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Slide 1 Supporting Early Diagnosis in cancer in primary care Improving GP Coding&Safety Netting The key to quality data with quality outcomes in cancer and beyond. Dr Afsana Bhuiya Macmillan GP Improvement Lead LONDON CANCER Contact: [email protected] *London 5 year cancer commissioning strategy Slide 2 Early Diagnosis The Problem: • Cancers are not being diagnosed early enough in primary care. • Emergency presentations of cancer up to ¼ - lung and colorectal most common. • It can be difficult to differentiate early symptoms of a cancer – up to 50% of cancer patients in UK seen in did not have NICE symptom suspicious for cancer (Neal et al 2014 Bjc). Non-specific symptoms rather than RED flags. • Significant disease but relatively uncommon. • Two week wait referrals have a 10% conversion rate (lower in London) – this is going down – as more GPs refer since new guidance. Why does it matter? • Better outcomes, survival and patient experience.* • NICE guidance June 2015 What are the DRIVERS for early diagnosis in a primary care surgery? *London 5 year cancer commissioning strategy AIM: Patient Factors General Practice Increase early diagnosis in cancer Doctor Slide 3 Community Team Community Public Health Lack Of knowledge Appointment system Consultation : Time and Priorities Practice Nurse Knowledge Screening Fear/Denial Access GATE KEEPER function HCA Stigma Awareness campaigns Language Barriers IT systems Complex patients Community Matron Consultation behaviour: hidden agenda Different GPs/lack of continuity Consultation style – not eliciting the correct symptoms District Nurse Cultural factors Safety Netting styles/systems Information documented – CODING Coding&Safety Netting KEY AREA IDENTIFIED FOR QUALITY IMPROVEMENT Slide 5 Why? Good standards in Coding and Safety-Netting enhances patient safety by having the most upto-date, relevant and connected information about your patient at your fingertips, regardless of how long you have known them. This quality improvement initiative would lead to more meaningful results from risk assessment tools, like QCancer. Together, these processes will reduce misses, lead to earlier cancer referrals and early detection, as well as improved screening and care for patients who have survived cancer. There are no agreed guidelines/standards for coding or safety netting and there is little agreement on how to interpret or apply safety netting. No formal training for GPs for coding/using computer systems.GP VTS trainees do not have standard teaching on this and it often depends on their individual trainers knowledge. The aim of project was to develop primary care coding and safety netting standards, to educate GPs on effective coding and to support them in applying tis change. The quality of input – determines the quality of the output. Slide 6 Coding in Primary care Most patient contact is recorded in a consultation electronically and can be written coded as it is entered. The Read Code system was developed in the early 1980s by Dr James Read (who was a GP in Loughborough) to handle the problems of recording information in a way that could be retrieved from the computers available to GPs at the time. In 1989, the importance of the system became clear and the number of codes rapidly expanded, it was purchased by the NHS Executive for further development. Letters, correspondence, investigations and other contacts (appointments, tasks etc) are integrated in the same interface and can be coded. Slide 7 What is Safety Netting? The term ‘safety-netting’ was introduced to general practice by Roger Neighbour – central to GP consult. A process where people at low risk, but not no risk, of having cancer are actively monitored in primary care to see if the risk of cancer changes. Safety Netting can go wrong! little agreement on how to interpret or apply safety netting. Good safety netting is dependent on good continuity of information and record keeping/coding. NICE guidance July 2015 and the cancer task report both highlight the need for rigorous safety netting. And this in turn is dependent on continuity if records and good record keeping. Slide 8 GP SURVEY Slide 9 Slide 10 Where are we now? What is coding and safety netting like now? The three major systems are: EMIS WEB, SYSTEM ONE, VISION. CODING AND SAFETY NETTING practices are immensely variable from practice to practice and system to system. CANCER RISK ASSESSMENT TOOLS like QCANCER may help minimise the risk of not thinking of cancer, BUT these rely on correct information being CODED! If relevant data isn’t coded then the risk calculator will not know it exists. NICE NEW URGENT CANCER GUIDANCE (July 2015) – the referral criteria has changed and is much based on ‘softer’ symptoms – not just RED flags (too late). Hence importance of recording these symptoms and safety netting in a systematic/stringent manner. Improve the quality CODING & SAFETY NETTING GP – the clinician Attitude to coding Practice Organisational systems GP2GP Competence in coding The SOFTWARE chosen to use ie. Emis, system one, vision Coding