Download System wide approach to improving Cancer Waiting Times

System wide approach to improving
Cancer Waiting Times performance
The London Cancer Alliance West and South
London Cancer Alliance
• One of 2 Integrated Cancer Systems established within
London in 2011
• Covered North West and South London, covering 5.7m
local population
• Separate commissioning support function provided by
Transforming Cancer Services for London
• Focus of LCA has been pathway improvement rather
than performance management of trusts
The London Cancer Alliance West and South
London Cancer Alliance
• Work focused through 12 tumour specific & several
cross cutting pathway groups
• Additionally work through clinical board, and members
board, whose membership consisted of the 14 CEOs of
the member organisations.
• LCA transitioned into RM Partners part of the National
Cancer Vanguard on the 1st April 2016. Plan now is for
informatics including Cancer Waits analysis to be panLondon +/- Manchester
The London Cancer Alliance West and South
Approach to improving Cancer Waiting Times performance
• Tumour specific analysis and improvement
• Analysis and focus on quarterly performance
– To ensure case volumes are high enough to
be significant
– To make best use of analytical resource
The London Cancer Alliance
Overview
• Overview of Cancer Waits performance within LCA
• Embedding cancers waits within cancer metrics
• Clinical engagement – wider CWT context
• Examples of data improvement work
• Examples of performance comparisons
• Pathway specific initiatives to improve performance
The London Cancer Alliance
Overview of performance - Cancer Waiting Times
Overview of all targets since 2008/09 - LCA
•
7/8 standards
generally met
across LCA
•
62 day urgent GP
referral to 1st
treatment standard
has not been
achieved for 3
years
The London Cancer Alliance
Cancer Waiting Times - Comparison to England
The London Cancer Alliance West and South
Trend in 2 week wait and 62 day volumes
2 week wait urgent GP referral to 1st seen
Tumour type
Brain/CNS
Breast
Children’s
Gynaecology
Haematology
Head and Neck
Lower GI
Lung
Other
Sarcoma
Skin
Upper GI
Urology
Total
2014/15
1115
28714
720
15189
1996
12812
20237
5499
613
400
27476
14159
16079
145009
2013/14
941
25511
600
12494
1664
11436
17429
4692
365
379
22572
11247
13907
123237
% Change
from
2013/14 to
2014/15
18%
13%
20%
22%
20%
12%
16%
17%
68%
6%
22%
26%
16%
18%
62 day urgent GP referral to 1st treatment
Tumour type
Brain/CNS
Breast
Children’s
Gynaecology
Haematology
Head and Neck
Lower GI
Lung
Other
Sarcoma
Skin
Upper GI
Urology
Total
2014/15
12
1879
2
670
573.5
483
952
881
96
93
1446.5
628.5
2456.5
10173
% Change
from
2013/14 to
2013/14 2014/15
11.5
4%
1769
6%
5.5
-64%
656.5
2%
485.5
18%
424
14%
823.5
16%
890.5
-1%
97
-1%
91
2%
1254
15%
587.5
7%
2353.5
4%
9449
8%
• Overall 2 week wait referrals increased by 18% and 62 day cases treated increased by 8%
from 2013/14 to 2014/15
• Further increases expected with revised NICE guidance introduced in summer 2015
The London Cancer Alliance
Overview
• Overview of Cancer Waits performance within LCA
• Embedding cancers waits within cancer metrics
• Clinical engagement – wider CWT context
• Examples of data improvement work
• Examples of performance comparisons
• Pathway specific initiatives to improve performance
The London Cancer Alliance West and South
Tumour specific scorecards
• Tumour specific metrics developed including tumour specific
