Download osphe 144 - Faculty of Public Health

Faculty of Public Health
Of the Royal Colleges of Physicians of the United Kingdom
Working to improve the public’s health
OSPHE 144
Cancer delays
OSPHE 144
QUESTION 5
Cancer delays
CANDIDATE PACK
OSPHE 144
Candidate task
You are a public health professional working in a Primary Care Organisation1 (PCO).
A research study in another PCO has recently explored the reasons for delays
referring patients with symptoms suggestive of cancer to specialists. This has been
widely shared locally. Your local service user representative2, who is also a member
of the local cancer planning forum, has seen the research and wants to meet with
you and sort out a plan to remedy what they see to be the failings of General
Practitioners in your PCO.
You have 8 minutes to prepare for the station. You are not required to prepare any
visual aids. At the station you will present the research findings (2 to 3 minutes)
and spend the remainder of the 8 minutes discussing the task with a role-player.
You may use paper notes to aid your verbal briefing.
Outline of situation
Speedy access to appropriate investigation, diagnosis and treatment is recognised to
be central to improving outcomes for patients with cancer. This is enshrined in
various national waiting time standards and also in referral guidelines to support
appropriate and timely primary care referrals. Nevertheless only the minority of
patients have their cancers diagnosed in this way because they may not fit the
guidelines, may be referred to a different service and have it picked up there,
incidentally, or may present as an acute emergency.
Overall delays to initial referral can come about because of the behaviour of patients
or clinicians. It is the clinicians’ role in this delay that the user has already indicated
they are most concerned about.
Candidate guidance
You are to meet with the user representative to summarise and discuss the research
and agree on any subsequent actions in discussion.
At the station
You will be greeted by a marker examiner who will take your candidate number and
name, and then hand over to the role-player by saying:
“This is the service user representative. They will now start the station”.
1
A Primary Care Organisation (PCO) is a health organisation that provides community and primary
health care and commissions health care from community and hospital services. In England these
are called Primary Care Trusts (PCTs). A Health Board in Scotland performs some similar functions.
PCTs and Health Boards generally cover designated areas and populations within those areas.
2
A member of the public who is involved in providing a representative patient view about a specific
service (in this case cancer services) or services in general across an organisation responsible for
providing healthcare. In this case they are also a member of the local cancer planning forum, a
multidisciplinary group helping to plan and develop cancer services.
Page 1 of 2
OSPHE 144
Candidate Briefing Pack
The study
The work took place outside your PCO, about one year previously. A 10% systematic
sample was drawn from existing lists of patients in active contact with a hospital1. Six
specialities were involved and patients who responded were given semi-structured
interviews by cancer nurse specialists attached to each speciality.
Table 1 - Response Rate
Cancer site
Gynaecology
Haematology
Head & neck
Lung
Skin
Urology
Total
Number
invited
36
11
31
29
18
22
114
Number
responding
12
4
9
10
4
19
58
Response rate
%
33
36
29
34
22
86
51
Results
53% of patients were referred at the first contact with the General Practitioner (GP) as a
result of a decision made at that first contact/consultation.
Table 2 - Pattern of delays
Cancer site
Gynaecology
Haematology
Head & neck
Lung
Skin
Urology
Median delay
(weeks)
13
0
5
10
67
8
% delayed by site
Number delayed
50
0
44
60
25
55
6
0
4
6
1
10
Why were patients being delayed? Descriptions of main reasons given by respondents:




Symptoms were still being investigated (57%).
Symptoms were being investigated but patient saw another GP, who made a referral
(13%).
Lack of GP skills (as reported by the patients) (22%).
System failings (appointments missed, wrong addresses, no transport) (9%).
1
Source – unpublished data – drawn from a student dissertation distributed via a cancer network
mailing.
Page 2 of 2
OSPHE 144
Cancer delays
MAIN MARKER
EXAMINER PACK
OSPHE 144
Examiner situation
The candidate will be greeted by a marker examiner who will take their candidate
number and name, and then hand over to the role-player by saying:
“This is the service user representative. They will now start the station”.
Examiner Answer guidance
The study seeks to answer an important question and goes about it in a systematic
way but is neither large enough to draw conclusions nor does it have a good enough
response rate. The overall presentation of the results is loose and lacks elements of
detail one would prefer to see, as would usually be the case for a robust, peerreviewed piece. Also, it is not clear from the presented material what professional or
academic review of the study has taken place (if any).
