Download Findings - Referral Details and Processes

Cancer Diagnostic Pathway Audit
Report
North of England Cancer Network
Title
North of England Cancer Diagnostic Pathway Audit Report
Reference
Final Report National GP Audit NECN
Version
Release 2 Final V04
Date
22/11/10
Author
Parry Lothian Consultancy
Change History
6/10/10 – V01
For initial discussions with GP Cancer Leads
4/11/10 – V02
Final Draft for comments to GP Cancer Leads
12/11/10 – V03
Final Report for submission to client
22/11/2010 – V04
Final Report Release 2 - following client discussion
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Contents
1. Introduction
2. Context and Background
3. Methodology
• The Approach
• Practice Participation
• The Participating Practices
• Practice Locations and Population
• Tools, Parameters and Timelines
4. The Audit Process
5. Findings
• Overview
• Key Factors
• Base Information
• Attendances
• Referral Detail and Processes
• Diagnosis
• Possible Avoidable Delays
6. Practice Learning and Actions
7. Recommendations
8. Acknowledgements
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Introduction
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Introduction
Initial
presentation in
Primary Care
Reducing the time delay and waste in the patient journey to
support earlier cancer diagnosis
Diagnosis
This report describes the process and outcomes from the North of England Cancer
Networks’ participation in the National GP Cancer Audit. This is the third element of work
progressed under the umbrella of National Awareness and Early Diagnosis Initiative
(NAEDI).
Cancer in Primary Care
- the initial NAEDI
work
The second project on
NAEDI
The third project on
NAEDI – the subject of
this report
The report highlights the specific findings, the issues raised and the local actions taken to
improve specific elements of the care pathway both at practice level and within interfaces
with secondary care.
It makes recommendations on the transference of learning, local communication and
further work that will require action.
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Context and Background
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Context and Background
Building on the progress from the NHS Cancer Plan, the Cancer Reform Strategy 2007 identified one of the key areas for action was
diagnosing cancer earlier. From this main theme the National Awareness on Early Diagnosis Initiative (NAEDI) was launched, one element of
which, was to reduce delays in primary care.
This forms the back drop to the work in the North East.
Cancer in
Primary Care the initial
NAEDI work
The second
project on
NAEDI
As part of the NAEDI to promote timely diagnosis of cancer, a national significant event audit of cancer diagnosis in primary
care was commissioned and reported in 2009. This audit in the north east of England was carried out by a collaboration
between Durham, Glasgow and Dundee Universities. This primary care audit study was specifically to gain insight into the
events that surround the diagnostic process for two groups in cancer (lung cancer and cancer affecting teenagers and young
adults).
The study demonstrated appropriate recognition and referral for both cancer groups. Where recognition had taken longer
there were often reasonable explanations – for lung cancer these related to chest x-rays reported as normal, patient choice
factors or presentations complicated by co-morbidity. There was also system and practitioner issues and the use of guidelines
highlighted in the findings.
The full report can be found on www.cancernorth.nhs.uk
From the initial study above a further project was initiated by NHS County Durham and Darlington . This project was to work
more closely with primary care to identify, analyse and find solutions to issues that prevented quick diagnosis as identified in
the significant event audit (SEA).
As NHS North East were already well advanced in their application of the Virginia Mason Production System the proposal
suggested that this vehicle was used to carry out this ‘new ‘work building on from and using the initial findings for lung
cancer.
This proposal was supported by the National Cancer Action Team and was extended across the Cancer Network to include
NHS South of Tyne and Wear. Funding from the National Cancer Action was made available and planning began in November
2009. The initial report on this work was completed in April 2010.
Durham University, School of Medicine and Health has evaluated the Virginia Mason Production System as it is applied to the
primary care work. This study will be available later in 2010.
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Context and Background continued
Building on the progress from the NHS Cancer Plan, the Cancer Reform Strategy 2007 identified one of the key areas for action
was diagnosing cancer earlier. From this main theme the National Awareness on Early Diagnosis Initiative (NAEDI) was
launched, one element of which, was to reduce delays in primary care
This forms the back drop to the work in the North East.