outside QOF Risk assessment tools – QCancer – integrate to systems Understanding of SAFETY NETTING Read code limitations eg. Cancer stages or dx Clinicians IT competences Surgery structure eg. Who codes? GP type – Partner/Salary/Locum DOCMAN – implications of intellisense coding SUMMARISING of notes for new patients – rules/guidance Information dissemination for non-partners. GP Curriculum/RCGP CCG Slide 11 Health professional Hospital Systems Coding in curriculum Support practices with training Nurses attitude Radiology eg. Cxr missed Safety Netting in the curriculum Ensure information is available to all clinicians eg. locums HCA role Pathology lab eg. Abnormal results Wider community professionals eg Comm matron InHealth or other subcontracted companies Slide 12 The STRATEGY CODING AND SAFETY NETTING SET A STANDARD OF GOOD CODING PRACTICES Slide 13 • PROBLEM CODE all consultations – obligatory. Relevant. Symptoms. • Utilise SYMPTOM CODES more • SYMPTOM code within a consultation • Ensure problem title codes are subcategorised or linked properly – eg. CANCER diagnosis remain and ACTIVE problem INDEFINITELY. • Code FAMILY HISTORY, SMOKING, WEIGHT • Safety net codes – fast track cancer refs, follow up, advice issued, checking contacts details. • SCREENING coding – Cervical, Breast, Bowel • Use QCANCER risk assessment tool to aid decision making. • Living with cancer and beyond – code cancer treatment and side effects. Slide 14 Case Study – Problem title/coding • 64 year old lady seen for left shoulder pain for 1/12 – no trauma. Painful to move, but on o/e – gen bit sore – GH OA? • Patient recently joined the surgery. No other significant history seen on significant problem list. Ex-smoker. Due to see nurse next for her ‘new patient screen’ • Sent for XR of shoulder and analgesia given • Report: Abnormal apical shadow in the left lung! • GP arranges an urgent recall of the patient to discuss the results. • The GP reviews the hx – fortunately GP2GP notes have come through: • • • • Seen by several different clinicians in the last 12/12. ‘e’ appointments. Notes were v. difficult to follow as consultations had not been problem coded, many generic symptoms at different times. Seen by nurse 6/12 ago and had a cough – with flecks of blood once – haemoptysis wasn’t coded. CXR was requested but not followed up. Breast cancer was documented in one consult – the problem list checked – and it has been coded as ‘minor – past’ problem! Slide 15 Case Study: Commenting on screening/recall/docman coding • A 70 year old man, non frequent attender, completed a bowel screen – which was ABNORMAL. The result was commented on appropriately in path links by the clinician. As FOBt was abnormal, he was offered a bowel screening nurse appointment and advised to have a colonoscopy. • The GP was notified of a DNA for the colonoscopy – no code was applied through docman. No action was taken. • 8 months later – seen locum – non specific tiredness – nil else. Routine blood tests were requested. • Lab telephoned through results – VASTLY ABNORMAL – microcytic anaemia, low ferritin and a raised Hba1c – at 6.30pm. The regular dr arranged an urgent face to face consult the next day. • Plan – FAST TRACK LOWER GI CANCER ref made • Lesson – coding standards for the practice – who and what. Slide 16 Case Study: Wasting resources/time • A patient with known myeloma was seen by a locum in clinic for a minor illness. • The patient had her recent blood test results as the last recorded information and all were commented on as – ‘abnormal – speak to dr’ • The locum seeing the results did an FAST TRACK CANCER ref. • Few weeks later a letter was received from a confused Haematologist asking why a patient with known Myeloma (stable disease) being referred. • Myeloma was NOT coded anywhere. The letters from the haematologist were not coded. • Lesson: Problem coding imperative. Appropriate pathology commenting – ‘known myeloma’ or ‘consistent with known disease’. Why did the patient not know? Slide 17 QCancer RAT Video – demo on how to use: https://www.youtube.com/watch?v=p_elWswIeNo https://www.emisnug.org.uk/using-cancer-symptom-checker-emis-web RAT – risk of current cancer undiagnosed cancer. Not cancer dx. Access – Templates. View Individual risk. Why - uncertainty What % is relevant – no clear consensus. 3% threshold. Evidence: gets the GP thinking more about the diagnosis of cancer – further evidence needed re changes on early diagnosis rates. SAFETY NETTING Slide 18 Slide 19 Stages of Safety Netting BROADLY DIVIDED INTO: GP/Patient System Processes Practice/Hospital Slide 20 Stages of Safety Netting Stages of safety-netting 1.At the first consultation 2.With the same problem 3.Investigations 4.Communications with the hospital 5.Referrals 6.Follow-up of patients 7.Locums and Leave 8.Proactive Safety-Netting Case Study: Safety Net, High Risk Slide 21 45 year old Somalian man seen by your colleague for knee pain. He had requested an XR. You receive an urgent fax reporting a likely bone sarcoma! The fax was slightly odd as it did not on heading paper and did not say where it came from. But the