Download New Cancer Waiting Times Targets

Better Cancer Care, An Action Plan
New Cancer Waiting Times Targets
Data & Definitions Manual
Version 4.0 – 29 July 2011
Document Purpose
Title
Author
Issue date
Issue Version
Target Audience
Circulation List
Cross References
Superseded Documents
Definitions Manual for NHS Boards for the new cancer
waiting times targets
New Cancer Waiting Time Targets Definitions Manual
Information Services Division of NHS National Services
Scotland
29 July 2011
4.0
NHS staff involved in implementing the new cancer
waiting times targets and Scottish Government Policy
Leads
NHS Board Chief Executives
Scottish Government Health Directors
National Tumour Groups
Regional Cancer Advisory Groups
National Waiting Times Delivery Group
Scottish Primary Care Cancer Group
Scottish Cancer Task Force
1. Better Cancer Care, An Action Plan
2. Scottish Referral Guidelines For Suspected Cancer
NHS HDL (2007) 9
3. NHS Scotland Cancer waiting Times National Data
Definitions, update version from 01 October 2007
Data & Definitions Manual Version 1 (considered expired
from 30 November 2009)
Data & Definitions Manual Version 2 (considered expired
from 31 January 2010)
Data & Definitions Manual Version 3 (considered expired
from 30 June 2010)
Data & Definitions Manual Version 3.1 (considered
expired from 28 July 2011)
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Contents
Page
Updates From Previous Version (v3.1) ............................................................................. - 4 1 Introduction ................................................................................................................ - 6 2 Responsibility for Delivering the Cancer Waiting Times Targets ............................... - 7 3 Data Collection and Publication ................................................................................. - 8 4 Performance and Quality Measures ........................................................................ - 13 5 Cancer Waiting Times Targets Cohort..................................................................... - 15 6 Dataset .................................................................................................................... - 17 6.1 .. Person Demographics.......................................................................................... - 18 6.1.1
CHI Number .............................................................................................. - 18 6.1.2
Unique Care Pathway Number (UCPN) .................................................... - 18 6.1.3
Hospital Patient Identifier........................................................................... - 18 6.1.4
Patient Postcode at Referral...................................................................... - 19 6.1.5
Ethnic Group ............................................................................................. - 19 6.2 .. Referral ................................................................................................................ - 20 6.2.1
Date of Receipt of Referral ........................................................................ - 20 6.2.2
Board of Receipt of Referral ...................................................................... - 22 6.2.3
Urgency and Source of Referral ................................................................ - 23 6.3 .. Diagnosis ............................................................................................................. - 25 6.3.1
Cancer Type .............................................................................................. - 25 6.4 .. Decision to Treat Date ......................................................................................... - 27 6.5 .. First Treatment ..................................................................................................... - 29 6.5.1
Type of First Treatment ............................................................................. - 29 6.5.2
Date of First Treatment.............................................................................. - 30 6.5.3
Board of First Treatment............................................................................ - 31 6.6 .. Waiting Times Adjustment ................................................................................... - 32 6.6.1
Waiting Times Adjustment Pre/Post-DTT – Number of Days .................... - 32 6.6.2
Waiting Times Adjustment Pre/Post-DTT – Main Reason ......................... - 32 Adjusted Waiting Times Scenarios .......................................................................... - 33 6.7 .. Adjusted Length of Pathways ............................................................................... - 44 6.7.1
Referral to Treatment ................................................................................ - 44 6.7.2
Decision to Treat to Treatment .................................................................. - 44 6.8 .. Reason for Delay 62-day/31-day.......................................................................... - 45 Clinically Complex Patients ..................................................................................... - 45 Appendix 1 - General Recognised First Treatments .................................................... - 46 Appendix 2 - Recognised First Treatments for Tumour Specific Sites ......................... - 48 Breast …………………………………………………………………………………….- 48 Cervical …………………………………………………………………………………….- 49 Colorectal ................................................................................................................ - 50 Head and Neck ........................................................................................................ - 51 Lung
…………………………………………………………………………………….- 52 Lymphoma ............................................................................................................... - 53 Melanoma ................................................................................................................ - 54 Ovarian …………………………………………………………………………………….- 55 Upper GI .................................................................................................................. - 56 Urology …………………………………………………………………………………….- 57 Appendix 3 - Old and New Target 62-Day Target Differences ..................................... - 58 Appendix 4 - 31-day Target Criteria. ............................................................................ - 59 Acknowledgements ...................................................................................................... - 60 -
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Updates From Previous Version (v3.1)
Version
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Summary of Changes
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Updated „When and how should the data be reported?‟
Inserted „Data Submissions Flowchart‟.
Inserted „Eligible and Non-Eligible referrals‟ flowchart‟.
Updated information on Who is responsible for the
accuracy and sign off of the publication data?
Inserted Process for sign off and data quality process for
the quarterly publication reports.
Updated Publication Revisions section and removed
Publication Timetable.
Inserted link to view publication timetable on website.
Updated „Annual publication of acute leukaemia and
paediatric cancers‟ information.
Inserted Data Quality Assurance Audit and Case
Ascertainment information.
Inserted additional wording for Cancer Waiting Times
Target Cohort.
Inserted „Carcinoid Tumours‟ under „Performance will not
be monitored on the following cancer types‟.
Updated Dataset table – Waiting Times Adjustment
„Mandatory‟ column and UCPN Format.
Inserted UCPN Format and Definition.
Updated „Date of Receipt of Referral‟ definition for Bowel
and Cervical Screening Programme patients.
Updated Multiple Referrals Information for „Date of
Receipt of Referral‟ Additional Information.
Updated „Urgency and Source of Referral‟ – Additional
Information.
Updated Multiple Referrals information for „Urgency and
Source of Referral‟.
Deleted „Carcinoid Tumours‟ as an exclusion from
„Colorectal‟.
Inserted „PTA Tumours‟ as an exclusion from „Urology Bladder‟.
Inserted „Additional Information‟ for Cancer Type.
Inserted „General Inclusions and Exclusions‟ for Cancer
Type.
Updated definition of „Decision to Treat Date‟.
Moved „General Recognised First Treatments‟ to
Appendix 1.
Inserted additional wording to Waiting Times Adjustment.
Inserted Waiting Times Adjustment Scenarios.
Updated 06 Medical Suspension – WTA 6 – New &
Emerging Technologies.
Inserted Appendix 1 - General Recognised First
Treatments.
Added „Cryotherapy‟ to Other therapy examples –
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Appendix 1 - General Recognised First Treatments.
Moved „Recognised First Treatments for Tumour Specific
Sites‟ to Appendix 2.
Updated information for Cervical Cancer - Additions to
procedures listed in general table.
Changed „Head and Neck - Other Therapy‟ to „Y‟ for
Recognised First Treatment for Head & Neck cancer.
Added „Cryotherapy‟ to „Other therapy‟ - Additions to
procedures listed in general table.
Added „Biopsy Intent‟ table – Additions to procedures
listed in general table.
Inserted tables highlighting main differences between the
old and new 62-day target and 31-day target.
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1
Introduction
Better Cancer Care – An Action Plan was launched on 27 October 2008. Central to this is
development of a comprehensive programme of work to assure the quality of care delivered.
Two key and complimentary strands of this work are assuring compliance with national
clinical standards and guidelines through robust clinical governance and delivery of 2 new
cancer targets:
Target 1
62-day target to treatment for all patients referred urgently with a suspicion of cancer and for
screened positive patients.
Target 2
31-day target from decision to treat to first treatment for all patients diagnosed with cancer
irrespective of their route of referral.
These new targets have to be implemented and achieved in and from Quarter 4 (October –
December) 2011.
This document aims to cover all the necessary definitions for implementing the new cancer
waiting times targets, however if you have any further questions please contact
[email protected].
When considering the definitions for the new cancer waiting times targets, the Data &
Definitions subgroup of the National Waiting Times Delivery Group (NCWTDG) noted that
ideally these should align exactly with 18 weeks referral to treatment (RTT) definitions.
However, it was concluded that cancer has a different cohort of patients, with different
decisions and needs, from the cohort of elective care patients in 18 weeks RTT, but where
appropriate definitions are aligned.
The following criteria were used as the basis for developing the definitions:
Clear &
Transparent
Ensuring that the new cancer waiting times targets are easy to
understand, both for patients and the public, and for the NHS staff
responsible for ensuring that patients are able to start their treatment
within the target timescales
Measurable
Avoiding any unnecessary increase in NHS data collection requirements
within the context of existing or planned information systems
Resilient
The definition and scope of the targets need to remain workable and
robust in the changing clinical and technological environment of NHS
Scotland
Patient
Focussed
Ensuring that the new cancer waiting time targets drive sustained
improvements in patient experience and that patient choices are
reflected within the definitions
Affordable
The targets must be achievable within the resources allocated to NHS
Scotland by the Scottish Government
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2
Responsibility for Delivering the Cancer Waiting Times Targets
What is Primary Care responsible for?
General practitioners are responsible for referring patients with a suspicion of cancer in line
with the Scottish Referrals Guidelines for Suspected Cancer NHS HDL (2007) 9. In line with
established best practice, referrals should be submitted electronically via SCI Gateway.
Boards should ensure that practices are supported to achieve this. Practices should have
systems in place to ensure that urgent referrals with a suspicion of cancer are submitted on
the same or the day following the decision to refer.
Exceptionally, where electronic methods are not available, referrals to secondary care
providers should be sent as soon as possible. NHS Boards should audit levels and
efficiency of electronic and other referral methods.
Which Board is responsible for delivering the 62-day target?