The North of England Cancer Network are now building upon the previous NAEDI work by participating
in the National GP Audit developed by the Royal College of General Practitioners and the National
Cancer Action Team. An audit tool supports this work and is called the Diagnostic Pathway Template.
The aim of this audit is
The third project
on NAEDI – the
subject of this
report
• To identify any delays in patient pathways
• To identify any potential groups of patients or tumour types which are particularly vulnerable to delay
• To use the findings to plan interventions to improve early diagnosis across the North of England
Cancer Network
• To ensure that the findings inform the commissioning intentions for each PCT
• To inform and supply information to the National Database
Overall the aim is to build on current good practice and inform service improvements thereby ensuring
that individuals with symptoms suspicious of cancer are referred appropriately and early.
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Methodology
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Methodology – The Approach
Phase 1- Project
Initiation
Audit by North of England
Cancer Network and Network
Primary Care Group.
Aims and objectives of the
audit agreed.
Phase 2 – Planning and
Recruiting
Scope of practice participants
agreed.
Remuneration for practices
agreed.
Phase 3 – Date Collection
and Cleansing
Each participating practice
was given from June to
October 2010 to complete
the audit template.
The records were validated
and the data cleansed and
amendments agreed with
each practice audit lead.
Audit parameters agreed.
Project Group and Activity
Plan developed.
External Consultant support
agreed and recruited.
Briefing Pack and Practice
agreement developed.
Timelines and GP practice
responsibilities agreed
GP Cancer Leads identify and
recruited practices
Each practice was given a
further month to produce a
report of their findings and
any action taken.
Output
Output
Output
Project Plan
Terms of Reference for
Project Group.
Audit parameters and
timelines.
Briefing pack for
participating practices
and GP Cancer Leads
Completed ,
consolidated and
validated audit template
Phase 4 – Data Analysis
and Reporting
The data was analysed and
the main findings agreed
with the GP Cancer Leads.
Guidance supplied by
Professor Greg Rubin,
Wolfson Institute,
University of Durham
The report developed and
signed off in November
2010.
Output
Data analysis
Final Report
A practice report from
each participating
practice
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Methodology – Practice Participation
The Cancer Network was keen to ensure involvement from Primary Care in all localities and therefore from the outset of
the project the GP Cancer Network Leads were involved in the decision making around the project , its implementation
and the Practices to be recruited
GP Practice participation
The Practices
GP Practice roles and
responsibilities
GP Practice remuneration
24 GP Practices were recruited from across the five localities in the NECN . There was
no systematic recruitment based on agreed criteria. Practices were approached based
on the knowledge they would cooperate, they would find the capacity to participate
and would meet the timelines.
Participating Practices varied in size from small < 1000 registered list size to large >
20,000 registered list size. There was a mixture of both rural and urban practices .
The Practices were asked to identify a lead for the practice who would coordinate the
completion of the audit and ensure the timelines were met. Each Practice also agreed to
conduct a practice meeting/learning event to discuss the audit, identify key areas for
improvement and produce an action plan for implementation. This report was shared
with the Cancer Network and formed part of the audit process.
Each practice was to receive £500 + £30 per patient record audited, completed and
validated. Payment was made retrospectively upon completion of the template with
validated records and the production of their practice report template.