radiologist name was at the bottom. What do you do now? What could have done in the first consult? Confirm the result. We rang the patient. Then his wife. Then any other family member at the address. Not trackable. Estranged from wife. Sent him letter. Spoke to the initial dr – patient didn’t report he was going on holiday. Sent TASK to myself to track patient. Two weeks later he has been booked on my list by a different receptionist who wasn’t aware about how hard we were trying to get hold of him? And then DNAs. This time I refer to royal national sarcoma clinic 2ww in the hope he may just go there. What could have been improved? I put an alert on his notes after that. Sent a TASK to all staff to be aware of him. Sent him another letter. What happened: ? Case Study: Safety Net, Low risk – but NO risk Slide 22 You see a 53 yr old Romanian lady who came with her daughter to see you about tiredness. Language barrier. Daughter translates. Her 3yr old granddaughter is running around the consultation room. What do you do? What challenges do you identify? Hx – nil. BP – normal. Plan: ‘tiredness screen’ blds. Adv to call back for results. Concern levels: low. Next – 2/12 later she returns, on her own. She did not do her blood tests as you had advised. She looks pale, thinner and c/o of a lump in neck. LB still. Now? Language line. Appetite loss and weight loss. O/e – pallor and wide spread lymphadenopathy. Impr – Lymphoma. Actn: fast track cancer referral. Concern relayed re cancer and next steps. Address and number checked. Ref emailed. What next? End of month fast track cancers search reveals no letters from hospital – concern – arrange recall. She reports she missed the appointment as she had to baby sit the grandchildren when her daughter was was having housing problems with the council. You reiterate how important this appointment is. Leaflet issued in Romanian. Two weeks later – she returns with her daughter – she has come to get the biopsy results and they seem very anxious. You don’t remember receiving anything through docman – you check the notes – NO hospital communication. What now! Slide 23 At the first consultation Give the patient clear oral and written instructions. Book the follow-up appointment. Ensure that the patients contact details are correct, and that their mobile number is documented. Send him/herself a patient TASK to remember to follow-up with the patient. Ensure that the patient understands how and where to go for investigations, and how to get any results. Document and code follow-up (9N7). With the same problem With the same problem after several consultations the GP should: Implement investigations for recurring and/or unresolved problems. Slide 24 During the investigations process the GP should: Tell the patient to chase results within a reasonable timeframe and told how to do so. Not rely on patient calling - significant result recall should be in place. Relay significant results urgently and in person or telephone. Document their recalls and any failed recalls. Keep electronic list of worrying results Ensure pathology comments are suitable, and that reception staff can understand them. During communication with the hospital, the GP should: Check their local hospital pathology and radiology policies regarding how urgent results are communicated. Phone through urgent results (this is ideal but not universal) Ensure new clinical colleagues have pathology codes set-up so results are not sent elsewhere. Review near misses/SEA. Advocate that the hospital communicates new cancer diagnoses in a timely fashion. Advocate that the hospital sends up-to-date diagnoses and treatment plans in a timely fashion. Ask the hospital to clarify follow-up plans if there are spurious (sometimes the clinician can be contacted on NHS.net). Slide 25 During the referral process the GP should: Communicate to patient what to expect, and give them the cancer referral leaflet. Recommend using electronic methods to send cancer referrals (many sites now have dedicated email referral). Keep an electronic list of cancer referrals (this is made easier if referrals are coded). During follow-up of the patients: Proactively chase non-attenders by calling or writing to them. Consider that vulnerable patients will require more flexibility (i.e.: elderly, illicit drug user, and alcohol dependent patients etc.). Ensure locums use electronic methods of relaying concern (i.e. tasks/alerts for patient with concerns). Administrative staff should also document their attempts to follow-up with the patient. Strategies for Locums and when you are on leave: Give Locums a Locum Pack with information on how to refer and code. Ensure that the Locum uses the right pathology code so results come back to the regular doctor. Ensure results and/or letters are buddied up with another colleague if you are away. Ensure any concerns are relayed to a colleague before taking leave. This should be documented in notes. Slide 26 Safety Netting Codes: Slide 27 FULL GUIDANCE AT: http://www.londoncancer.org/media/126626/15070 8_Guide-to-coding-and-safety-netting_report_DrA-Bhuiya_V3.pdf