Cancer Waiting Times performance and analysis
• Additional sections (with examples)
• Data quality – COSD, SACT dataset, National audits
• Patient experience – NCPES
• Prevention/early diagnosis – Screening, routes to diagnosis
• Diagnosis - 6 week diagnosis waits, stage distribution
• Treatment – Laparoscopic rates, emergency re-admissions
• Incidence/Mortality/Survival
• Cancer Research – Recruitment to trials
Lung pathway group metrics
Last updated November 2015 Log of updates
1. Cancer Waiting Times
3. Patient experience
5. Diagnosis
1.2. 31 day decision to treat to 1st treatment
3.1 NCPES – Q12 - Patient felt they were told
sensitively they had cancer
5.4 – Stage at diagnosis
5.4.1 By CCG (from NCRS data)
5.4.2 By provider (LUCADA)
1.3. 31 day subsequent surgery
3.2 NCPES Q21 – Patient given name of the
CNS in charge
5.5. – CT before 2 week wait OPA
1.4. 31 day subsequent drugs
3.3 NCPES Q22 – Patient finds it easy to
contact CNS
1.5. 31 day subsequent radiotherapy
3.4 NCPES – Q30 – Cancer Research discussed
with patient
1.1. 2 week wait GP urgent referral to 1st seen
1.6. 62 day GP urgent referral to 1st treatment
1.7 62 day consultant upgrade to 1st
treatment
1.8 62 day GP urgent referral to
– distribution of week treated
1st
treatment
2. Data collection /Numbers
2.1. COSD MDT feed data quality
(Level 2)
2.1.1 Staging
2.1.2 Basis of diagnosis
2.1.3 Performance status
2.1.4 CNS indicator
3.5 NCPES – Q38 – Patient had confidence in
doctors treatment patient
3.6 – NCPES Q44 – Enough/nearly enough
ward nurses on duty
3.7 NCPES Q53 – Patient given clear written
information about what should/should not
do post discharge
3.8 NCPES Q67 - Patient given right amount
of information about condition and
treatment
3.9 NCPES Q70 – Patient’s rating of care ‘very
good’/’excellent’
2.2 COSD completeness all feeds combined
(Level 3)
2.2.1 Staging
2.2.2 Basis of diagnosis
2.2.3 Performance status
2.2.4 CNS indicator
2.2.5 Discussed at MDT
4.1 % emergency presentation
2.3 SACT data completeness
5.1 Patients receiving CT scan prior to
bronchoscopy (LUCADA)
2.4 LUCADA data quality
5.2 Histological diagnosis (LUCADA)
4. Prevention/Early diagnosis
5. Diagnosis
5.3 CNS involvement in the pathway
Collated by Stephen Scott
[email protected]
In strictest confidence – For
NHS internal use only
5.6 – Proportion of NSCLC with a PET scan by
stage
5.7 Performance status at diagnosis (LUCADA)
6. Treatment
6.1 SACT top 10 regimens
6.1.1 Overall England – NSCLC
6.1.2 By Trust – NSCLC
6.1.3 Overall England – SCLC
6.1.4 – By Trust – SCLC
6.1.5 – Overall England – Mesothelioma
6.1.6 – By Trust – Mesothelioma
6.2 – SACT chemotherapy mortality
6.2.1 – All lung cancers – All treatment intents
6.2.2 – All lung cancers – Curative intent
6.2.3 – All lung cancer – Palliative intent
6.2.4 – Mesothelioma – All treatment intents
6.2.5 – Mesothelioma – Palliative intent
6.2.6 – SCLC – All treatment intent s
6.2.7 – SCLC – Curative intent
6.2.8 - SCLC – Palliative intent
6.2.9 – NSCLC – All treatment intents
6.2.10 – NSCLC – Curative intent
6.2.11 – NSCLC – Palliative intent
6.3 Lung cancer resection rates
6.3.1 – Resection rates (NCRS) by CCG
6.3.2 – NSCLC (LUCADA) by provider
6.4 Chemotherapy rates
6.4.1 – SCLC chemotherapy rates (LUCADA)
6.4.2 - Stage 3b and 4 NSCLC rates with
performance status 0 or 1 (LUCADA)
6. Treatment
6.5 AHP access (NCPES)
6.5.1 - Physiotherapist
6.5.2 - Occupational Therapist
6.5.3 – Dietician
6.6– HNA/Recovery package
