via the suspected
cancer route the opportunity of
an appointment within 7 days
Decrease the effect of patient choice June 2009
by enabling patients to cancel and
re-book appointments still within
the required 2 weeks
Work collaboratively with NHS Improve the quality and timeliness
Bristol to fully implement
of suspected cancer referrals
Choose and Book for suspected
cancer referrals across the
health community
Pilot to start July
2009
Work collaboratively with NHS Ensure patients are referred
Bristol to agree a local policy
knowing they will receive an
for the management of patients appointment within 14 days and
June 2009
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4
5
6
who do not wish to receive
their first appointment within
14 days
improve the performance against
the 2-week wait standard
Review the outpatient capacity
for all specialities identified
from breach analysis as being
at risk of insufficient capacity
(colorectal, Urology, lung)
Reduce the length of the pathway
before a patient reaches a decision
to treat to increase the number of
patients being treated within 62days
April 2009
Ensure all specialities have the
required theatre capacity to
offer a treatment time within
target
Reduce the length of the pathway
from decision to treat to treatment,
increasing the number of patients
that will be treated within both 31
and 62-day targets
April 2009
Redesign pathways to ensure
all patients to reach a decision
to treat by day 41
Remove all unnecessary delays
from the patient pathway, ensuring
appropriate time available to plan
care
June 2009
Reduce the length of the pathway
before a patient reaches a decision
to treat to increase the number of
patients being treated within 62days
7
Re-affirm and reinforce via
regular feedback, the tertiary
referral process and timeliness
by which referrals should be
received from other trust
Improve the length of time in which
we have to plan and deliver
treatment
June 2009
Reduce the length of the pathway
before a patient reaches a decision
to treat to increase the number of
patients being treated within 62days
Prepared by: Teresa Levy (Cancer Service Manager)
Xanthe Whittaker (Head of Performance Improvement)
Presented by: Irene Scott (Chief Operating Officer)
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