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Methodology – The Participating Practices
Participating Practices
Dr Cloak and Partners
Sunderland
Springwell Medical
Group,
Sunderland
Glenpark Medical
Centre,
Gateshead
Bridges Medical
Practice
Gateshead
Coquet Medical
Group, Morpeth
Northumberland
Biddlestone Health
Group,
Newcastle upon Tyne
Lane End Surgery
Newcastle upon Tyne
Harbottle Surgery
Northumberland
Branch End Surgery,
Stocksfield
Northumberland
The Linthorpe Surgery
Middlesbrough
Havelock Grange
Practice
Hartlepool
Tennant Street
Practice
Stockton
Yarm Medical
Practice
Yarm
Blackhall and Peterlee
Practice
Peterlee
Jupiter House
Practice
Peterlee
Station View Health
Centre
Bishop Auckland
Co Durham
Murton Medical
Group
Murton, Seaham
Co Durham
Consett Medical
Centre , Consett
Co Durham
Waterloo House
Surgery
Millom, Cumbria
Flatt Walks Health
Centre
Whitehaven
Cumbria
West Street Practice,
Aspatria
Cumbria
Brunswick House
Medical Group
Carlisle
Cumbria
-
-
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Methodology – Practice Locations and Population
22 Practices from across the NECN agreed to
participate in this audit
Commissioning Cluster
Participating Practice
Cumbria
4
Durham
5
North of Tyne
5
South of Tyne
4
Tees
4
Total Participating Practice Population approximately
207,000
Total NECN Population = > 3 million
Dotted Eyes © Crown copyright and/or database right 2008. All rights reserved. Licence number 100019918
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Methodology – Tools, Parameters and Timelines
The audit process was supported by the diagnostic pathway audit template
The Template
The data fields were developed to:
• Determine any relationship between age/gender/ethnicity/communication and access
and the likelihood of urgent referral or diagnosis of cancer
• Indicate where health promotion campaigns may encourage earlier attendance
• Identify delays in referrals for certain cancers
• Identify delays that practice systems may affect onward referral
• Identify potential delays in the method or urgency of referral
The Audit Parameters
The Audit, collected data from the period between the 1 April 2009 and the 31 March
2010. Records to be included needed to have demonstrated at least one of the following
within the timeframe:
• a patient presentation
• a patient referral
• a specialist appointment
The Exclusions
Records of patients diagnosed through screening were excluded as were dyscrasias , pre
malignant states and non melanotic carcinoma of the skin
The Timelines
The Audit process started in June 2010 and ran through until the end of October 2010 in
which time the Practices were required to submit their completed audit template and
their practice meeting /learning event report.
Data cleansing, analysis and report development started in September and ran through
until Mid November 2010.
North of England Cancer Network Cancer Diagnostic Pathway Audit
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The Audit Process
North of England Cancer Network Cancer Diagnostic Pathway Audit
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The Audit Process
Stage 1- Template
completion and Submission
Two practices withdrew from
the Audit.
The remaining 22 participating
Practices met the timelines for
template submission 30/9/10
There was some support
required for a few practices
during template completion.
This was carried out by email
or telephone and mainly
concerned the functionality of
the spreadsheet template.
Support was supplied by
external consultants who
were commissioned to project
manage the process, analyse
the data and produce the
report.
Stage 2 – Data Cleansing and
Analysis
Data cleansing was carried
out in two parts:
Part 1 where all dates were
checked and validated.
Part 2 where data was
checked for logic,
completeness and clarity.
Where anomalies and or
blanks in data was discovered
the Practices where asked to
recheck and/or to complete
selected data fields.
Data analysis was carried out
across the consolidated data
set for the whole Network.
Individual practice analysis
and locality analysis was
considered problematic due
to the limited amount of
records in each cohort and
the danger of revealing any
individual patient record or
source.
Stage 3 – Individual Practice
learning and report
submission
Stage 4 - Report development
and sign off
All practices were asked to
consider their audit findings
at a Practice meeting and /or
learning event.
An initial draft report was
produced for a meeting with
the GP Cancer Leads on the
15/10/10.
Each Practice submitted a
record of these discussions
using a pre prepared template
or free text notes or minutes
by 31/10/10.
At this meeting the scope of
the analysis was discussed and
agreed.
The Practices were required to
consider the following for their
report:
• Issues from the Audit
• Learning from the results
• Action taken in the practice
Further development of the
report was undertaken and
submitted to the Cancer Leads
for input on 4/11/10.
The report was finalised on 12
November 2010.
The main themes from these
reports were collated and
summarised for this report.
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings - Overview
This section provides graphical representations of the data recorded. Findings have been presented within five sections:
• Base information
• Attendances
• Referral details and processes
• Diagnosis, including staging information; and
• Possible Avoidable Delays
Many of the graphs do not require very much in the way of explanation or commentary, although if included clarification and observation has
been kept to a minimum.
In most cases the graphs present a view of all records and then ‘drill down’ to specific cancer site detail. In determining the range and extent of
analysis consideration has been given to the number of records and the statistical value of any findings.