The Board of receipt of referral is responsible for meeting 95% compliance with the 62-day
target.
Which Board is responsible for delivering the 31-day target?
The Board of first treatment is responsible for meeting 95% compliance with the 31-day
target.
A 5% tolerance level will be applied to the cancer targets to allow for patients whom it is not
appropriate or advisable to expedite through the system for the purpose of achieving target
compliance.
If a NHS Board chooses to outsource part of a patient‟s care (e.g. to the independent sector
or NHS England) the responsibility for delivering the target will remain with the relevant NHS
Board.
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3
Data Collection and Publication
Who is responsible for collating and submitting the data?
The Board responsible for collating and submitting the data is the Board of receipt of the
initial referral to secondary care. Data for both performance management and official
reporting of the new targets should come from a single source - the tracking systems within
Boards. This will be subject to the same degree of scrutiny, validation and quality assurance
as current methods of target performance measurement.
When and how should the data be reported?
The data should be submitted to the Information Services Division (ISD) of NHS National
Services Scotland monthly via SWIFT (Submission With Internet File Transfer), based on
patients treated within the month. This should be submitted once per Board for all tumour
sites by the 20th of the following month. If the 20th falls on a weekend or public holiday, the
data should be submitted the next working day. The submission and reporting timetable can
be found within the Rules and Guidance section on the New Cancer Waiting Times page
(http://www.isdscotland.org/Health-Topics/Waiting-Times/Cancer/).
If a resubmission of a previous month‟s data is required, due to an extra patient identified or
a record already submitted needs to be amended, then the whole submission for that
treatment month must be uploaded. Data for the quarterly publication can be submitted one
month after the submission deadline of the last month in that quarter, e.g. Quarter 1
(January – March) monthly submission deadline is in April therefore the quarterly submission
deadline will be in May.
Any submission queries should be directed to [email protected].
Data Validation
Validation of submitted data will be carried out by ISD on uploading of the data. This is a
series of logic checks to see if the data is feasible, e.g. if the patient is born before they are
referred for treatment. The SWIFT system will not accept the Board submission if any of
these logic checks fail. It should be noted, however, that this is not a measure of accuracy
of the data.
A second level of validation will occur at ISD, and specific anomalies will be brought to the
attention of each Board. Examples of this are if the wait to treatment is over a year, or if the
patient was referred a long time after they were treated.
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Data Submissions
Flowchart shows the different stages of what happens to the data when it is extracted from
NHS Board systems, submitted to ISD and reports produced.
PAS/PMS system
Lab Reports
Tracking system
Resubmission of enitre treatment
month's data e.g. extra patient
identified or record already submitted
requires to be amended.
Submission Template
File checked for
errors
SWIFT DVL
Oracle Database
File interrogated for
duplicates and
inappropriate recording
Business Objects
Quarterly
Reports
generated
Monthly reports
generated
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Eligible and Non-Eligible referrals
Once NHS Boards have submitted NCWT data, records that are not eligible for reporting on
the relevant targets are filtered out along with records that are excluded (died before
treatment, refused treatment or clinically complex). This leaves just eligible referrals that all
performance calculations are based on.
Data Flowchart for 62-Day Target
Total number of referrals submitted
(Urgent + non-urgent)
Remove
Non-urgent referrals
(Urgency/Source of
Referral code 16 &
17)
Urgent Referrals (Urgency/Source of
Referral code is 02, 14 or 15)
Remove
Eligible Referrals (Urgent referrals
minus exclusions)
Look at referral to
treatment days
(the number of
days from receipt
of referral to first
treatment minus
any pre/post DTT
WTA)
Number of eligible referrals
treated within 62 days
Exclusions (died
before treatment,
refused treatment or
clinically complex)
Max, median and
percentile calculated
from this (based on
referral to treatment
days).
Number of waiting
times adjustments
i.e. patient/medical
delays + median
adjustments based
on WTA pre/post
DTT days.
Number of eligible referrals not
treated within 62 days, or where
date of receipt of referral or date
of first treatment is 09/09/0909
Percentage treated within 62days (No. of eligible referrals
treated within 62 days/ no. of
eligible referrals x 100)
Number of target breaches (62day)
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Data flowchart for 31-Day Target
Total number of referrals submitted
(Urgent + non-urgent)
Exclusions (died
before treatment,
refused treatment or
clinically complex)
Remove
Eligible Referrals (Urgent and nonurgent referrals minus exclusions)
Look at decision
to treat to
treatment days
(the number of
days from DTT
to treatment
minus any postDTT WTA)
Number of eligible referrals
treated within 31 days
Max, median and
percentile calculated
from this (based on
DTT to treatment
days).
Number of waiting
times adjustments
i.e. patient/medical
delays + median
adjustments based
on WTA post-DTT
days.
Number of eligible referrals not
treated within 31 days, or where
date of decision to treat or date
of first treatment is 09/09/0909
Percentage treated within 31days (No. of eligible referrals
treated within 31 days/ no. of
eligible referrals x 100)
Number of target breaches
(31-day)
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Who is responsible for the accuracy and sign off of the publication data?
The Board responsible for signing off the accuracy of publication data is:
62-day target – The Board of receipt of referral
31-day target – The Board of first treatment
For some patients in the 31-day target cohort, it is possible that a Board other than the one
that submits the data is responsible for delivering the target. Boards should have
mechanisms in place for data submission and sign off for these patients.
Process for sign off and data quality process for the quarterly publication reports
As of the March 2011 publication, the process for sign off and data quality for the quarterly
publication reports is as follows. ISD will:
No longer send excel versions of the BOXI snapshot data to each NHS Board. This
information is currently available through Business Objects locally.
No longer send the sign off documentation (word document) to the main and
alternative contact for each board.
Continue to highlight key trends/variations and raise any data quality issues with NHS
Boards, to enable a complete picture of any issues to be understood and footnoted
within our publication tables and interpreted in our data quality paper.
In summary:
ISD will email NHS Boards to notify that snapshot data for publication is available via
BOXI. Scotland-level tables will still be provided for comparative purposes.
ISD will highlight key trends/variations and raise specific data quality issues that arise
from the latest analysis in the email to allow NHS Boards the opportunity to provide
specific information around the accuracy and quality of data which can be footnoted in
the publication tables or included within the data quality paper.
NHS Boards and ISD will have a shared responsibility to highlight any data issues
prior to publication. If no comments are received from NHS Boards prior to the final
sign-off date via emailing: [email protected], then the NHS Board‟s
quarterly data will be published.
Publication Revisions
If after publication it transpires that the data originally submitted was incomplete or incorrect,
NHS Boards will be given the opportunity to re-submit the historical data. ISD will then
revise the published data at the next quarterly publication. This will be in line with the NSS
Statistical Revisions Policy and will align cancer waiting times with other ISD statistical
releases and should ensure openness, transparency and the most up-to-date and relevant
data being used for publication.
The latest published data will be used for the generation of responses to information
requests, parliamentary questions, etc.
To view the reporting timetable, please visit the Rules and Guidance section on the New
Cancer Waiting Times page (http://www.isdscotland.org/Health-Topics/WaitingTimes/Cancer/).
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4
Performance and Quality Measures
Quality Standards for Cancer Services
There are many standards for Quality Assurance and accreditation of clinical cancer
services in NHS Scotland, some of which measure performance of an aspect of waiting time
for patients, e.g. NHS Quality Improvement Scotland standards.
For those services involved in measuring against the quality standards, the new cancer
waiting times targets supersede the standards for the purposes of performance management
of cancer access.
Annual publication of acute leukaemia and paediatric cancers
A review of all ISD statistical waiting times‟ publications has taken place. This consultation
process took place between ISD, the Scottish Government and data providers to consider
the user-need and frequency of a suite of waiting times‟ publications. The Acute Leukaemia
and Paediatric Cancers publication which has been published annually since 2007 was
included within this review. The outcome of the consultation is published on the waiting
times web pages. The final recommendation was that these statistics will no longer be
published by ISD; however NHS Boards should continue to ensure that data collection
continues to facilitate the monitoring of performance locally. The last annual publication of
acute leukaemia and paediatric cancers can be found on the Historical Data section of our
web pages.
HEAT
The new 31- and 62-day targets are both included as performance measures in HEAT.
Quality Assurance
Data Quality Assurance Audit
The Data Quality Assurance (DQA) team on behalf of the New Cancer Waiting Times
(NCWT) Team carried out and completed a data quality audit for patients who fall under the
62 and 31-day targets based on quarter 2 data (April-June 2010) as at 28th September 2010.
Audits are required to ensure that data being recorded is accurate and that recording is
consistent across Scotland. Audits will support the NHS Boards in determining any areas
where data quality can be improved and help them resolve any issues. Audits will contribute
towards the fitness for publication exercise and help ensure that when recording and
submitting data for publishing national statistics that data quality is taken into account.
The DQA team investigated the following areas to determine:
If correct codes are being used.
If waiting times adjustments and exclusions (patient refused treatment, patient died
before treatment or clinically complex) are being applied correctly and consistently,
and whether there is any supporting evidence on the NHS Boards systems.
If the rules and guidance are being appropriately applied.
More information on data quality including the results of the DQA can be found within the
Data Quality section of our web pages.
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Case Ascertainment
It is important that the performance against the new cancer waiting times targets is
measured in conjunction with the number of cancer patients in NHS Scotland to assess
coverage of the application of the targets. ISD will continue to monitor case ascertainment
figures compared with cancer registrations. For this reason data on all patients in the cancer
waiting times targets cohort (see section 5) will be required for the analysis, including
patients who will be excluded from performance calculation.
