Download New Targets - East and North Herts NHS Trust

Trust Board Briefing Paper December 2008 Cancer Waiting Times 1) Executive Summary In 2007/08, the Trust received a total of 4,129 ‘urgent’ suspected cancer referrals compared to 3,415 in 2006/07. These referrals, together with any ‘routine’ referrals are subject to the existing cancer waiting times (CWT) targets (14, 31 and 62 days targets) and are currently monitored for ten tumour sites by eight Multi­Disciplinary Teams (MDTs). In April 2008, guidance was issued by the Department of Health pertaining to additional CWT targets. These targets known as ‘Vital Signs’ consist of the following: Ø Breast Symptoms: ALL breast symptom patients where cancer is NOT suspected, are to be seen within 14 days from the date of decision to refer made by the GP. (National requirement by December 2009) Ø Subsequent treatments: Maximum one month wait for all subsequent treatments for new cases of primary and recurrent cancer where an anti­cancer drug regimen or surgery is the chosen treatment modality. (National requirement by December 2008 ­ for all treatments except radiotherapy where this is December 2010) Ø Screening patients: Maximum two month wait from referral from a cancer screening service to first treatment for all cancers, from the date the Trust receives the referral (National requirement by December 2008) Ø Consultant upgrade: Maximum two month wait from a consultant’s decision to upgrade the urgency of a patient they suspect to have a cancer to first treatment for all cancers, from the date the decision to upgrade was made. (National requirement by December 2008) The Cancer Reform Strategy First Annual Report (published 1 December 2008) states that: “Because the data collection rules will be more consistent with the 18 weeks data collection rules, there will need to be a change in the operational standards for both the current and new waiting time standards, in order to preserve time for patients to consider treatment options and to reflect good clinical practice (ie the fact that some patients cannot be appropriately treated within these timescales). Reported performance against the current standards will change because of the new rules:
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performance against the existing two­week standard (for urgent referral to a specialist) is 99+%, against an operational standard of 98% – we expect reported performance will move to about 93%
performance against the existing 31 day standard (from diagnosis to treatment) is 99+%, against an operational standard of 98% – we expect reported performance will move to about 98%
performance against the existing 62 day standard (from referral to treatment) is 97+% against an operational standard of 95% – we expect reported performance will move to about 86%.” The Cancer Reform Strategy ­ First Annual Report (Published 1 December 2008
1 2) Current targets Existing Cancer Waiting Times targets consist of 14, 31 and 62 day pathways for GP newly suspected cancers and new cancers referred through other routes to the MDTs’. Two Week Wait GP Receipt 31 Day Wait First Seen Decision to Treat Treatment Start Date 62 Day Referral to Treatment Wait The targets are met by the tracking and monitoring of each individual patient’s pathway by the cancer waiting times team to ensure that all outpatient appointments, diagnostics, outcomes and treatment take place within the target timeframe. 3) New Targets The individual pathways for each of the above targets are quite detailed but the over­arching pathway for the extended cancer waiting times will now look as follows. 2­week Target Wait Original referral request received date UBRN conversion Current 31 Day Wait Date first seen Decision to treat date Decision to treat date Cancer treatment period start date Cancer referral to treatment period start date Extended 31 day wait Start date Earliest clinically appropriate date
Start date Cancer treatment period start date Consultant upgrade date 31/62 day refer to treatment waits 2 4) ·
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5) Guidance on the new targets
The national cancer action team produced guidance in September 2008 to bring the measurement of cancer waiting time rules into line with 18 week rules.
In particular, there will no longer be a general provision for pausing the clock on cancer waiting times for clinical, social, patient choice delays.