The Diagnostic Audit Template facilitated the direct
recording of 29 key data items associated with the
patient journey
•Given the nature of these data items it was not
expected that submitted records would be 100%
complete
From the recording of four key dates specific timelines
and days durations were calculated and these
calculations were included within the template
•Date patient first noted signs / symptoms – 31% of which were blank
•Date patient informed primary care – 14% of which were blank
•Date of Referral – 10% of which were blank
•Date first investigated or seen by specialist – 6% of which were blank
Consideration of patient vulnerability is a key issue in the
audit. The template provided for the identification of • Approximately 10% of the records submitted indicated “Not
Sure” or were left blank with regard to identifying whether the
patients with specific communication issues or were patient had problems communicating or were housebound
housebound
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings – Key Factors
28 Cancer Sites
represented
“Top 5 Cancer
Sites” recorded
in this audit
reflect the
national
incidence
Only 5 cancer
sites with > 50
records
The numbers of records for each cancer site ranged from 2 to
105.
696
validated
Records
The total
population
represented
>207,000
Analysis at NE
Cancer Network
level
85% of records
were recorded
as white British
To qualify as a valid record it was agreed that the following key
data items had to be 100% complete:
• Age
• Gender
• Ethnicity
• Diagnosis
• Stage at Diagnosis
• Where the patient first presented
• Would rapid access to investigations alter case management
• Type of referral
For the purposes of this report analysis at cancer site level has
been restricted to the 5 sites with >50 records:
• Lung
• Colorectal
• Prostate
• Breast
• Bladder
To maintain overall effective analysis this has been carried out
at Network level only.
(13% are
unknown)
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings - Base Information
Number of records within Cancer Site
120
105
100
100
97
87
80
60
40
52
32
26
21
20
20
20
15
15
14
11
10
10
8
7
7
6
6
6
5
5
4
3
2
2
0
0
“Top 5 Cancer Sites” – this colour coding, where relevant, has been used within site specific graphs
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings - Base Information
Age and Gender - all records
140
124
123
Count of Records
120
100
85
80
52 53
60
Female
35
40
20
57 59
57
0
0
2
1
3
1
11
Male
17
7
4
5
0
0-10
11-20
21-30
31-40
41-50
51-60
61-70
71-80
81-90
90+ Years
Ages
Records as a % of the combined practice population by age and gender
(based on 686 audit records from 21 of the 22 participating practices)
2.5%
2.0%
Percentage
2.0%
1.8%
1.5%
1.1%
1.3%
Female
1.0%
1.0%
0.8%
0.4% 0.4%
0.5%
0.0%
0.0%
0.0%
0.1% 0.0%
0.2%
0.9%
Male
0.5%
0.1%
0.0%
0-10
11-20
21-30
31-40
41-50
51-60
61-70
71-80
North of England Cancer Network Cancer Diagnostic Pathway Audit
81-90
90+ Years
21
Findings - Base Information
Age and Gender - Lung Cancer
30
28
25
20
18
14
15
10
Female
10
9
8
Male
9
6
5
0
0
0
0
0
0
0
0
0
1
1
1
0
0-10
11-20
21-30
31-40
41-50
51-60
61-70
71-80
81-90
90+ Years
Age and Gender - Colorectal Cancer
17
18
15
16
13
14
12
10
11
11
12
10
Female
8
Male
6
4
4
2
0
0
0
0
1
2
0
0
2
2
0
0
0
0-10
11-20
21-30
31-40
41-50
51-60
61-70
71-80
North of England Cancer Network Cancer Diagnostic Pathway Audit
81-90
90+ Years
22
Findings - Base Information
Age Range - Breast Cancer
Age Range - Prostate Cancer
37
40
35
30
25
20
15
10
5
0
23
25
35
20
17
15
15
15
11
0
0
0
0
11
10
11
3
5
2
1
0
0
3
0
0
0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 90+
Years
0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 90+
Years
Age and Gender - Bladder Cancer
18
16
16
14
11
12
10
Female
8
6
6
4
7
Male
4
4
2
1
0 0
0 0
0 0
0 0
0
0-10
11-20
21-30
31-40
41-50
0
0
51-60
61-70
1
2
0
71-80
81-90
North of England Cancer Network Cancer Diagnostic Pathway Audit
90+ Years
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Findings - Base Information
Vulnerable Groups
Patients with problems communicating
•There were 651records where the patient had no
problems communicating
•A further 7 records stated “Not Known” or were left
blank
• 38 records provided details of the communicating
problem, with 28 of these records relating to the ‘Top
5’ Cancer Sites
Does the Patient have any communication problems?