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5
Cancer Waiting Times Targets Cohort
The cancer waiting times targets are applicable to adult (over 16 at date of diagnosis)
NHSScotland patients with a newly diagnosed primary cancer. NHS Boards should ensure
patients are over 16 at diagnosis prior to data submission. A patient should only be
recorded and submitted as a NCWT patient where the patient has been diagnosed with
cancer and is not just an urgent with suspicion referral. For waiting times purposes, a
diagnosis is assumed if a patient has been told they have cancer and/or have received
treatment for cancer. Recurring cancers are not covered by these waiting times targets. For
further details of which cancer types should be included in waiting times submission please
see Page 25.
The 62-day target applies to patients who:
were referred urgently by a primary care clinician or General Dental Practitioner
(GDP) with a suspicion of cancer;
were detected through the National breast, bowel and cervical Screening
Programmes; or
attended A&E or were referred directly to hospital.
The 31-day target applies to all patients irrespective of route of referral.
Patients should be included in the relevant waiting times target cohort when they have part
of or their entire pathway within NHSScotland. Patients who choose to have part of their
pathway out with NHSScotland will be exempt from the relevant target as follows:
If the part of their pathway outwith NHSScotland is pre decision to treat the patient will
not be subject to the 62-day target, irrespective of route of referral. The patient will be
subject to the 31-day target decision to treat to first treatment.
If the part of their pathway outwith NHSScotland is post decision to treat the patient
will not be subject to the 62-day target or the 31-day target. As the patient is not
subject to either of the cancer waiting times targets, data should not be submitted to
ISD for these patients.
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Applicable cancer types
Performance will be monitored on the following cancer types:
Breast
Cervical
Colorectal
Head & Neck
Lung
Lymphoma
Melanoma
Ovarian
Upper Gastro-Intestinal (hepato-pancreato-biliary (HPB) and oesophago-gastric (OG))
Urological (prostate, bladder, other)
Performance will not be monitored on the following cancer types:
Carcinoma in situ (with the exception of breast, which is included)
Some non-invasive tumours e.g. pTa tumours (see Page 25)
Mesothelioma
Carcinoid Tumours
All other tumour types not identified above
Wider coverage of monitoring of the targets to these and other cancer types will form part of
future consultation with NHS Boards.
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6
Dataset
For each patient the following data items need to be recorded:
Field
CHI Number
Unique Care Pathway Number
Patient
Demographics Hospital Patient Identifier
Patient Postcode at Referral
Ethnic Group
Date of Receipt of Referral
Referral Board of Receipt of Referral
Urgency and Source of
Referral
Diagnosis Cancer Type
Decision To Decision to Treat Date
Treat
Type of First Treatment
First Treatment Date of First Treatment
Board of First Treatment
Waiting Time Adjustment PreDTT - Number of Days
Waiting Time Adjustment PreDTT - Main Reason
Waiting Times Waiting Time Adjustment
Adjustment Post-DTT - Number of Days
Format
10 numbers
13
alphanumeric
characters
10 characters
7 characters
2 characters
DDMMYYYY
1 character
2 characters
2 characters
Yes
DDMMYYYY
Yes
2 characters
DDMMYYYY
1 character
Number
Number
Yes
Yes
Yes
Yes, if a patient is in the
62-day target cohort
Yes, if a patient is in the
62-day target cohort
Yes, if a patient is in the
62-day and 31-day
target cohort
Yes, if a patient is in the
62-day and 31-day
target cohort
Yes, if a patient is in the
62-day target cohort
Yes
2 characters
Yes
2 characters
Yes
2 characters
Number
2 characters
Referral to Treatment (days)
Number
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Page
18
18
No
Yes
Yes
Yes, if a patient is in the
62-day target cohort
Yes
Yes
Waiting Time Adjustment
Post-DTT - Main Reason
Adjusted Length
of Pathway Decision to Treat to Treatment
(days)
Reason for Delay 62-day
Reason for
Delay Reason for Delay 31-day
Mandatory?
Yes
No
18
19
19
20
22
23
25
27
29
30
31
32
32
32
32
44
44
45
45
6.1
6.1.1
Person Demographics
CHI Number
Format: 10 characters
The Community Health Index (CHI) number is a unique numeric identifier, allocated to each
patient on first registration with the system. The CHI number is a 10-character code
consisting of the 6-digit date of birth (DDMMYY), two digits, a 9th digit that is always even for
females and odd for males and an arithmetical check digit.
The CHI number should always be used to identify a patient. However, Health record
identifiers, such as hospital numbers in Patient Administration Systems (PAS), may be used
locally, in conjunction with the CHI number or in the absence of the CHI number, to track
patients and their records.
Although there may be no number when a patient presents for treatment, there must be an
allocation at some point in the episode of care as CHI is mandatory on all clinical
communications.
6.1.2
Unique Care Pathway Number (UCPN)
Format: 13 alphanumeric characters
The Unique Care Pathway Number (UCPN) is a unique number that will be allocated to all
new referrals and will identify patient pathways.
The UCPN will be allocated by the organisation receiving the first referral. Where an activity
is the result of a previous activity in the pathway, the existing UCPN will be used. All
activities on the pathway will require the collection and transmission of the UCPN. This will
include tertiary referrals and requests for diagnostic investigations. Referrals between care
providers and organisations will be required to include the UCPN.
6.1.3
Hospital Patient Identifier
Format: 6-10 alphanumeric characters
The hospital patient identifier is a code that uniquely identifies a patient on the main index of
a hospital (i.e. within the hospital health records system). The code is normally allocated on
the patient's first contact with the hospital except where the contact is through Accident &
Emergency. This should be the identifier allocated at the hospital of initial referral.
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6.1.4
Patient Postcode at Referral
Format:
AN NAA
ANN NAA
AAN NAA
AANN NAA
ANA NAA
AANA NAA
AAA NAA
Example
G5 8BW
M34 3AB
EH5 3SQ
EH12 6UP
W1A 4WW
EC1A 1HQ
GIR 0AA (only one in UK)
This is the postcode of the patient, as recorded on the referral. If not recorded, and for
patients who are not resident in the UK, use the code NK01 0AA.
6.1.5
Ethnic Group
Format: 2 characters
This is self assigned by the patient, and should be sourced from the GP referral or the PAS
system.
Code
01
02
03
04
05
97
99
Description
White
Mixed
Asian, Asian Scottish or Asian
British
Black, Black Scottish or Black
British
Other ethnic background
Not disclosed
Not known
A further list of subcategories can be found in the ISD Data Dictionary part of the Data
Definitions and References section of the ISD website.
- 19 -
6.2
6.2.1
Referral
Date of Receipt of Referral
Format: DDMMYYYY
The date of receipt of referral is defined below for each referral source.
GP/GDP patients
The referral date is the date of receipt of initial referral into secondary care.
In line with established best clinical practice, referrals should be submitted electronically.
For electronic referrals the date of receipt of referral is the GP submission date. In
exceptional circumstances referrals can be made by letter, fax or telephone. For referral
letters and faxes the date of referral is the date with which the referral is stamped as having
first been received in secondary care. For telephone referrals this is the date the verbal
communication took place.
N.B. This field is only mandatory for GP/GDP referrals that are urgent with suspicion of
cancer. Other urgencies of referral can be coded 10/10/1010 (inapplicable).
Bowel Screening Programme patients
The referral date is the date a request for a further diagnostic intervention is received via
SCI gateway.
Breast Screening Programme patients
The referral date is the date that the letter for the assessment centre is generated to request
recall to an assessment centre for further diagnostic intervention.
Cervical Screening Programme patients
The referral date is the date a request for a further diagnostic intervention is received via
SCI gateway.
A&E or other direct referral to hospital patients
The referral date is the date the patient presents to hospital (A&E or other).
Other referrals
For these referral types (coded 17 under Urgency and Source of Referral) this field is
optional. Code 10/10/1010 (inapplicable) can be used.
Date not known
If no date is documented, use 09/09/0909 (not recorded). This would count as a breach of
the 62-day target, if applicable.
- 20 -
Additional Information
Multiple referrals
It is possible for a patient to be referred in to secondary care and already be under a care
pathway in secondary care for the same tumour type. In this situation there should be a
clinical decision as to whether this new referral overrides the current pathway, and therefore
which target cohort the patient is in. This decision should be documented, and will
determine the Date of Receipt of Referral.
Downgraded referrals
If an urgent referral with suspicion of cancer is downgraded in agreement with the GP (see
page 24) the date of receipt of referral will no longer be a mandatory field.
Fast track referrals
Many NHS Boards have set up arrangements to enable GPs to refer directly for specific
tests. Some NHS Boards also have set up arrangements whereby, if the results of this test
highlight a suspicion of cancer, a referral is sent by „fast track‟ directly to a hospital
consultant and the GP is not required to send a referral for the patient . Where a NHS Board
has an agreement between primary & secondary care that a GP referral is not required, the
patient pathway should be managed within the 62-day target. In these cases the date of
receipt of referral should be taken as the date of the report of the first open access
investigation that triggered the „fast track‟ process and this should be coded as GP urgent
with suspicion of cancer.
For NHS Boards who do not have such an agreement in place between primary and
secondary care and who require a GP referral, the urgency and date of receipt of referral
should be recorded as dictated by the GP referral received.
- 21 -
6.2.2
Board of Receipt of Referral
Format: 1 character
This is the Board that receives the initial referral into secondary care. For breast screening
referrals the Board of receipt of referral is the screening unit‟s host Board, e.g. women in
NHS Lanarkshire are screened by a unit hosted by NHS Greater Glasgow & Clyde and
therefore NHS Greater Glasgow & Clyde would be the Board of receipt of referral.