6.6.1 HNA At Diagnosis
6.6.2 HNA At End of Treatment
6.6.3 End of treatment summary
6.6.4 Health and Wellbeing event
6.7 – Numbers of surgical procedures by
provider
7. Incidence/mortality/survival
7.1 – Incidence rates
Trachea, Bronchus and Lung (C33-34)
Mesothelioma (C45)
7.2 - Mortality rates
Trachea. Bronchus and Lung (C33-34)
Mesothelioma (C45)
7.3 – Population Survival rates
- Trachea, Bronchus and Lung (C33-34)
- 1 year survival by cancer network
- 1 year survival by age group
7.4 – Provider level survival rates (LUCADA)
7.4.1 - Median Survival of patients
7.4.2 - 3 month survival
7.4. 3 - 1 year survival
7.5 – Number of cases
7.6 Number of deaths
7.7 – Prevalence rates
Male
Female
8. Cancer research
8.1 – Details of NCRN badged trials
11
The London Cancer Alliance West and South
Trust scorecard
• Tailored trust specific quarterly scorecard produced & circulated
via LCA members board (i.e direct to Trust CEOs)
• Includes 12 key cancer measures including:• 2 week wait urgent GP to 1st seen standard
• 62 day urgent GP referral to treatment standard
• Comparable position for each measure including ranking within
LCA
• Trust specific breakdown of performance by tumour type included
• Brief commentary included for all measures
Cancer Scorecard
Example NHS Foundation Trust
Area
Measure
Operational
Effectiveness
Clinical
Outcomes
Benchmark
Period
Trust value
Previous
period
reported
Change since
last
last period
report
England
average
LCA average
LCA ranking
1. 2 week wait: Urgent suspected cancer
GP referral to 1st seen
93%
Q3 2015/16
88.2%
Q2 2015/16
+10.4%
94.8%
94.6%
18/18
2. 62 day: Urgent suspected cancer GP
referral to 1st treatment (DH position)
85%
Q3 2015/16
85.9%
Q2 2015/16
+3.1%
83.4%
83.1%
9/18
57.8%
2/15
3. 1 year survival by trust
Awaiting data to be made available from National Cancer Registration Service
4. 30 day mortality after chemotherapy
Data Quality
2013
10.7%
N/A
5. COSD – MDT feed - % of cases with full
stage
70%
2015
74.3%
2014
-12%
6a.SACT – Data completeness –
Treatment intent
70%
2015
100%
2014
0%
91.9%
88%
4/13
6b – SACT – Data completeness –
Performance status
70%
2015
96%
2014
+6%
60.3%
74%
3/13
7. NCPES 2013/14 – Q21 – Patient given
name of CNS in charge of care
80%
2013/14
89%
2012/13
+3%
89%
89%
5/16
8. NCPES 2013/14 - Q38 – Patient had
confidence and trust in all doctors
treating them
80%
2013/14
88%
2012/13
+5%
85%
85%
3/16
9. Holistic Needs Assessment (Completed)
- Within 31 days of diagnosis
60%
Q2 2015/16
50%
Q1 2015/16
48%
6/15
10. Risk stratified pathways implemented
–Breast/Colorectal/Prostate (number of
services implemented)
All
June 2014
3/3
N/A
Research
11. NCPES 2013/14 – Q30 – Taking part in
cancer research discussed with patients
30%
2013/14
37%
2012/13
-3%
41%
5/16
Workforce
12. COSD – MDT feed – % of cases seeing
a CNS
70%
2015
7%
2014
-2%
40.8%
12/15
Patient
Experience
-8%
31%
1. Two week wait urgent GP referral to 1st seen – Tumour breakdown
Example NHS Foundation Trust
2 week wait performance by Tumour Type
Q3 2015/16
Q2
2015/16
Q1
2015/16
2014/15
overall
Number
Breaches
Q3
2015/16
Change
from last
quarter
Other
1
0
100.0%
100.0%
0.0%
100.0%
75.0%
Sarcoma
1
0
100.0%
100.0%
0.0%
0.0%
50.0%
Childrens
11
0
100.0%
20.0%
80.0%
100.0%
98.5%
Lung
98
3
96.9%
5.8%
91.1%
98.1%
96.8%
Urology
412
14
96.6%
-0.6%
97.2%
96.2%
94.3%
Lower GI
358
17
95.3%
4.4%
90.9%
92.4%
96.8%
Haematology
61
4
93.4%
10.1%
83.3%
98.5%
98.6%
Breast
709
48
93.2%