Lung
Colorectal
Bladder
Breast
Prostate
Dementia
2
1
0
1
1
Learning
Difficulties
1
0
0
1
0
Mental
Health
2
0
2
0
1
Poor Hearing
2
3
2
0
2
Poor Vision
1
3
1
1
1
Is the Patient Housebound ?
•573 of the 696 records stated that the patient was not
housebound
•62 Records stated “Yes” the patient was housebound;
and
•The remaining 61 records were either “Not sure” or
left blank
•Of the 62 records stating “Yes”, 46 related to the ‘Top
5’ Cancer Sites
Is the Patient Housebound?
Lung
Colorectal
Bladder
Breast
Prostate
NO
81
80
40
76
83
YES
15
15
6
8
2
Not
Known
9
5
6
3
12
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings - Attendances
Number of Attendances before being referred - All Records
350
291
300
250
200
162
Number of Patients
150
100
56
54
50
28
14
10
6
2
3
1
1
1
1
1
5
6
7
8
9
12
13
14
15
18
0
0
1
2
3
4
Number of Attendances
It seems that by far the majority of patients only attend once or twice before being referred to Secondary Care. With regard to the 56 patients with zero
attendance the assumption is that these were emergencies or not referred by the practice. However there is insufficient information to arrive at such a
conclusion. Of these 56 records, 4 were recorded “Unknown” in terms of the referral type and 25 appear to have been referred by the practice. 9 of the 25
‘subset’ were referred on the day of attendance, therefore the practices may have recorded these as a zero attendance.
This graph represents 631 records, the remaining 65 records presented insufficient detail on number of attendances to be used in this analysis.
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings - Attendances
Number of Attendances before being referred - Lung
28
30
27
25
20
Number of Patients 15
12
10
9
8
10
4
5
1
2
1
1
1
1
6
7
9
13
14
15
0
0
1
2
3
4
5
Number of Attendances
Number of Attendances before being referred - Colorectal
45
40
35
30
25
Number of Patients
20
15
10
5
0
39
24
12
7
0
1
2
3
10
5
4
1
1
1
5
6
8
Number of Attendances
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings - Attendances
Number of Attendances before being referred - Bladder
25
22
20
Number of Patients
15
10
10
5
3
5
9
1
1
1
4
6
7
0
0
1
2
3
Number of Attendances
Number of Attendances before
being referred - Breast
70
60
50
Number of 40
Patients 30
20
10
0
Number of Attendances before
being referred - Prostate
37
40
61
30
24
Number of
20
Patients
12
6
1
1
1
5
10
12
11
6
6
1
0
0
1
2
3
5
Number of Attendances
6
0
1
2
3
4
5
Number of Attendances
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings - Referral Details and Processes
Days from First Visit to Referral by Volume of Patients - All Records
450
420
400
350
300
250
Number of Patients
200
150
93
100
39
50
32
13
19
29-35
36-42
80
0
0-14
15-21
22-28
43+
Unknown
Number of Days
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings - Referral Details and Processes
Days from First Visit to Referral by Volume of Patients - Lung
60
54
50
40
Number of Patients 30
24
20
10
7
5
5
3
15-21
22-28
29-35
36-42
7
0
0-14
43+
Unknown
Number of Days
Days from First Visit to Referral by Volume of Patients - Colorectal
60
55
50
40
Number of Patients 30
17
20
11
10
10
3
2
2
22-28
29-35
36-42
0
0-14
15-21
43+
Unknown
Number of Days
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings - Referral Details and Processes
Days from First Visit to Referral by Volume of
Patients - Breast
90
80
70
60
Number of 50
Patients 40
30
20
10
0
Days from First Visit to Referral by Volume of
Patients - Bladder
45
40
35
30
Number of 25
Patients 20
15
10
5
0
78
1
1
1
5
0
1
39
3
Number of Days
6
1
0
1
2
Number of Days
Days from First Visit to Referral by Volume of
Patients - Prostate
60
50
49
40
Number of
30
Patients
20
10
18
6
8
1
5
10
0
Number of Days
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings - Referral Details and Processes
Average number of days between attendance and referral
66.5
70.0
60.0
50.0
Days
37.0
40.0
30.0
20.0
10.0
2.7
10.5 11.0