Code
A
B
Y
F
V
N
G
H
L
S
R
Z
T
W
Description
NHS Ayrshire & Arran
NHS Borders
NHS Dumfries & Galloway
NHS Fife
NHS Forth Valley
NHS Grampian
NHS Greater Glasgow & Clyde
NHS Highland
NHS Lanarkshire
NHS Lothian
NHS Orkney
NHS Shetland
NHS Tayside
NHS Western Isles
- 22 -
6.2.3
Urgency and Source of Referral
Format: 2 characters
This combines the urgency and source of the initial referral to secondary care.
To determine if a referral should be coded „14‟ as „Urgent with a Suspicion of Cancer‟ apply
the following:
For SCI referrals or template/proformas: The urgency should be taken from the
urgency/priority field in the top section of the letter, and not determined from the free
text/body of the letter.
For other methods of referral: The letter/fax/phone call must clearly indicate if urgent with
suspicion.
Code
02
14
15
16
17
Description
Referral from a National Cancer Screening Programme
Primary care clinician or GDP urgent referral with suspicion of cancer
Direct referral to hospital (self, GP or NHS24 referral to A&E or other)
GP/GDP referral other
Other
Additional Information
62-day target cohort
Patients who are referred as „Type of Referral‟ 02, 14 or 15 are in the cohort for the 62-day
target.
GP/GDP Referral Other
A referral from GP/GDP referral other, coded 16 includes the following referral types:
GP/GDP Routine
GP/GDP Soon
GP/GDP Urgent
Code 17 Other
Code 17 – Other, includes the following referral types:
Incidental finding
Review Patient
Private Patient
Other
Incidental findings
A referral should be considered an incidental finding and coded 17 (Other) if one of the
following applies:
the cancer diagnosed does not relate to the symptoms of the initial referral to
secondary care
the cancer diagnosed does not relate to the symptoms of direct referral to hospital
(A&E or other)
the cancer diagnosed is a cancer other than that for which the patient was screened.
- 23 -
Multiple referrals
It is possible for a patient to be referred in to secondary care and already be under a care
pathway in secondary care for the same tumour type. In this situation there should be a
clinical decision as to whether this new referral overrides the current pathway, and therefore
which target cohort the patient is in. This decision should be documented, and will
determine the Urgency and Source of Referral.
Downgrading referrals
The urgency and source of referral may be downgraded from 14 (Primary care clinician or
GDP urgent referral with suspicion of cancer) if the primary and secondary clinicians agree
the referral did not meet the Scottish Referral Guidelines for Suspected Cancer. The result
of this correspondence must be clearly documented. Downgraded referrals should be
coded as the agreed urgency of referral, i.e. 16 (GP/GDP referral other) or 17 (Other).
Upgrading referrals
Referrals upgraded by a consultant to urgent with suspicion of cancer should be coded as
16 (GP/GDP referral other) or 17 (Other) as received, but this should not affect their clinical
care. If a patient is diagnosed with cancer they will then be subject to the 31-day target from
decision to treat to treatment.
Pathways outwith NHSScotland – Patient Choice
If a patient chooses to have part of their diagnostic pathway outwith NHSScotland, but has
the decision to treat to treatment within NHSScotland, this should be coded 17 (Other).
- 24 -
6.3
6.3.1
Diagnosis
Cancer Type
Format: 2 characters
The cancer type must fit into one of the following thirteen cancer types to be included in the
target.
Cancer Type
Code
01
Description
Breast
02
03
04
Colorectal
Head & Neck
Lung
05
06
Lymphoma
Melanoma
07
Gynaecological – Ovarian
08
10
Upper GI –
Hepatopancreatobiliary
Upper GI –
Oesophagogastric
Urology – Bladder
11
Urology – Prostate
C61
12
13
Urology – Other
Gynaecological – Cervical
C60, C62-66, C68
C53
09
ICD-10 Codes included
C50, D05
All patients with a new
primary breast cancer or
carcinoma-in-situ
C18-20
C00-14, C30-32, C76.0
C33-34
C81-85
New primary invasive
(i.e. Clark level > 1)
melanoma of any site
except eye. Includes
C43 (Skin)
Proven secondary
melanoma where the
origin of the primary
lesion has never been
identified.
C56, C48 (only if
ovarian type), D39.1
C22-25
C15-16, C17.0
C67
Additional Information
To see the full list of ICD-10 Codes please visit
http://apps.who.int/classifications/apps/icd/icd10online/
- 25 -
Exclusions, if applicable
None
Sarcoma and lymphoma
Mesothelioma, cancer of
pleura
In situ disease i.e. Clark
level ≤ 1
Melanoma of eye
(choroidal, conjunctival)
Patients with recurrent
disease rather than a new
primary
Lymphoma, carcinoma-insitu, high grade dysplasia
Non-invasive tumours and
PTA Tumours
Patients with non-invasive
tumours (e.g. prostatic
intraepithelial neoplasia)
D06, CIN 1, CIN 2 and
CIN3
General Inclusions
Some patients never have microscopic verification of the tumour (i.e. histology or
cytology). In these cases diagnosis is made on information such as imaging
investigations or a clinical decision.
A patient should only be recorded and submitted as a NCWT patient where the
patient has been diagnosed with cancer (clinical or pathological) and is not just an
urgent with suspicion referral.
If a patient has been given a diagnosis, whether this is clinical or pathological, of
cancer and/or have received treatment for cancer then the relevant primary diagnosis
code should be used.
Include patients if they have had a previous primary malignancy of any cancer site or
a concurrent primary malignancy of another cancer site.
General Exclusions
Patients where the origin of the primary tumour cannot be determined.
Recurrent cancer.
Metastatic cancers (except melanoma where the origin of the primary lesion has
never been identified).
Carcinoma in situ tumours (with the exception that patients diagnosed with breast
cancer should be included).
Carcinoid tumours.
Good relationships should be built with clinicians, secretaries and other administrative staff
in order to obtain information required for NCWT. Local procedures regarding the recording
of information should be developed and implemented to ensure that information is clearly
visible and obtainable.
- 26 -
6.4
Decision to Treat Date
Format: DDMMYYYY
The date on which the treatment plan was agreed between the patient and the clinician (or
delegate) responsible for first treatment. This usually follows an MDT discussion.
Notwithstanding target delivery, it is in the best interests of patient care that in all cases the
decision to treat discussion with the patient should take place as soon as possible after the
MDT meeting, if this took place. NHS Boards should audit the interval between these dates
and take appropriate action to ensure that delays are avoided.
Additional Information
If the first treatment is to be surgery:
This is the date that the consultation between the patient and the surgeon (or delegate)
responsible for first treatment took place and a treatment plan for surgical treatment was
agreed.
If the first treatment is to be chemotherapy or other drug treatment:
This is the date that the consultation between the patient and the oncologist (or delegate)
responsible for first treatment took place and a treatment plan for chemotherapy treatment
was agreed.
If the first treatment is radiotherapy:
This is the date that the consultation between the patient and the oncologist (or delegate)
responsible for first treatment took place and a treatment plan for radiotherapy treatment
was agreed.
If a decision is taken to provide supportive care:
This is the date that the consultation between the patient and clinician took place and a plan
for supportive care was agreed.
If the first treatment is active monitoring:
This is the date that the consultation between the patient and the clinician responsible for
active monitoring took place and a plan for active monitoring was agreed.
Patient dies or refuses treatment
If a patient dies before treatment or refuses all treatment the date of decision to treat should
be recorded as either the date decision to treat occurred or 10/10/1010 (inapplicable).
Date not known
If no date is documented, use 09/09/0909 (not recorded). This would count as a breach of
the 31-day target.
- 27 -
Example decision to treat scenarios
Scenario 1
Patient is diagnosed with breast cancer and discussed at MDT. The treatment plan is
decided as surgery with a surgeon in that NHS Board. The surgeon telephones the patient
the next day to discuss the MDT decision and the patient agrees to surgery. The date of
decision to treat is the date of the telephone conversation.
Scenario 2
Patient is diagnosed with oesophageal cancer and discussed at MDT. Surgery is decided
as treatment but the patient is frail and requires a high risk anaesthetic assessment. The
surgeon and patient agree on surgery as treatment pending the anaesthetic assessment
and they agree that a further appointment will not be necessary unless the opinion of the
anaesthetist is that surgery is too risky. The anaesthetist sees the patient and assesses him
fit for surgery and the patient is listed for surgery. The date of decision to treat is the date of
the anaesthetic assessment.
Scenario 3
Patient is diagnosed with lung cancer. MDT discussion concludes that surgery at a tertiary
NHS Board is the best plan for this patient. The patient comes in to see their local lung
physician who discusses the option of thoracic surgery at a different NHS Board. A referral
is made to the tertiary service and the patient meets the thoracic surgeon two days later.
They discuss the operation in more detail, including some information not mentioned at the
previous consultation. The patient agrees to go ahead with the surgery. The date of
decision to treat is the date of the discussion between the patient and thoracic surgeon.
Scenario 4
Patient is diagnosed with colorectal cancer. The MDT discussion concludes that this patient
should have neo-adjuvant chemoradiotherapy at a tertiary NHS Board followed by surgery in
their local NHS Board. The colorectal clinical nurse specialist knows the patient well and
offers to discuss the treatment options with the patient. The patient is referred to and
attends an oncology appointment at the tertiary NHS Board, and agrees to go ahead with
the chemoradiotherapy. After the course of chemoradiotherapy the patient has an
appointment in their local NHS Board and subsequently attends for surgery. The date of
decision to treat is the date of the outpatient consultation with the oncologist at which the
patient decides to opt for chemoradiotherapy.