5.9%
87.3%
88.8%
96.0%
Head and Neck
366
29
92.1%
6.3%
85.8%
96.8%
98.2%
Brain/CNS
23
2
91.3%
-0.4%
91.7%
100.0%
100.0%
Upper GI
366
49
86.6%
13.7%
72.9%
91.3%
95.7%
Skin
660
138
79.1%
22.6%
56.5%
93.6%
94.6%
Gynaecology
282
90
68.1%
13.1%
55.0%
81.5%
97.7%
Trust overall
3348
394
88.2%
10.4%
77.9%
92.4%
95.9%
Collated by Stephen Scott [email protected]
In strictest confidence – For NHS internal use only
14
1. Two week wait urgent GP referral to 1st seen – Tumour breakdown
Example NHS Foundation Trust
62 day performance performance by Tumour Type
Q3 2015/16
Number
Brain/CNS
0.5
Breast
35.5
Skin
18
Urology
70
Lower GI
17
Upper GI
12
Head and Neck
13
Haematology
8.5
Lung
13
Gynaecology
14
Trust overall
201.5
Change
Q3
from last
Q2
Q1
2014/15
Breaches 2015/16 quarter 2015/16 2015/16 overall
0
100.0%
0.0%
100.0%
0%
100.0%
0
100.0%
13.2%
86.8%
97.0%
94.4%
1.5
91.7%
3.9%
87.7%
93.1%
92.2%
6.5
90.7%
11.0%
79.7%
71.7%
80.9%
2.5
85.3%
-4.7%
90.0%
62.5%
82.1%
2.5
79.2%
-2.7%
81.8%
76.2%
79.5%
3.5
73.1%
-1.3%
74.4%
77.8%
78.8%
2.5
70.6%
-23.4%
93.9%
100.0%
92.0%
4
69.2%
-10.8%
80.0%
57.5%
78.4%
5.5
60.7%
-7.3%
68.0%
85.7%
80.2%
28.5
85.9%
3.1%
82.7%
80.0%
84.9%
Collated by Stephen Scott [email protected]
In strictest confidence – For NHS internal use only
15
The London Cancer Alliance
Overview
• Overview of Cancer Waits performance within LCA
• Embedding cancers waits within cancer metrics
• Clinical engagement – wider CWT context
• Examples of data improvement work
• Examples of performance comparisons
• Pathway specific initiatives to improve performance
The London Cancer Alliance West and South
Measure beyond CWT standards
Surgery to radiotherapy (H&N cancer)
• Guidance states that radiotherapy should commence 6 weeks
after surgery for head and neck cancer
• LCA Head and Neck pathway group set a standard of 80% to allow
for patients where clinically not possible or patient choice factors
• Measure could be influenced by many factors
• Surgical complications (e.g wound infection)
• MDT wait
• Referral between surgeon & oncologist
• Radiotherapy planning
• Radiotherapy wait
The London Cancer Alliance West and South
Measure beyond CWT standards
Surgery to radiotherapy (H&N cancer)
• Methodology to measure
• Extracted patients who had surgery between 1st April 2014
and 30th September
• Next 6 months of CWT dataset searched for each patient to
see if chemo/radiotherapy or radiotherapy received and if so
time lapse from surgery.
The London Cancer Alliance West and South
Measure beyond CWT standards
Surgery to radiotherapy (H&N cancer) - Results
Trust of subsequent
chemo-radiotherapy or
radiotherapy
% of patients chemo-rad
or radiotherapy within 6
weeks of surgery (80%
target)
Weeks and days after
surgery that 80% of
patients treated
Imperial College
Healthcare NHS Trust
Imperial College
Healthcare NHS Trust
67% (4/6 patients)
7 weeks, 3 days
Guy’s and St Thomas’ NHS
Foundation Trust
Guy’s and St Thomas’ NHS
Foundation Trust
57% (13/23 patients)
8 weeks, 0 days
St George’s University
Hospital NHS Foundation
Trust
The Royal Marsden NHS
Foundation Trust
43% (3/7 patients)
8 weeks, 1 day
London North West
Hospital NHS Trust
East and North
Hertfordshire NHS Trust
14% (3/22 patients)
9 weeks, 6 days
LCA (all trusts)
LCA (all trusts)
37% (25/67 patients)
8 weeks, 3 days
Trust of
1st
surgery
Routes to diagnosis
Overview
• Routes to diagnosis work produced by National Cancer Intelligence
Network (NCIN) within PHE.