6.0 7.9
40.5 41.2
49.1 51.7
45.0
56.4
28.6 29.4 29.5 29.8
25.1 27.1 27.3
22.2
19.0 19.4
15.0 15.6 15.8 16.4 16.8
0.0
Endometrial
Melanoma
Breast
Oesophageal
Testicular
Gallbladder
Mesothelioma
Ovarian
Colorectal
Unknown Primary Thyroid
Oropharyngeal
Stomach
Leukaemia
Average Days
2.7
6.0
7.9
10.5
11.0
15.0
15.6
15.8
16.4
16.8
19.0
19.4
22.2
25.1
No Records
11
21
87
20
2
6
5
14
100
6
3
7
15
15
Min days
0
0
0
0
8
0
0
0
0
1
1
0
0
0
Max days
22
56
170
40
14
40
61
125
176
40
37
73
99
135
Bladder
Average Days
Pancreatic
Prostate
Other
Renal
Liver
Cervical
Sarcoma
Lung
Laryngeal
Myeloma
Lymphoma
Brain
Vulval
27.1
27.3
28.6
29.4
29.5
29.8
37.0
40.5
41.2
45.0
49.1
51.7
56.4
66.5
52
8
97
32
20
5
4
6
105
7
10
26
10
2
Min days
0
0
0
0
0
0
0
0
0
0
5
0
0
1
Max days
303
114
377
246
185
77
138
127
436
197
167
269
472
132
No Records
Reviewing average number of days between attendance and referral needs to be aligned with the number of records e.g. Vulval
shows an average of 66.5 days between attendance and referral. However there are only two records, one with 1 day between
attendance and referral and the other with 132 days.
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings - Referral Details and Processes
All Records by Type of Referral
‘Top 5’ Cancer Sites
2 week
2 week
Emergency
Emergency
Not known
Not known
Not referred by Practice
Private
Not referred by Practice
Routine
Private
Routine
‘Top 5’ Cancer Sites
80
70
72
63
62
56
60
2 week
Emergency
50
40
30
Not referred by Practice
21
20
10
Not known
34
12
4
15
11
1
5
5
13
0
Private
15
9
8
2
0
2 1 4 1
7
5
6
0
2
5
Routine
0
Lung
Colorectal
Prostate
Breast
Bladder
The “2 Week” referral option is by far the most common type of referral with more than 50% of all referrals falling into this group. A similar
pattern is seen when selecting the ‘Top 5’ cancer sites . The follow page separates out the ‘Top 5’ cancer sites to illustrate the percentage
share of type of referral
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings - Referral Details and Processes
Colorectal - by Type of Referral
Lung - by Type of Referral
2 week
2 week
Emergency
Emergency
Not known
Not known
Not referred by Practice
Not referred by Practice
Private
Private
Routine
Routine
Bladder - by Type of Referral
2 week
Emergency
Not known
Not referred by Practice
Private
Routine
Prostate - by Type of Referral
Breast - by Type of Referral
2 week
2 week
Emergency
Emergency
Not known
Not known
Not referred by Practice
Not referred by Practice
Private
Private
Routine
Routine
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings - Referral Details and Processes
Days from Referral to First Seen or Investigated by Specialist by Volume of Patients - All Records
500
431
400
300
Number of Patients
200
56
100
33
27
90
48
11
0
Number of Days
Days from Referral to First Seen/Investigated by Specialist
All Records
Lung
Colorectal
Bladder
Breast
Prostate
0-14 days
431
75
63
25
64
60
15 – 21 days
56
3
11
5
9
6
22 – 28 days
33
3
0
8
3
6
29 – 35 days
27
3
4
1
3
6
36 – 42 days
11
2
2
1
1
0
43 + days
48
5
10
3
0
9
Unknown
90
14
10
9
7
10
696
105
100
52
87
97
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings - Diagnosis
Staging at Diagnosis - All Records
20.26%
Distant metastases
44.68%
Local spread
Not known
20.55%
Organ
14.51%
Lung
Colorectal
Bladder
1.92%
15.38%
22.00%
22.86%
35.24%
Breast
41.00%
7.69%
Prostate
13.79%
18.56%
7.22%
45.98%
25.29%
61.86%
17.14%
29.00%
24.76%
8.00%
12.37%
75.00%
14.94%
In this audit it appears that the majority of cases are diagnosed at organ level. Lung being the exception, where a greater
percentage appears to be diagnosed at later stages of the disease
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings - Possible Avoidable Delays
With most cancers, the earlier the diagnosis is made, the better the prognosis. One of the aims of the audit was to identify whether there were
any avoidable delays in the patient journey.