Scenario 5
A patient has a skin lesion which the dermatologist removes completely in the course of a
biopsy. The pathology suggests that although it is a melanoma, no further treatment is
indicated. In this case the date of first treatment should be used as the decision to treat.
- 28 -
6.5
First Treatment
6.5.1
Type of First Treatment
Format: 2 characters
The definition of first treatment is the treatment or drug that genuinely attempts to begin
the patient‟s first treatment, including if this is palliative care or supportive care. Cancer
waiting times definitions have been formed for performance monitoring and not for clinical
outcome purposes. Patients should be included in the target where a first treatment was
attempted, but either not carried out or not completed for clinical reasons, e.g. „open and
shut‟ cases would be included under 01 „Surgery‟. Diagnostic biopsies should only be
included if the whole tumour has been removed and margins are clear.
Code
01
02
03
04
05
06
07
08
09
11
12
14
Description
Surgery
Radiotherapy
Chemotherapy
Synchronous chemoradiotherapy
Endoscopic
Hormone therapy
Supportive care
Patient refused all treatment *
Not recorded ~
Other
Watchful wait/active surveillance
Patient died before treatment *
* Patients who die before treatment or who refuse all treatment will be excluded from the
cancer waiting times targets.
~ Patients coded as 09 will be calculated as a breach of any eligible target.
Please see appendix 1 for general first treatment types and appendix 2 for guidelines on
recognised first treatment types.
- 29 -
6.5.2
Date of First Treatment
Format: DDMMYYYY
This is the date of first cancer treatment. The table below gives guidelines for date of
treatment per treatment type.
Mode of first treatment
Surgery
Radiotherapy
Date of first treatment
Date of surgery (not date of
admission)
Date of first fraction
Chemotherapy
Date of first pulse
Synchronous
chemoradiotherapy
Date of first pulse
Endoscopic
Date of procedure
Hormone therapy
Date of communication to GP
requesting prescription plus 2 days,
or date of prescription if given
directly to patient.
Date symptom control intervention
commences. If no symptom control
intervention planned the date of
decision to treat should be used.
Date patient refused any treatment
Supportive care
Patient refused all treatment
Not recorded
Other
Watchful wait/active
surveillance
Patient died before treatment
09/09/0909 (not recorded)
N.B. This will be counted as a
breach of any eligible target.
Date of other documented first
treatment
Date of decision to treat
Date of death, as on death
certificate
- 30 -
6.5.3
Board of First Treatment
Format: 1 character
This is the Board who has responsibility for the first (intended) treatment.
Code
A
B
Y
F
V
N
G
H
L
S
R
Z
T
W
D
Description
NHS Ayrshire & Arran
NHS Borders
NHS Dumfries & Galloway
NHS Fife
NHS Forth Valley
NHS Grampian
NHS Greater Glasgow & Clyde
NHS Highland
NHS Lanarkshire
NHS Lothian
NHS Orkney
NHS Shetland
NHS Tayside
NHS Western Isles
Golden Jubilee National
Hospital
If first treatment is performed out with an NHS Scotland Board, the Board that outsourced
the treatment should be coded here.
- 31 -
6.6
Waiting Times Adjustment
On reflection of a whole patient pathway there may be some areas of delay not attributable
to Board performance. These pathways may be adjusted to discount periods of patient
unavailability, for patient-induced delays and medical suspensions. It is recognised that
these adjustments can be complex to record and quality assure, however consultation
showed that it is the right thing to do for measuring performance on waiting times for cancer
patients, and aligns to wider waiting times principles and measurement across NHS
Scotland.
Consultation also concluded that there cannot be a maximum length of adjustment or
maximum number of adjustments allowed. As such, a record should be taken of all
adjustments in the pathway, and on completion of the pathway all adjustments added
together for submission. It will be important to check whether the adjustment occurs before
or after the decision to treat, as adjustments can be made to both the 62-day and 31-day
targets. Waiting Time Adjustments (WTA) are only applicable to the reportable component
of the target. A pre-DTT WTA for 31-day target patients should be recorded as a Waiting
Time Adjustment Pre-DTT - Main Reason „07‟ No adjustment with Waiting Time Adjustment
Pre-DTT - Number of Days being zero. Each adjustment should be documented – if there is
no documented evidence, an adjustment cannot be made.
6.6.1
Waiting Times Adjustment Pre/Post-DTT – Number of Days
Format: Number
This is the cumulative number of days by which the waiting times pathway can be adjusted
before/after the decision to treat. This can equal 0.
For each adjustment, the number of days should be calculated on the basis of the patient
unavailability being an inclusive period. The dates should be the start date of unavailability
and the end date of unavailability. Availability for the patient begins on the next subsequent
date e.g.
The patient becomes unavailable on 3rd of May until the 1st of June. The patient is then
available to continue their pathway on 2nd June. This would total as a 30 day adjustment.
2nd June minus 3rd May = 30 day adjustment.
6.6.2
Waiting Times Adjustment Pre/Post-DTT – Main Reason
Format: 2 characters
The main reason for the number of days adjustment before/after the decision to treat is the
one that contributed the longest delay, or if two are equal, the first delay that occurred.
Code
01
02
03
04
05
06
07
Description
Patient did not attend
Patient cancelled
Patient defers
Temporary co-morbidity
Other patient-induced suspension
Medical suspension
No adjustment
- 32 -
Adjusted Waiting Times Scenarios
In this section “appointment” should be taken to mean any pathway step, e.g. referral, clinic,
test, treatment. “Waiting list” should be taken to mean the wait to any pathway step.
01 - Patient did not attend
If a patient does not attend an appointment a waiting times adjustment can be applied.
Adjustment is from DNAd appointment back to previous step in the pathway.
Previous step in
the pathway
DNA
appointment
Attended
appointment
Patient pathway
Adjustment
Patent does not attend – Scenario 1
Patient has decision to treat on 1 June and has an appointment for 21 June. Patient
does not attend.
Answer
Adjustment is from the date the patient did not attend back to the previous step in the
pathway.
This can be calculated in 2 different ways:
Unavailability calculation
Unavailability is from 2 June to 21 June (inclusive) making it a post WTA of 20 days.
Or shown as:
M
30
7
14
21
28
T
1
8
15
22
29
June 2010
W
T
F
2
3
4
9
10
11
16
17
18
23
24
25
30
1
2
S
5
12
19
26
3
S
6
13
20
27
4
= 20 days
Dates calculation
Using the appointment dates this would be 21 June minus 01 June giving a post-DTT
WTA of 20 days.
- 33 -
Patient does not attend – Scenario 2
Patient was referred with an urgent suspicion of cancer; the date of receipt of referral
was 01 April and an appointment was made on 10 April. The patient did not attend this
appointment. Patient then offered further appointment on 23 April and the patient also
did not attend this appointment.
Answer
Adjustment is from the date the patient did not attend back to the previous step in the
pathway.
This is calculated the same way as in scenario 1 but the calculations can be treated as
two separate episodes or as one episode.
1 episode
Unavailability calculation
Unavailability is from 2 April to 23 April (inclusive) making it a pre-DTT WTA of 22 days.
Or shown as:
M
29
5
12
19
26
T
30
6
13
20
27
W
31
7
14
21
28
April 2010
T
F
1
2
8
9
15
16
22
23
29
30
S
3
10
17
24
1
S
4
11
18
25
2
= 22 days
Dates calculation
Using the appointment dates this would be 23 April minus 1 April making it a pre-DTT
WTA of 22 days.
2 episodes
Unavailability calculation
Unavailability is from 2 April to 10 April (inclusive) which is 9 days and 11 April to 23 April
(inclusive) which is 13 days. This would make a total pre-DTT WTA of 22 days.
Dates calculation
Using the appointment dates this would be 10 April minus 1 April = 09 days and 23 April
– 10 April = 13 days making it a total pre-DTT WTA of 22 days.
- 34 -
02 - Patient cancelled
A patient may have to cancel a booked appointment. Adjustment is from date the patient
cancelled their appointment back to previous step in the pathway.
Patient
cancels
appointment
Previous step in
Original
the pathway
appointment
New
appointment
Patient pathway
Adjustment
Patient Cancelled Scenario
Patient is referred in with an urgent suspicion of cancer; the date of receipt of referral is 15
August. Patient accepts an appointment on 14 September. Patient phones on 28 August to
cancel.
Answer
Adjustment is from the date the patient cancelled their appointment back to the previous
step in the pathway.
This can be calculated in 2 different ways:
Unavailability Calculation
Unavailability is from 16 August to 28 August (inclusive) making it a pre-DTT WTA of 13
days.
Or shown as days:
M
26
2
9
16
23
30
T
27
3
10
17
24
31
August 2010
W
T
F
28
29
30
4
5
6
11
12
13
18
19
20
25
26
27
1
2
3
S
31
7
14
21
28
4
S
1
8
15
22
29
5
= 13 days
Dates calculation
Using the appointment dates this would be 28 August minus 15 August giving a pre-DTT
WTA of 13 days.
- 35 -
03 - Patient defers
Patients may choose to defer the next appointment until after a holiday or until they can
make arrangements for other commitments. Adjustment is the length of unavailability,
e.g. length of time patient is on holiday.
Previous step in
Patient
the pathway
unavailable
Patient
available
Attended
appointment
Patient pathway
Adjustment
Patient Defers Scenario
Patient has decision to treat on 18 November. Whilst making an appointment to
start treatment the patient advises they will be on holiday from 30 November till 15
December. An appointment is made on 18 December.
Answer
Adjustment is the length of unavailability.
