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Highland NHS Board
7 April 2009
Item 5.4
Report by Christine McIntosh, Cancer Network Manager, Highland & Western
The Board is asked to:
Note the NHS Highland Implementation Plan for“Better Cancer Care, An Action Plan”
Endorse the priorities and actions on identified risk areas.
NHS Highland Board noted the launch of the new national strategy for cancer at its
December Board meeting. Through the Cancer Steering Group, and the leadership
and work of the NHS Highland Cancer Executive Team, a proposed delivery plan has
been brought for the Board’s endorsement.
Cancer continues to have a significant impact in Highland, and as the population
ages, statistically the number of people diagnosed with cancer will continue to rise.
Highland has 1600 new registrations of cancer per year, and in any year about 8000
people and their families are living with cancer.
More people will be living longer after their diagnosis, and efforts are already focused
on encouraging self-management and self-care, supporting people and their families,
rehabilitating people back to work and back to as full a life as possible. Longer term
survival is associated with early presentation, and we will continue efforts to
encourage people with worrying symptoms to present to their GP as early as
possible. However, cancer remains the most common cause of premature death in
Highland in people under 65 (40%). There are 900 deaths per year from cancer
which accounts for 25% of all deaths.
The attached delivery plan identifies work already underway in relation to each of the
action-messages within the strategy; some in response to other existing national
policy drivers, and others which have been raised and advocated by clinical
specialists, primary care clinicians, patients and lay representatives and by various
departments. The plan also highlights areas of exceptional good practice and
innovation, those of challenge and risk, and longer term developments to be taken
through the clinical and financial planning routes.
Key priorities
While our specialist cancer clinicians and their respective Multi-Disciplinary Teams
have responded to the strategy individually – note the detail contained within the
delivery plan – there are some common themes which have been captured against
the strategy’s framework for quality improvement. Most areas are inter-related, and
Framework for Quality Improvement
2.1.1 Patient Centred
The strength of impact of active patient involvement – individually, and via support
groups - in influencing patient centred, high quality care and treatment is evident in
many specialties e.g. in Gynae-oncology the active EMBRACE support group. The
Cancer Steering Group endorsed the need to strengthen this, and seek to facilitate a
variety of creative ways to establish meaningful patient and public involvement in
areas where small numbers and geography impact most. Every cancer journey for
patients and their families is momentous for them, each experience of care and
treatment is unique, and therefore is a vital responsibility for us to get it right every
Seeking and responding to the views of patients and families on our cancer service is
a priority and will feature in all service improvement activities.
2.1.2 Safe, Effective, and Efficient
Standardised evidence-based guidelines and protocols are a mainstream feature
within the cancer specialties, and also support patients’ pathways which span Board
boundaries. Robust review and update procedures are in place, and Critical Incident
Review, and reflective practice is well established.
The notable use of audit information, to assess the effectiveness of clinical
management in those specialties and respond with improved procedures is well
embedded in only some specialties. Recent local investment in audit staff will ensure
this vital source of evidence is available in all specialties.
Particular innovation in Dermatology to aid the management of the increasing burden
of referrals will encourage similar responses in other specialties – noted is the use of
community triage and tele-dermatology. We are working to maximise the potential for
other specialties to adapt the emerging model in Dermatology which has focussed on
shifting certain aspects of care from secondary to primary care.
Action is in progress to reduce the impact of unnecessary referrals, avoidable
admissions, and to encourage feedback to prompt change in practice. Primary Care
Cancer Leads have undertaken an audit of referral practice for suspected cancer and
have agreed with the specialist cancer leads a number of areas for improvement.
2.1.3 Outcomes
Clinicians in NHS Highland have welcomed the investment in Cancer Audit which
has provided the means to gather and analyse data locally to guide clinical practice,
and comprehensively demonstrate clinical outcomes as a cancer centre. It has also
enabled participation in national audit programmes for an increasing number of
specialties, providing vital comparison with national trends, and clinical practice in
larger numbers of cancer centres around the UK. An example of the level of detail
and the benefit of this participation is shown below, in an extracted analysis from the
UK Lung Cancer Audit LUCADA.
“It is known that biopsy or cytology confirmation of lung cancer is associated with an
increased likelihood of receiving treatment. In NHS Highland in 2007 85% of patients
who were diagnosed with lung cancer had this diagnosis based upon the results of a
biopsy or cytology. This percentage was only exceeded by two other health boards
and compares favourably with audit data for England and Wales.
At the time of diagnosis of lung cancer not all patients are well enough to receive
active treatment for their lung cancer, but audit data shows that NHS Highland were
able to give treatment to 67% of patients. This figure was only exceeded by two other
health boards and compares with an average figure of 51% for England and Wales”
Similarly, outputs from Colorectal and Breast audits demonstrate the essential nature
of audit data collection.
As previously presented from the National Information Services Division Cancer
Scenarios work; for NHS Highland as a whole, the increase in the numbers of
cancers expected to be annually diagnosed is 27% between 2005 and 2015 This is
equivalent to a year on year increase of 2.4% with the largest proportionate
increases expected in the haematological cancers, bowel cancer, Head and Neck,
oesophagus, stomach and pancreas.
2.1.4 Equitable
The Highland geography has always driven creativity in terms of the design of
services, and in the field of cancer care it has encouraged a shift in the balance of
care to provide certain tried and tested areas of care and treatment more locally.