A wide range of factors possibly affecting the patient journey were reported. For the purposes of this report these have been categorised within
the context of “A Health System” modelled below.
67% of records stated that there was no avoidable delays in the patient journey. Of the total 696 records 128 indicated avoidable delays with a
further 67 records recording “Unsure”.
“Health System Model”
Clinical Decisions
and Actions
Communications
Issues
Investigations and
Reporting
Factors relating to
the clinical decisions
and actions made
in both primary and
secondary care
Factors relating to
poor or inappropriate
communication that
could have occurred
at any stage within
the patient journey
Factors relating to the
failure, delay or
reporting of
investigations
including relevance
and timeliness
72
Records
17
Records
27
Records
Patient Decisions
and Actions
Factors relating to
decisions
and actions made by
the patient
45
Records
Referral Processes
Non Specific
Factors relating to
aspects of referral –
such as timeliness,
appropriateness and
the referral protocols
themselves
Some comments
were too vague or
unique to categorise
36
Records
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Records
36
Findings - Possible Avoidable Delay
Delay Categories - All Cancer Sites
5.74%
17.22%
34.45%
Clinical Decisions and Actions
Communication Issues
Investigations and Reporting
Patient Decisions and Actions
Referral Process
Non specific
21.53%
8.13%
12.92%
The above presents the “Health System Model” categories across all records and shows a summary of comments made regarding
possible avoidable delays. In indicating possible delays 195 records stated “Yes” or “Unsure”. It should be noted that some
records recorded “No” but still provided comments. All comments have been included in this categorisation. 487 comments have
been reflected in this section.
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings - Possible Avoidable Delay
Delay Categories - Lung
Delay Categories - Colorectal
32.35%
Clinical Decisions and
Actions
44.44%
Clinical Decisions and
Actions
26.47%
Communication Issues
20.59%
Investigations and
Reporting
19.44%
13.89%
11.11%
5.56%
5.56%
Communication Issues
20.59%
Investigations and
Reporting
Patient Decisions and
Actions
Patient Decisions and
Actions
Referral Process
Referral Process
0.00%
Non specific
0.00%
Non specific
Delay Categories - Bladder
33.33%
Clinical Decisions and
Actions
Communication Issues
22.22%
Investigations and
Reporting
11.11%
11.11%
11.11% 11.11%
Patient Decisions and
Actions
Referral Process
Non specific
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Findings - Possible Avoidable Delay
Delay Categories - Breast
Delay Categories - Prostate
Clinical Decisions and
Actions
50.00%
Clinical Decisions and
Actions
29.63%
Communication Issues
Communication Issues
22.22%
22.22%
Investigations and
Reporting
22.22%
14.81%
Patient Decisions and
Actions
22.22%
Referral Process
5.56%
0.00%
Investigations and
Reporting
Patient Decisions and
Actions
Referral Process
7.41%
Non specific
3.70%
Non specific
0.00%
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Practice Learnings and Actions
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Practice Learning and Actions
The Key Themes from the Practice Reports are summarised below
Issues
Learning's
Some Practices identified changes to specific
process and/or administrative procedures to
improve communication. Examples of these
include:
• Regular forums where suspect cases can be
discussed. These discussions would take
place prior to referral and help the decision
making processes around case
management and the referral ;
• ‘red flagging’ suspected cancer on Practice
systems to ensure all clinicians are aware of
potential diagnosis.