This can be calculated in 2 ways:
Unavailability calculation
Unavailability is from 30 November to 15 December (inclusive) making it a post-DTT
WTA of 16 days.
Or shown as:
M
29
6
13
20
27
T
30
7
14
21
28
December 2010
W
T
F
1
2
3
8
9
10
15
16
17
22
23
24
29
30
31
S
4
11
18
25
1
S
5
12
19
26
2
= 16 days
Dates calculation
This would be 16 December minus 30 November giving a post-DTT WTA of 16
days.
- 36 -
04 - Temporary co-morbidity
The patient has or develops an illness or condition that makes the patient unfit to attend for a
diagnostic investigation or treatment, e.g. viral infection, neutropaenia, exacerbation of a
chronic or pre-existing condition like chest disease or hypertension. Adjustment is from
the date the patient is fit to attend the next appointment back to the previous step in
the pathway.
Patient now fit to
attend appointment
Previous step in
the pathway
Patient
cancels/DNAs
original appointment
New
appointment
Patient pathway
Adjustment
Temporary co-morbidity scenario
Patient sees the clinician on 4 May and the clinician decides the patient should have
some investigations carried out and an appointment is made on 28 May. The patient
phones on 26 May to advise they are too ill to attend the appointment and cancels. The
patient advises they should be well enough next week (2 June) and a new appointment is
made for 4 June.
Answer
Adjustment is from the last date the patient is unfit to attend the appointment back to the
date of the last appointment with clinician.
It can be calculated in 2 different ways:
Unavailability calculation
Unavailability is from 5 May to 1 June (inclusive) making it a pre-DTT WTA of 28 days.
Or shown as:
M
26
3
10
17
24
31
T
27
4
11
18
25
1
W
28
5
12
19
26
2
May 2010
T
29
6
13
20
27
3
F
30
7
14
21
28
4
S
1
8
15
22
29
5
S
2
9
16
23
30
6
= 28 days
Dates calculation
Using the appointment dates this would be 1 June minus 4 May giving a pre-DTT WTA of
28 days.
- 37 -
05 - Other patient-induced suspension
Occasionally a patient may require a repeat appointment in their pathway, because they
choose to take some time to think over their options, or because they did not follow preappointment instructions such as bowel prep or stopping a medication. Adjustment is from
the repeat appointment back to the first.
Previous step in
the pathway
“Repeat”
appointment
Appointment
Patient pathway
Adjustment
Other patient-induced suspension – Scenario 1
Patient at previous appointment (15 July) with clinician was instructed to stop taking their
medication 5 days before having an investigation (1 August). On day of appointment
patient advised that they forgot to stop their medication. Another appointment was made
on 15 August.
Answer
Adjustment is from the repeat appointment back to the first.
It can be calculated in 2 different ways:
Unavailability calculation
Unavailability is from 1 August to 14 August (inclusive) making it a WTA of 14 days.
Or shown as:
M
26
2
9
16
23
30
T
27
3
10
17
24
31
August 2010
W
T
F
28
29
30
4
5
6
11
12
13
18
19
20
25
26
27
1
2
3
S
31
7
14
21
28
4
S
1
8
15
22
29
5
= 14 days
Dates calculation
Using the appointment dates this would be 15 August minus 1 August giving a WTA of
14 days.
- 38 -
Other patient-induced suspension – Scenario 2
Patient is offered treatment on 25 July at the Hospital A, but refuses treatment and
wishes to have treatment at Hospital B. A date of 1 August is offered at Hospital B.
Answer
Adjustment is from the date the patient could have been seen at hospital A to the time
they are seen at hospital B.
Unavailability calculation
Unavailability is from 25 July to 31 July (inclusive) making it a post-DTT WTA of 7 days.
Or shown as:
M
28
5
12
19
26
2
9
T
29
6
13
20
27
3
10
July 2010
W
T
30
1
7
8
14
15
21
22
28
29
4
5
11
12
F
2
9
16
23
30
6
13
S
3
10
17
24
31
7
14
S
4
11
18
25
1
8
15
= 7 days
Dates calculation
Using the appointment dates this would be 1 August minus 25 July giving a post-DTT
WTA of 7 days.
- 39 -
06 - Medical suspension
Medical suspension should be used when an additional and necessary pre-treatment step is
required, or when a step in the pathway has to be delayed because an unacceptable risk
would be incurred if that step were to take place within a fixed time period. Below are a few
examples of medical suspension.
1. Patient deemed not fit for the next step in the pathway until certain criteria met, i.e.
patient not to be added to waiting list until their general condition allows (e.g. optimal
nutritional status met, patient recovered from previous procedure, for pregnant women
waiting until foetus is viable). Adjustment is from date ready for next step back to
previous step, i.e. date medically fit to be placed on waiting list for appointment back
to date unfit to continue.
Criteria met for patient to be
added to waiting list
Medical decision to delay
adding patient to waiting list
Appointment
Patient pathway
Adjustment
2. Patient needs a pre-treatment step that is not part of a routine pathway for that cancer,
e.g. dental clearance, extra investigation to participate in a clinical trial, second opinion.
Adjustment for this is the extra time taken away from the routine pathway.
Previous step in
the pathway
Additional
appointment
Appointment
Patient pathway
Adjustment
- 40 -
Medical suspension – Scenario 1
At the outpatient appointment (28 august) the clinician decides to send the patient for
an extra investigation that is not part of the routine pathway. An appointment is made
for 10 September which the patient attends.
Answer
An adjustment is made to remove the additional time added to the patients pathway
therefore the date of the additional appointment back to the last step in the pathway
which for this cases is the outpatient appointment. (inclusive of 10 September – 29
August). This gives a pre-DTT adjustment of 13 days.
It can be calculated in 2 different ways:
Unavailability calculation
Unavailability is from 29 August to 10 September (inclusive) making it a pre-DTT WTA
of 13 days.
Or shown as:
M
23
30
6
13
20
27
T
24
31
7
14
21
28
September 2010
W
T
F
25
26
27
1
2
3
8
9
10
15
16
17
22
23
24
29
30
1
S
28
27
11
18
25
2
S
29
5
12
19
26
3
= 13 days
Dates calculation
Using the appointment dates this would be 10 September minus 28 August giving a
pre-DTT WTA of 13 days.
- 41 -
3. Investigation failed and needs to be repeated as soon as possible. Adjustment is from
failed investigation back to previous step in the pathway.
Previous step in
the pathway
Failed
investigation
Repeat
investigation
Patient pathway
Adjustment
4. At diagnostic test no cancer is diagnosed, however cancer still suspected. Continue to
track the patient and recall for a repeat diagnostic in a few weeks. Adjustment is from the
diagnostic test until the recall diagnostic.
Previous step in
the pathway
Investigation
Recall
investigation
Patient pathway
Adjustment
N.B. If after a diagnostic test cancer was no longer suspected the patient would be removed
from tracking onto a review pathway. If a future diagnostic test produced a positive cancer
diagnosis this patient would be included in the 31-day target only.
5. If an agreed treatment type is no longer appropriate, or if a patient changes their decision
to a different specialty, an adjustment may be made between the two different decision to
treats. Adjustment is from the second decision to treat with clinician y back to the
previous decision to treat with clinician x.
Previous step in
the pathway
Decision to treat
– consultant x
Decision to treat
– consultant y
Patient pathway
Adjustment
- 42 -
6. Some new and emerging technologies have been identified as not being available in all
regional cancer networks. This is considered inequitable and penalises those NHS Boards
that provide additional services and have the burden of responsibility for providing first
treatment for meeting the 31-day target. Treating and referring NHS Boards in regions
where such a treatment is offered can apply waiting times adjustments. Adjustment is
from the date that the New and Emerging Technologies is available back to when an
alternative treatment would have been available to the patient.
The current list of New and Emerging Technologies can be found within the Rules and
Guidance
section
on
the
New
Cancer
Waiting
Times
web-page
(http://www.isdscotland.org/Health-Topics/Waiting-Times/Cancer/).
Previous step in the
pathway
Alternative Treatments
Available in All
Networks
New & Emerging
Technologies
Available
Adjustment
07 - No adjustment
Problems resulting from hospital operational circumstances should not result in any
detriment to the patient; for example, the cancellation of a clinic at short notice, or
appointments being cancelled or moved by the hospital. Therefore, waiting times
adjustments cannot be made in these situations.
- 43 -
6.7
Adjusted Length of Pathways
6.7.1
Referral to Treatment
Format: Number
This is the number of days from referral to treatment, after any adjustment. This is:
Referral to Treatment =
6.7.2
Total number of days from referral to treatment
minus
Total waiting times adjustment
Decision to Treat to Treatment
Format: Number
This is the number of days from decision to treat to treatment, after any adjustment. This is:
Decision to Treat to Treatment = Total number of days from decision to treat to treatment
minus
Waiting times adjustment post DTT
Example
2nd June, patient is referred urgently with suspicion of cancer. Patient goes on holiday from
15th June to 20th June (inclusive). They have a decision to treat on 7th July. Patient is
medically unavailable between 23rd July and 3rd August (inclusive). Patient receives first
treatment on 17th August. This diagram shows the adjusted lengths of pathways:
Referral
02/06/09
Patient
unavailable
15/06/09
Patient
available
21/06/09
DTT
07/07/09
6 day
adjustment
Patient
unavailable
23/07/09
Patient
available
04/08/09
Treatment
17/08/09
12 day
adjustment
Referral to treatment = 76 days
Total waiting times adjustment = 18 days
Adjusted length of pathway - Referral to Treatment
= 58 days
Decision to Treat to Treatment = 41 days
Waiting times adjustment post-DTT = 12 days
Adjusted length of pathway - decision to treat to treatment
= 29 days
- 44 -
6.8
Reason for Delay 62-day/31-day
Format: 2 characters
This field should be used to indicate the main reason for a breach of target, after the waiting
time has been adjusted. The main reason is the one that contributed the longest delay, or if
two are equal, the first delay that occurred.