• Looks at Cancer Waiting Times (CWT) Dataset, Screening dataset
and Hospital Episode Statistics (HES) to identify presentation route
for new cancers.
• National reports produced published on NCIN website
http://www.ncin.org.uk
• PHE have also produced a London version for use within London
20
Routes to diagnosis
Route distribution 2006-2013
21
The London Cancer Alliance West and South
Survival by route of diagnosis – 3 years
19 tumour types
Breast Cancer (Male)
Head and Neck – Hypopharynx
Head and Neck – Larynx
Head and Neck – Oropharynx
Hear, mediastrium and pleura
A. Tumour types were 2 week wait referrals
have better 3 year survival than other GP
referrals
Non- Hodgkin Lymphoma
Kidney
Other and unspecified urinary
Leukaemia – Acute lymphoblastric
B.
Tumour types were 2 week wait referrals have
similar 3 year survival than other GP referrals
C.
Tumour types where 2 week wait referrals have
worst 3 year survival than other GP referrals
Leukaemia – Acute myeloid
Leukaemia – Chronic Lymphocytic
Other heamatology malignancies
Biliary tract cancer
Multiple Myeloma
Nasal Cavity and Middle Ear
Penile
Sarcoma (Bone)
Uterus
Vagina
The London Cancer Alliance West and South
Survival by route of diagnosis – 3 years
19 tumour types
Breast Cancer (Male)
Head and Neck – Hypopharynx
Head and Neck – Larynx
Head and Neck – Oropharynx
Hear, mediastrium and pleura
A. Tumour types were 2 week wait referrals
have better 3 year survival than other GP
referrals
Non- Hodgkin Lymphoma
Kidney
Other and unspecified urinary
Leukaemia – Acute lymphoblastric
Leukaemia – Acute myeloid
B. Tumour types were 2 week wait referrals have
similar 3 year survival than other GP referrals
Leukaemia – Chronic Lymphocytic
Other heamatology malignancies
Biliary tract cancer
Multiple Myeloma
Nasal Cavity and Middle Ear
Penile
Sarcoma (Bone)
Uterus
Vagina
C.
Tumour types where 2 week wait referrals have
worst 3 year survival than other GP referrals
The London Cancer Alliance West and South
Survival by route of diagnosis – 3 years
23 tumour groups
Anus
Brain
Meninges
Cervix
Gall Bladder
A. Tumour types were 2 week wait referrals
have better 3 year survival than other GP
referrals
Head and Neck – Nasopharynx
Head and Neck – Oral Cavity
Head and Neck Palate
Head and Neck – Salivary glands
Head and Neck - Thyroid
B. Tumour types were 2 week wait referrals have
similar 3 year survival than other GP referrals
Head and Neck - Non specific
Liver (exc intrahepatic bile duct)
Lung
Mesothelioma
Oesophagus
Other malignant neoplasms
Ovarian
Pancreas
Prostate
Sarcoma (Connective and soft tissue)
Small intesting
Stomach
Vulva
C.
Tumour types where 2 week wait referrals have
worst 3 year survival than other GP referrals
The London Cancer Alliance West and South
Survival by route of diagnosis – 3 years
23 tumour groups
Anus
Brain
Meninges
Cervix
Gall Bladder
A. Tumour types were 2 week wait referrals
have better 3 year survival than other GP
referrals
Head and Neck – Nasopharynx
Head and Neck – Oral Cavity
Head and Neck Palate
Head and Neck – Salivary glands
Head and Neck - Thyroid
B. Tumour types were 2 week wait referrals have
similar 3 year survival than other GP referrals
Head and Neck - Non specific
Liver (exc intrahepatic bile duct)
Lung
Mesothelioma
Oesophagus
Other malignant neoplasms
Ovarian
Pancreas
Prostate
Sarcoma (Connective and soft tissue)
Small intesting
Stomach
Vulva
C.