Subject bias’ may be present as people who have had a poor experience may be
more likely to respond in this sort of study. Those from more deprived communities
(who generally have poorer cancer outcomes) are less likely to respond. Disease
severity (possibly worse in later presenters) itself may preclude some from
responding. As such the validity of the findings, even to the whole population being
sampled within this relatively narrow list of specialties, is suspect.
Systematic sampling is one way of constructing a sample to help to avoid bias, but
the method used is not reported, and taken with low response rates, makes judging
the usefulness of this theoretically good practice approach more difficult.
Average candidates should bring most of these points out in the discussion – failure
to do so indicates a very weak performance. All candidates should identify the much
higher response rate in Urology – future work in planning any subsequent studies
may consider how this was achieved.
Examiner briefing pack (these will be inserted by the Faculty
office)
Candidate pack, Role-player briefing pack.
OSPHE 144
Marking Guide for Examiners
1. Has the candidate appropriately demonstrated presenting skills in a typical public
health setting (presenting to a person or audience)?
Avoids jargon. Is clear. Appropriate language for the audience.
contact. Appropriate manner for the situation. Shows empathy.
Maintains eye
2. Has the candidate appropriately demonstrated listening skills in a typical public
health setting (listening and responding appropriately)?
Ensures role-player questions are answered appropriately. Answers totality of the
question. Manner of response appropriate to actor scenario.
3. Has the candidate demonstrated ascertainment of key public health facts from
the material provided and used it appropriately?
Describes the study design. Sets out what the study shows and what it does not
show. Draws out the fact that it is a small study in the first place with very small
numbers responding. Refers to possibility of response bias and representativeness
of findings and that disease severity may influence response. Candidates who fail to
identify the weaknesses of the study will have performed very badly. Half the
patients responded, half the patients had primary care delays of which a third were
GP/system failings. The delays are significant but it is not possible to extrapolate
the size of the problem. What about the commonest cancers such as breast? There
are too many uncertainties as it stands to use as a basis for intervention.
Candidates who need prompting to discuss the Urology data will have performed
weakly.
4. Has the candidate given a balanced view and/or explained appropriately key
public health concepts in a public health setting?
Have they explained how this study might be used to better inform service
development? Contains some useful information but cannot be the basis for
wholesale changes to cancer care in primary care. Proposes ways in which the
study could be usefully built on e.g. looking at other specialties. Reviewing the
guidance and guidelines to support those specialties with biggish numbers in the
study e.g. Gynaecology, lung and urology. Seek GPs views on the study.
5. Has the candidate demonstrated sensitivity in handling uncertainty, the
unexpected, conflict and/or responding to challenging questions?
Does not demonstrate complacency about the findings but is realistic about what
action can be taken. Is able to justify not jumping in when evidence is thin. Can
see the merits of the study and using this as a basis for future work, education,
information and further investigation. Simply writing off a poor study and not
responding to the prompt about what can be drawn from it would also represent
very poor performance.
OSPHE 144
Cancer delays
ROLE-PLAYER BRIEFING
PACK
OSPHE 144
Station background
As candidate briefing.
Role-Player Brief
The role-player is a user representative who sits on the local cancer planning forum1. You
are well-informed about national and local policy and having had a missed cancer you are
keen to ensure that delays are eradicated. That’s why you have become involved in the
planning forum. You are a bit impatient with the perceived complacency although your own
treatment was very good when you got to it.
The candidate has 2 to 3 minutes to describe the study and its limitations, you can then
interrupt. Start by saying:
“Thank you for coming to meet with me today. Can we start by just reviewing
this research?”
“This study seems to be saying that we have some major problems with GPs
referring patients on time or missing cancers”
Depending on the response – if the candidate agrees it’s a poor study:
“Well if it’s such a poor study what can we usefully draw out of it?”
If they support its findings:
“So you think we should accept what this study says - could you comment on
the quality of the study?”
“What about breast cancer – that isn’t included?”
“What about the Urology data – that seems different?”
At the one minute bell if the candidate has not made it quite clear to you what their
interpretation and/or advice is, ask:
“So can we summarise what this research is saying?”
Finish with: “Thank you for meeting with me”.
Any ‘no go’ areas
None.
Level of conflict
High.
1
Multi-professional group including cancer care specialists, GPs, patients, PCO commissioners and
public health/health promotion specialists.