Code
11
12
13
14
15
16
17
18
19
08
09
10
Description
Staffing issues (e.g. through vacancies, annual leave or illness)
Lack of other resources (e.g. theatre, equipment, facilities)
Routine staging or further investigation
Clinically complex *
Administrative error
Initially not suspicious of cancer
Downgraded by consultant
Initially referred to another speciality
Range of treatment options offered but patient‟s choice not available within target
Other reason
Not recorded
Inapplicable
* Clinically complex patients will be excluded from the cancer waiting times targets.
Clinically Complex Patients
For those patients in whom there is ambiguity around the application of clinical complexity,
open discussion is expected within teams though the final decision should rest with the NHS
Board lead cancer clinician. The new definitions in this manual and the option for clock
adjustments have been written to minimise the need to use this code but it is acknowledged
that there will be situations where complexity applies. The following scenarios provide
guidance.
Scenario 1
A patient requires a particularly complex combination of scans and biopsies that are not part
of a routine pathway for that cancer.
Scenario 2
There is genuine clinical uncertainty about the diagnosis and a final decision on whether the
patient has cancer cannot be reached. „Watchful wait‟ treatment applies only when a definite
diagnosis is made, whereas clinical exclusion applies if the diagnosis is not reached despite
exhaustive tests and some monitoring of the patient is still required.
Scenario 3
Complex staging and multiple investigations are required to determine an optimal treatment
plan for an individual patient (and where waiting times adjustment is not practical). Boards
should consult timed pathways agreed by Regional Managed Clinical Networks as a
reference point.
Scenario 4
If the patient has an ongoing co-morbid condition for which any of the usual treatments are
not recommended or appropriate and an alternative treatment is necessary.
- 45 -
Appendix 1 - General Recognised First Treatments
The summary table below is not an exhaustive list and any queries should be sent to
[email protected].
01 Surgery
02 Radiotherapy
03 Chemotherapy
Examples include:
 partial or total resection of the primary tumour and/or
metastases
 palliative procedures, e.g. to bypass obstructive lesions
 debulking
 transplants
 procedures converted from laparoscopic to open surgery
 intra-operative radiotherapy
 „open & shut‟ cases
 wide local excision (WLE)
 therapeutic laparoscopic surgery
Does not include diagnostic biopsies such as punch, incisional,
needle or core etc. unless all tumour removed and margins
were clear.
Examples include:
 neoadjuvant
 radical
 palliative
 brachytherapy
Additionally this includes radiotherapy to metastatic site prior to
treatment of primary site.
Examples includes:
 neoadjuvant
 primary
 palliative
 new drugs given as part of a clinical trial, even if a
placebo
04 Synchronous
Where chemotherapy and radiotherapy treatments are
Chemoradiotherapy combined and administered concurrently/synchronously.
05 Endoscopic
06 Hormone therapy
07 Supportive care
Examples include:
 endoscopic laser therapy
 argon beam therapy
 endomucosal resection
 photodynamic therapy (PDT)
 stenting
 cystodiathermy
 panendoscopic debulking
Use code 07 if dilatation is carried out as a supportive care
procedure.
Includes new drugs given as part of a clinical trial, even if a
placebo.
Requires that a clinical decision has been made and agreed
- 46 -
with the patient for supportive care only (which might mean no
intervention).
Examples of symptom control intervention include:
 blood transfusion
 percutaneous endoscopic gastrostomy (PEG)
 draining of pleural or ascitic fluid and insertion of kaolin
if these were the only treatment given
 steroids given for initial stabilisation or palliative care
 analgesics
 antiemetics
 dilatation
 complementary alternative therapies
 psychological support
 Specialist Palliative Care consultation
 nursing care
 tracheostomy, if no other treatment carried out
 antibiotics, if no other treatment carried out
The patient may receive subsequent treatment after a variable
interval.
Does not include treatments given for other conditions e.g.
warfarin for stroke patients subsequently diagnosed with
cancer.
11 Other therapy
12 Watchful wait /
active surveillance
Examples include:
 stent insertion (other than endoscopic)
 bisphosphonates
 biological therapy (including immunotherapy and
biological response modifiers)
 liver embolisation
 alcohol injections
 helicobacter eradication therapy
 radio ablation therapy
 cryotherapy
Requires that a clinical decision has been made and agreed
with the patient for no active treatment at this time, but the
patient may receive subsequent treatment after a variable
interval.
- 47 -
Appendix 2 - Recognised First Treatments for Tumour Specific Sites
The tables below will be updated with new treatments for tumour specific types. Any queries
on first treatments or new treatments should be made to
[email protected].
Breast
Mode of
Treatment
01 Surgery
Recognised
for breast
cancer?
Y
Additions to procedures listed in general
table (Appendix 1)
Includes:
 duct excision
Does not include:
 sentinel node biopsies
 vacuum biopsies
unless whole tumour removed and margins
were clear.
02 Radiotherapy
03 Chemotherapy
04 Synchronous
Chemoradiotherapy
Y
Y
N
05 Endoscopic
06 Hormone therapy
N
Y
07 Supportive care
11 Other therapy
Y
Y
12 Watchful wait /
active surveillance
Y
Includes:
endocrine therapy, e.g. tamoxifen, letrozole
including prescribed by a GP
Includes:
 bisphosphonates for bone metastases
 imiquimod cream (immunotherapy)
for Pagets disease.
- 48 -
Cervical
Mode of
Treatment
01 Surgery
Recognised
for cervical
cancer?
Y
Additions to procedures listed in general
table (Appendix 1)
Includes:
 excisional biopsy - margins MUST be
clear / patient wishes to retain fertility
(LLETZ, SWETZ, NETZX, Cone
biopsy)
Excisional treatment may be appropriate
treatment for some selected patients with
stage 1A1 cervical cancer.
02 Radiotherapy
Y
03 Chemotherapy
04 Synchronous
Chemoradiotherapy
05 Endoscopic
06 Hormone therapy
07 No active treatment
(Supportive care)
Y
Y
N
N
Y
11 Other therapy
Y
12 Watchful wait /
active surveillance
Y
Excisional treatment and Lymph node
dissection is required in patients with stage
1A2/1B1 disease who wish to retain fertility.
Includes:
 external beam
Includes:
 primary chemoradiation
Includes:
 palliative radiotherapy for control of
bleeding
Includes:
 laser therapy
- 49 -
Colorectal
Mode of
Treatment
01 Surgery
Recognised
for
colorectal
cancer?
Y
02 Radiotherapy
Y
03 Chemotherapy
Y
04 Synchronous
Chemoradiotherapy
Y
05 Endoscopic
Y
06 Hormone therapy
N
07 Supportive care
Y
11 Other therapy
Y
12 Watchful wait /
active surveillance
Y
Additions to procedures listed in general
table (Appendix 1)
Includes:
 laparotomy
 colostomy
 ileostomy
 defunctioning stoma/loop colostomy/
ileostomy
Includes:
 polypectomy at colonoscopy
- 50 -
Head and Neck
Mode of
Treatment
01 Surgery
Recognised
for head &
neck cancer?
Y
02 Radiotherapy
Y
03 Chemotherapy
Y
04 Synchronous
Chemoradiotherapy
Y
05 Endoscopic
Y
06 Hormone therapy
N
07 Supportive care
Y
11 Other therapy
Y
12 Watchful wait /
active surveillance
Y
Additions to procedures listed in general
table (Appendix 1)
Includes:
 neck dissection
 curettage if tumour removed for
therapeutic benefit
Includes:
 microlaryngoscopy to strip the vocal
cord
- 51 -
Lung
Mode of
Treatment
01 Surgery
02 Radiotherapy
Recognised
for lung
cancer?
Y
Y
03 Chemotherapy
Y
04 Synchronous
Chemoradiotherapy
05 Endoscopic
Y
06 Hormone therapy
07 Supportive care
N
Y
11 Other therapy
Y
12 Watchful wait /
active surveillance
Y
Y
Additions to procedures listed in general
table (Appendix 1)
Includes:
 CHART
Does not include:
 mediastinoscopy without removal of
whole tumour
 diagnostic bronchoscopy unless whole
tumour removed and margins were
clear
Includes:
 Pleurodesis and aspirate
 Drainage of pleural fluid to relieve
breathlessness etc (i.e. if for
therapeutic purposes) but not if for a
sample for cytology
Includes:
 cryotherapy
- 52 -
Lymphoma
Mode of
Treatment
01 Surgery
Recognised
for
lymphoma?
Y
02 Radiotherapy
Y
03 Chemotherapy
Y
04 Synchronous
Chemoradiotherapy
N
05 Endoscopic
N
06 Hormone therapy
N
07 Supportive care
Y
11 Other therapy
Y
12 Watchful wait /
active surveillance
Y
Additions to procedures listed in general
table (Appendix 1)
Includes:
 surgery if there is a therapeutic benefit
Includes:
 steroids
- 53 -
Melanoma
Mode of
Treatment
01 Surgery
Recognised
for
melanoma?