Tumour types where 2 week wait referrals have
worst 3 year survival than other GP referrals
The London Cancer Alliance West and South
Survival by route of diagnosis – 3 years
8 tumour groups
Bladder
Breast Cancer (female)
Unknown primary
Colorectal
Hodgkin Lymphoma
A. Tumour types were 2 week wait referrals
have better 3 year survival than other GP
referrals
Leukaemia – Chronic Myeloid
Melanoma
Testicular
B. Tumour types were 2 week wait referrals have
similar 3 year survival than other GP referrals
C.
Tumour types where 2 week wait referrals have
worst 3 year survival than other GP referrals
The London Cancer Alliance West and South
Survival by route of diagnosis
GP survival better (23 tumour groups)
Survival the same for 2 week and routine
referrals (19 tumour types)
Survival better for 2 week wait patients
( 8 tumour groups)
Anus
Breast Cancer (Male)
Bladder
Brain
Head and Neck – Hypopharynx
Breast Cancer (female)
Meninges
Head and Neck – Larynx
Unknown primary
Cervix
Head and Neck – Oropharynx
Colorectal
Gall Bladder
Hear, mediastrium and pleura
Hodgkin Lymphoma
Head and Neck – Nasopharynx
Non- Hodgkin Lymphoma
Leukaemia – Chronic Myeloid
Head and Neck – Oral Cavity
Kidney
Melanoma
Head and Neck Palate
Other and unspecified urinary
Testicular
Head and Neck – Salivary glands
Leukaemia – Acute lymphoblastric
Head and Neck - Thyroid
Leukaemia – Acute myeloid
Head and Neck - Non specific
Leukaemia – Chronic Lymphocytic
Liver (exc intrahepatic bile duct)
Other heamatology malignancies
Lung
Biliary tract cancer
Mesothelioma
Multiple Myeloma
Oesophagus
Nasal Cavity and Middle Ear
Other malignant neoplasms
Penile
Ovarian
Sarcoma (Bone)
Pancreas
Uterus
Prostate
Vagina
Sarcoma (Connective and soft tissue)
Small intesting
Stomach
Vulva
The London Cancer Alliance West and South
Survival by route of diagnosis – colorectal example
The London Cancer Alliance West and South
Survival by route of diagnosis – colorectal example
The London Cancer Alliance West and South
Survival by route of diagnosis –prostate example
The London Cancer Alliance West and South
Survival by route of diagnosis –prostate example
The London Cancer Alliance West and South
Routes to diagnosis
• Important to remember not all cancer patients present
via 2 week wait and many will be on the 18 week
pathway
• Being referred via a 2 week wait does not necessary
mean you have a better prognosis
• Where worse survival seen for 2 week wait referrals this
could be due to differences in stage distribution so
further analysis is required at tumour level
The London Cancer Alliance
Overview
• Overview of Cancer Waits performance within LCA
• Embedding cancers waits within cancer metrics
• Clinical engagement – wider CWT context
• Examples of data improvement work
• Examples of performance comparisons
• Pathway specific initiatives to improve performance
The London Cancer Alliance West and South
Radiotherapy guidance
2013/14 distribution of 1st treatment where teletherapy treatments by radiotherapy centre
The London Cancer Alliance West and South
Radiotherapy guidance
2013/14 distribution of subsequent teletherapy treatments by radiotherapy centre
The London Cancer Alliance West and South
Radiotherapy guidance
• Discussion with LCA radiotherapy pathway group identified that the main
difference was actually in data recording rather than difference in waits for
radiotherapy
• Differences in application of start data radiotherapy (E.g CT planning scan)
• Differences in recording of ECAD
• Reviewing national guidance identified there were some areas open to
interpretation
• Guidance produced by pathway group in collaboration with commissioners and
IST to ensure consistent approach to recording across LCA
• Published on LCA website
http://www.londoncanceralliance.nhs.uk/media/124400/lca-radiotherapy-cwtpolicyfinal.pdf
The London Cancer Alliance West and South
Active monitoring usage audit
• In March 2014 the LCA clinical board reviewed 62 day performance and the
potential variation in active monitoring usage was raised particularly for prostate
cancer.