For the 31 day target for subsequent treatment (but not for the 62 day target for 1 st treatments) the clock start will be related to the “earliest clinically appropriate date” which will need to be determined clinically, for example, how long after surgery is it appropriate to start radiotherapy treatment
The objective of extending the 62 day target is that in principle it can cover all new cancer cases, but the guidance is likely to say that there needs to be discussion with local clinical teams about who takes the decision to upgrade non­cancer referrals to be subject to a 62 day pathway Meeting the new Targets Meeting the new 62 day target East & North Hertfordshire NHS Trust faces a number of risks in relation to the extended 62 day targets because many referral and diagnostic patients pathways for common cancers currently take longer than 62 days when the patient is not subject to an urgent referral by the GP (prostate, colorectal, gynaecology). According to how the 62 day consultant upgrade rule is applied, the impact of management of this risk will vary: a) Upgrades by consultant only, no formal priority or system given to help consultants upgrade: likely to result in small numbers of consultant upgrades, which may be a risk to the target if consultants selectively upgrade those patient pathways where diagnostics are slowest. b) General advice to consultant and team to upgrade appropriate cases is likely to result in variable application the impact of which is difficult to predict. c) We can support the process of consultant upgrades, for example by agreeing with clinical teams circumstances in which MDT co­ordinators would automatically upgrade cases that were on a cancer diagnostic pathway: this approach would be more manageable, and would mean a lot of cases where we will meet the target easily being included, to offset those the target is more difficult, but is still likely to require a significant improvement in diagnostic turnaround for key cancers if the target is to be met. Meeting the new 31 day target for subsequent treatments Chemotherapy or palliative care treatment usually starts very promptly, the target for radiotherapy has been postponed to December 2010, but there are some surgical cases where the 31 day target from decision to treat to treat may create a problem.
3 6) Challenges of the New CWT targets for East & North Hertfordshire NHS Trust The introduction of the new targets will result in a significant increase in workload for the existing MDTs, primarily around the ‘subsequent treatments’ target as not only will it result in tracking newly diagnosed patients beyond their first treatment, it will also involve monitoring any patient who has had a recurrence of cancer (currently excluded from the existing CWT targets) and any patient who has been under ongoing review, where a decision is then made to offer the patient a further treatment. The following table outlines the average number of patients to be monitored at any one time by tumour site: Tumour site Average number of patients Breast Colorectal (Lower GI) Gynaecology Haematology Head and Neck Lung Pancreatic Sarcoma, brain and other (no MDT meeting) Skin Upper GI Urology 85 85 45 4 30 35 N/a 20 30 25 70 An audit of 50 patients (5 patients per tumour site) was carried in relation to ascertaining how many of these patients went on to have a subsequent treatment. The findings were that approximately 40­60% of patients had more than one modality of treatment and this was more prevalent in particular tumour sites when compared to others. Based on these results, the experiences of the MDTs together with the knowledge of patient pathways for the various tumours sites and the type of cancer diagnoses, it is envisaged that the number of patients on the existing monitoring mechanisms will increase by the following amounts for patients undergoing subsequent treatments: Tumour site Breast Colorectal (Lower GI) Gynaecology Haematology Head and Neck Lung Pancreatic Sarcoma, brain and other (no MDT meeting) Skin Upper GI Urology Average number of patients on current 85 85 45 4 30 35 N/a 20 Anticipated increase (%) 90% 50% 25% 70% 60% 45% N/a 10% Proposed revised number of patients 162 128 56 7 48 51 N/a 22 30 25 70 10% 65% 65% 33 41 116
4 7) Progress to date on achieving the new CWT Actions carried out as at 16/09/2008 MDT Coordinators educated on the new targets Attendance of Cancer Manager and AGM at MDT meetings to talk about the new targets to clinical teams Basic crib sheet summarising the new targets has been produced for circulation to stakeholders Formal letter attaching the crib sheet has been circulated to MDT members and MDT leads Cancer Manual revised to include new targets Process and escalation system for achieving the new targets has been established Infoflex has been modified to capture data for the new targets and a new ‘subsequent treatment’ PTL is soon to be produced Formulation of a service improvement plan with timescales and deliverables has begun. This will inform developments needed to achieve CWT for the existing and new targets. 8) Impact of new monitoring system The monitoring and reporting of Cancer waiting times has been modified to mirror the process currently used to record the 18 week pathway. This reduces significantly the number of adjustments that can be made resulting in a subsequent reduction in performance. Modelling by the DoH predict a national reduction in performance for the two week wait from 99% to 93%, 31 day standard from 99% to 98% and the 62 day standard from 97% to 86%. The impact for the Trust and across the Eastern region can be seen in the 3 tables below. It is unclear at present what if any changes the Healthcare Commission may make to the current thresholds though and what data will be used to judge this year’s performance. See Appendix for more detailed impact assessment analysis of providers in the East of England. Clearly there will perception issues about performance when the new figures are reported and the DoH is currently developing a communication strategy in consultation with the Royal Colleges and SHA’s. The board is asked to note the revised Cancer Waiting Times Standards
5 Appendix – Performance Impact Analysis by Provider within EoE SHA
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