Y
Additions to procedures listed in general table
(Appendix 1)
Biopsy Intent
02 Radiotherapy
Y
03 Chemotherapy
Y
04 Synchronous
Chemoradiotherapy
N
05 Endoscopic
N
06 Hormone therapy
N
07 Supportive care
Y
11 Other therapy
N
12 Watchful wait /
active surveillance
Y
Margin
First Treatment Date
Diagnostic
Clear
Date of Biopsy
Excision
Clear
Date of Biopsy
Diagnostic
Date of subsequent treatment (irrespective of
Not clear subsequent treatment finding)
Excision
Not clear Date of Biopsy
- 54 -
Ovarian
Mode of
Treatment
01 Surgery
Recognised
for ovarian
cancer?
Y
02 Radiotherapy
Y
03 Chemotherapy
Y
04 Synchronous
Chemoradiotherapy
N
05 Endoscopic
Y
06 Hormone therapy
N
07 Supportive care
Y
11 Other therapy
Y
12 Watchful wait /
active surveillance
Y
Additions to procedures listed in general
table (Appendix 1)
Includes:
 Pleurodesis
- 55 -
Upper GI
Mode of
Treatment
01 Surgery
Recognised for Additions to procedures listed in
upper GI
general table (Appendix 1)
cancers?
Y
Includes:
 liver transplant
 gastroenterostomy
02 Radiotherapy
Y
03 Chemotherapy
Y
04 Synchronous
Chemoradiotherapy
Y
05 Endoscopic
Y
06 Hormone therapy
N
07 Supportive care
Y
11 Other therapy
Y
12 Watchful wait /
active surveillance
Y
Includes:
 Argon Plasma Coagulation (APC)
Includes:
 stent insertion by percutaneous
transhepatic cholangiography (PTC)
via guide wire
 portal vein embolisation
- 56 -
Urology
Mode of
Treatment
01 Surgery
Recognised
for urological
cancers?
Y
02 Radiotherapy
03 Chemotherapy
04 Synchronous
Chemoradiotherapy
Y
Y
N
05 Endoscopic
Y
Additions to procedures listed in general
table (Appendix 1)
Includes:
 bilateral orchidectomy for prostate
cancer
Includes:
 diathermy
 TURP carried out for therapeutic
benefit for a suspected prostate
cancer.
If prostatic cancer is found incidentally at
TURP (for what was thought to be benign
prostatic hyperplasia) the TURP should not
be considered first treatment. In this case
first treatment is the treatment agreed with
the patient postoperatively, e.g. watchful wait
06 Hormone therapy
Y
07 Supportive care
Y
Includes:
 nephrostomy to alleviate symptoms or
stabilise the patient
11 Other therapy
Y
Includes:
 Embolisation
12 Watchful wait /
active surveillance*
Y
* When patients with advanced or metastatic prostate cancer (not suitable for radical
therapy) are not started on immediate androgen deprivation therapy, then the treatment is
reserved until the time when the patient develops symptomatic progression. This is the
traditional "watch and wait" situation. Patients with localised prostate cancer, who might be
suitable for radical therapy, may be told that they have a choice between immediate radical
therapy and "active surveillance". Here the follow-up is fairly intense, usually according to
an agreed protocol and involves (usually) repeat clinic visits, repeat PSA and DRE, and
often repeat biopsies after an interval. Progression in the disease, in the form of rising PSA,
or change in grade of the tumour prompts a further offer of radical therapy.
- 57 -
Appendix 3 - Old and New Target 62-Day Target Differences
Table highlights the main differences between the old 62-day cancer waiting time target and
the new 62-day target.
Old 62-day target
New 62-day target
Measures the time from date the
referral is made until the date of
first treatment
Covers:
- patients urgently referred by a
primary care clinician (for
example GP) or dentist
- direct referrals to hospital (for
example. self referrals to A&E)
Measures the time from the date of receipt of initial
referral into secondary care until the date of first
treatment
Covers:
- patients urgently referred with a suspicion of
cancer by a primary care clinician (for example GP)
or dentist
- direct referrals to hospital (for example self referrals
to A&E)
- patients referred through a National Cancer
Screening Programme (breast, colorectal or
cervical)
Covers the nine major cancer types previously
monitored plus cervical cancers
These patients are included in the target calculations
Covers nine major cancer types
Patients are excluded from target
calculations if the initial referral
was to a specialty other than the
one relating to the patient‟s
diagnosed cancer
Patients are excluded from target
calculations if:
- there was a significant patientinduced delay (for example
through not attending
appointments)
- co-morbidities delayed
treatment
Patients are excluded from target
calculations if:
- they died before treatment
- refused all treatment
- the patient had a clinically
complex pathway
NB: If the patient chooses to have
any part of their pathway out with
NHSScotland they will be
excluded from both targets).
These patients are included in the target calculations
but their waiting times are adjusted to reflect patient
delays or medical delays
Patients who choose to have part of their pathway out
with NHSScotland will be exempt from the relevant
target as follows:
If the part of their pathway outwith NHSScotland
is pre decision to treat the patient will not be
subject to the 62-day target, irrespective of route
of referral. The patient will be subject to the 31day target decision to treat to first treatment.
If the part of their pathway outwith NHSScotland
is post decision to treat the patient will not be
subject to the 62-day target or the 31-day target.
As the patient is not subject to either of the
cancer waiting times targets, data should not be
submitted to ISD for these patients.
- 58 -
Appendix 4 - 31-day Target Criteria.
Measures the time from the date of decision to treat until the date of first treatment
All referrals (urgent & non-urgent) submitted from all sources i.e. regardless of the route of
referral.
Covers the nine major cancer types previously monitored plus cervical cancers
Patients are included in the target calculations if the initial referral was to a specialty other
than the one relating to the patient‟s diagnosed cancer
Patients are included in the target calculations if:
- there was a significant patient delay (for example through not attending appointments)
- co-morbidities delayed treatment
- medical suspension was deemed appropriate
Waiting times can be adjusted to reflect patient delays or medical delays.
Patients are excluded from target calculations if:
- they died before treatment
- refused all treatment
- the patient had a clinically complex pathway
Patients who choose to have part of their pathway out with NHSScotland will be exempt from
the relevant target as follows:
- If the part of their pathway outwith NHSScotland is pre decision to treat the patient will not
be subject to the 62-day target, irrespective of route of referral. The patient will be subject
to the 31-day target decision to treat to first treatment.
- If the part of their pathway outwith NHSScotland is post decision to treat the patient will
not be subject to the 62-day target or the 31-day target. As the patient is not subject to
either of the cancer waiting times targets, data should not be submitted to ISD for these
patients.
- 59 -
Acknowledgements
Kirsty Anderson, Principal Information Analyst, ISD
Jennifer Armstrong, Senior Medical Officer, Scottish Government
Gordon Birnie, Medical Director, NHS Fife
Karen Bonnar, Cancer Support Services Coordinator, NHS Forth Valley
Leigh Brown, Information Manager, ISD
Kathryn Burt, Information Analyst, ISD
Sarah Callaghan, Data Development Manager, ISD
Richard Carey, Chief Executive, NHS Grampian
Gillian Christie, Cancer Services Manager, NHS Tayside
Carol Colquhoun, National Screening Coordinator, NSD
Richard Copeland, Head of IM&T, NHS Greater Glasgow & Clyde
John Davies, SCAN Lead Cancer Clinician
Dominic Dick, Data Development Manager, ISD
Tom Divers, Chief Executive, NHS Greater Glasgow & Clyde
James Docherty, Consultant Surgeon, NHS Highland
Rachael Dunk, Team Leader, Cancer Strategies, Scottish Government
Stephen Gallagher, Head of Improvement & Support and Deputy Director of Health Delivery, SG
John Glennie, Chief Executive, NHS Borders
Jennifer Godsman, Cancer Audit Manager, NHS Highland
Kate Harley, Head of Programme, ISD
Jean Harvey, Cancer Definitions Manager, ISD
David Hill, Consultant Radiologist, NHS Dumfries & Galloway
Karen Jack, Cancer Audit Manager, NHS Tayside
Wilma Jack, Senior Clinical Research Fellow, NHS Lothian
Gary Jenkins, General Manager, Beatson West of Scotland Cancer Centre
Margaret Kelly, Cancer Services Manager, NHS Lanarkshire
Debora King, Data & Terminology Development Officer, ISD
Cath Lavery, New Cancer Waits IT Project Manager, ISD
David Linden, Programme Manager – Cancer Performance Support Team, Scottish Government
Cameron Martin, Consultant Gynaecological Oncologist, Royal Infirmary of Edinburgh
Tracy McKen, Policy Advisor (Screening), CMO & Public Health Directorate, Scottish Government
Sue McLaren, Cancer Pathway Lead, NHS Greater Glasgow & Clyde
Doug Main, Cancer Audit Administrator, NHS Fife
Sandra Mair, Director of Operations, NHS Lothian
Brian Murray, National Cancer Information Coordinator, ISD
Isobel Neil, Programme Director – Cancer Access, Scottish Government
Bill O‟Neill, Chair Scottish Primary Care Cancer Group, NHS Lothian
Mary Orzel, Cancer Services Manager, NHS Forth Valley
Alison Pickering, Data Analyst, Cancer Performance Support Team, Scottish Government
Elizabeth Preston, Head of Service Cancer & Palliative Care, Edinburgh Cancer Centre
Tony Rafferty, Cancer Pathways Facilitator, NHS Grampian
David Rowley, Assistant Statistician, Health Finance Directorate, Scottish Government
Shirley-Anne Savage, Cancer Services Programme Manager, NHS Fife
Tom Sim, Business Support Manager for Cancer, NHS Lanarkshire
Robert Williams, Head of Performance and Business Management, Scottish Government
Stan Wright, Consultant Respiratory Physician, NHS Forth Valley
- 60 -
Version 4.0 – 29 July 2011