With chemotherapy regimens being successfully delivered remotely in Caithness, Isle
of Skye, Belford, Lorne and the Isles, there is scope for building on that strong
foundation to explore sustainable ways for non-medical Review and Follow-up of
patients. Development work will guide any necessary strategic workforce and
succession-planning, particularly in light of the increasing cancer numbers.
2.1.5 Timely
IN addition to many well-thought-through pathway efficiencies to ensure as little time
away from home as possible, all specialties prioritise on the basis of clinical need and
have been pro-active in guiding improvements in all pathways to streamline delays.
Plans are already in progress to prepare to deliver the new cancer targets.
Investment in new equipment - New CT scanner in Caithness General Hospital, and
the upgrade of the CT Scanner in Belford Hospital, Fort William to 64-slice model –
will further benefit efficiency.
Straight to test pathways are in place for Gastro Intestinal scopes, for urology scopes
and biopsy.
Reduction in pathway time for PET scan (Aberdeen time reduced from 3 weeks to 1
Cancer Trails Programmes are an essential characteristic of any cancer centre, and
Better Cancer Care clearly encourages the integration of research into routine care in
order to help to improve patient care.
Areas of Risk and Challenge
There are a number of significant challenges in relation to the HEAT Targets which
Workforce risks have been identified in a number of areas.
 Recruitment issues for complex roles in Radiotherapy Physics
 Known gaps in Cancer Clinical Nurse Specialists teams, provides an
opportunity to review the existing model, reflect Shifting the Balance of Care,
and improve access for patients across Highland
Capacity issues in Breast, Haematology and Endoscopy services
The impact on patients and families will be significant when Macmillan
funding for the Highland Macmillan CAB service runs out in December 2009
The risk narrative and delivery plan for the HEAT Targets submitted in February to
the Scottish Government’s Delivery team describes actions to reduce the impact of
the risks identified above, and where necessary, discussions are underway to
explore other options, and put in place contingencies.
In relation to compliance with European Working Time Directive, changes have been
introduced for trainee medical staff, which impact significantly on senior medical and
consultant staff time particularly for outpatient clinic capacity. Clinically-guided
direction of the planned investment of £1m to support EWTD and redesign of
processes will ensure that specialists’ time is maximised appropriately.
Governance Implications
4.1 Staff Governance
Workforce and capacity actions which have already been identified will be prioritised
for action via the Cancer Steering Group and subsequently by Clinical and Financial
Planning Groups as necessary.
4.2 Patient and Public Involvement
Some examples of current and pending activity include:
 Significant contribution of patients and carers in the Audit and development
work on communication skills around ‘Breaking Bad News’ which will highlight
areas for targeted action and facilitate necessary improvements.
 Contribution of Highland Breastcare Association; last year’s conferences for
fitness instructors; planned conferences for hairdressers; Partnership work
with new patients and HBA contribution to recent consideration of focus group
work related to Breast Cancer services, as part of the shift to a Highlandwide breast cancer model
 Learning from the success of a local cancer support group in Thurso; the
benefits to participants, the partnership with local specialist staff.
4.3 Clinical Governance
Ensuring clinical safety and high quality care and treatment has the highest priority,
and robust systems are in place to govern compliance with best practice standards:
 Multi-Disciplinary Teams local review and audit.
 Monitoring as per HDL (2005) 29 via groups such as the Cytotoxic Users
Group for hospital and community-delivered chemotherapy,
 Internal and external Quality Assurance programmes in Radiotherapy (QPulse is a computer based quality management system, British Standards
Institute at level ISO 9000, IR(ME)R Inspection from the HSE)
 Cancer Clinical Nurse Specialists have developed systems to ensure Clinical
 Actions to agree a Highland-wide model for Breast Cancer in order to
standardise standards, procedures and access to specialist care and
treatment for all patients across Highland.
4.4 Financial Governance
A role, purpose and decision ladder have been endorsed by the Cancer Steering
Group which clarifies strategic decision-making processes and routes for cancer,
ensuring cancer service priorities are considered along with other organisational
Impact Assessment
Equality and Diversity Impact Assessments will be carried out by specific
departments and teams in relation to each action within the plan. The
recommendations from these EQIAs will be included within all reviewing and
monitoring processes for the action plan as a whole. Further review of the strategy
and action plan will also occur as part of the updates of the three current equality
schemes (Race Equality Scheme, Gender Equality Scheme and Disability Equality
Scheme). On this basis the action plan as a whole does not require an impact
assessment at this time.
Better Cancer Care, an Action Plan confirms that cancer remains one of the national
priorities. Many of the messages in the new strategy build on the previous cancer
plans Cancer in Scotland – Action for Change, and also Cancer in Scotland –
Sustaining Change.
Better Cancer Care has responded to patient and carer views and clinical influences,
and does feature a number of new commitments in relation to HEAT targets, cancer
genetics, self care and self-management for patients. The Scottish Government has
also pledged a commitment to strengthen links between complementary policy
directives and other related services, for example, 18 Weeks Referral to Treatment,
Gaun Yersel the strategy for Long Term Conditions, the contribution to cancer by
Macmillan Cancer Support, Better Together (Patient & Public Involvement strategy)
The Board is asked to recognise and support the ongoing and dynamic nature of
many of the longer term approaches, and endorse the role of the Cancer Steering
Group in guiding and prioritising developments, and for ensuring the delivery of
Better Cancer Care in Highland.
Christine McIntosh
Cancer Network Manager
(Highland and Western Isles)
27 March 2009