The majority of Practices highlighted issues
that had not been clear to them before the
audit . Examples include:
• Prostate Cancer protocols required review
• Repeat chest x-ray for suspected lung
cancer required further thought and action
• The 2 week referral criteria did not always
fit a patient presentation
• 2 week referrals were being seen within
the timeline but patients often waited a
long time for further investigations
• Co morbidity often masked underlying
cancer
• Negative investigation results delayed
diagnosis
By far the most important ‘learning’ the
practices described was that they were
required to be far more vigilant in their
suspicions of cancer even when the clinical
presentation did not ‘quite fit’ , the initial
investigations were negative and/or the
patient had co morbid disease that may mask
an underlying cancer.
Practices described the potential to establish
effective training and development, case
review and significant event audit to ensure
more effective and informed vigilance.
The other ‘learning’ that stood out was that
communication within the practice was vital.
To address this the following developments
were highlighted:
• Red flagging systems to identify potential
cancer cases
• Forums for complex case discussions
• Standardisation of patient review systems
and operational practices to ensure that
investigations are carried out appropriately,
consistently and timely.
The majority of the practices reported that
the audit had been beneficial and some
practices planned to repeat the audit in one
year.
Actions
All the practices reported some actions to
improve the current patient journey in primary
care.
The following are the key themed actions
reported:
• Forums for internal discussions
• Improving system coding/flagging
• Reviewing internal investigative protocols
e.g. Prostate
• Lowering threshold for investigations e.g.
Chest X-rays for smokers; further
investigations for anaemia.
• Improving teaching about diligence in
complex cases
• Significant event audit on complex cases
• Improve systems to track results
• Increase the amount of routine weighing of
patients
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Recommendations
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Recommendations
North of England Cancer Network
• Consider further analysis and review against national audit data findings.
• Further exploit the use of the audit tool with other practices to enhance and inform work arising from the ‘Practice
Profiles’.
• Share the finding with a wider stakeholder groups to agree further work/actions i.e. Practice Based Commissioning
Groups, Primary Care Trust commissioners and Secondary Care.
• Facilitate and support specific pathway discussions where there is a specific need i.e. Prostate Cancer.
• Agree the uploading of NECN data with the national cancer team.
Commissioners
• Facilitate further discussion and action on avoidable delays which may include locality specific issues .
• Consider an audit that tracks timelines for investigations following 2 week referral first appointments.
General
• Where possible share the practical implementation of improvements with a wider range of practices.
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Acknowledgements
North of England Cancer Network Cancer Diagnostic Pathway Audit
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Acknowledgements
Name
Organisation
email
Dr Duncan Leith
NECN – Cancer Lead and Chair of the Primary Care Group
[email protected]
Dr Jonathan Berry
NECN GP Cancer Lead
[email protected]
Dr Robin Armstrong
NECN GP Cancer Lead
[email protected]
Dr Henry Choi
NECN GP Cancer Lead
[email protected]
Dr Joan Bryson
NECN GP Cancer Lead
[email protected]
Dr Relton Cummings
NECN GP Cancer Lead
[email protected]
Susan Collins
Cancer Services Officer, NHS Cumbria
[email protected]
Professor Greg Rubin
Wolfson Unit, Durham University
[email protected]
Suzanne Thompson
NECN Cancer Modernisation Manager
[email protected]
Joanne Preston
NECN Service Improvement Facilitator
[email protected]
Linda Wintersgill
Information and Audit Manager NECN
[email protected]
All Participating Practices and their staff
North of England Cancer Network Cancer Diagnostic Pathway Audit
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North of England Cancer Network Cancer Diagnostic Pathway Audit
46