• Additionally it was noted that this was one of the issues raised in the Colchester
CQC report
• Methodology - reviewed all 62 day urgent GP cases for 6 month period,
separating out Prostate Cancer and all other cancers
• Part 1 – Calculate proportions of patients with 62 day clock stop recorded as
active monitoring
• Part 2 - For those patients with a clock stop recorded as active monitoring
look for a subsequent treatment of surgery, chemotherapy, radiotherapy
within 3 months of the clock stop and look at if this made a difference to
compliance
The London Cancer Alliance West and South
Active monitoring usage audit - Results
Part 1 - Rates of active monitoring for 62 day patients
• Prostate cancer – Rates of active monitoring varied from 59% to
18% by 1st seen trust (35% overall)
• All other cancers – Rates of active monitoring varied from 11%
to 1% by 1st seen trust (4% overall)
• Trust with highest rates in both was the same trust
The London Cancer Alliance West and South
Active monitoring usage audit - Results
Part 2 – Treatments with 3 months of a 62 day clock stop for active
monitoring
• Prostate cancer –
• Overall 205 active monitoring clock stops
• 25 had an active treatment within 3 months (17 at same trust)
• 18 of these would have been recorded as a breach if active monitoring
not used (15 at same trust)
• All other cancers
• Overall 133 active monitoring clock stops
• 22 had an active treatment within 3 months (11 at same trust)
• 19 of these would have been recorded as a breach if active monitoring
not used (10 at same trust)
The London Cancer Alliance West and South
Active monitoring usage audit - What we did?
• Presented to cancer managers to raise awareness of issues
(Cross referencing to CQC Colchester report)
• Circulated details of cases starting treatment within 3 months of
active monitoring to trusts to review locally
• One outlier trust identified with highest rate of active
monitoring for both prostate and all other cancers, and largest
numbers of cases where active treatments then commenced
within 3 months
•
Wrote to Medical Director and trust conducted local audit
The London Cancer Alliance
Overview
• Overview of Cancer Waits performance within LCA
• Embedding cancers waits within cancer metrics
• Clinical engagement – wider CWT context
• Examples of data improvement work
• Examples of performance comparisons
• Pathway specific initiatives to improve performance
The London Cancer Alliance
Distribution analysis
Distribution of when patients treated on 62 day pathway – LCA 2014/15
The London Cancer Alliance
Alternative way of looking at performance
Point at which 85% of patients are treated on 62 day pathway by
tumour type 2014/15 – LCA providers
Tumour type
Brain/CNS
Skin
Breast
Haematology
Sarcoma
HPB
OG
Urology (Excluding prostate)
Head and neck (Excluding thyroid)
Lung
Gynaecology
Lower GI
Other Cancers (including unknown primaries)
Prostate
Thyroid
All cancers
Day at which 85% of patients are
treated
Day 39
Day 52
Day 57
Day 66
Day 66
Day 70
Day 75
Day 75
Day 79
Day 80
Day 80
Day 84
Day 88
Day 89
Day 104
Day 70
The London Cancer Alliance West and South
Treatment modality analysis
The London Cancer Alliance West and South
Treatment modality analysis
The London Cancer Alliance
Sector comparisons
Sector comparisons – 62 day performance Q3 2015/16
England
overall
South East London
South West London
North West London
Tumour Type
LCA Overall
Complian Number
Complian Number
Complian Number
Complian Number
Complian
Breaches
Breaches
Breaches
Breaches
ce
of cases
ce
of cases
ce
of cases
ce
of cases
ce
Brain/CNS
93.8%
0
0
n/a
1
0
100.0%
2
0
100.0%
3.0
0
100.0%
Childrens
76.5%
0
0
n/a
0.5
0
100.0%
2
0
100.0%
2.5
0
100.0%
Skin
94.8%
124
4
97.0%
107
6
94.0%
108.5
4.5
96.0%
387.5
19.5
95.0%
Breast
95.1%
153.5
6.5
96.0%
161
5
97.0%
118.5
8
93.0%
482.5
25.5
94.7%
Haematology
81.2%
41
8.5
79.0%
27
4.5
83.0%
35.5
3.5
90.0%
123
19
84.6%
Other
72.1%
6
2
67.0%
11
2
82.0%
6.5
1.5
77.0%
30
6
80.0%
Gynaecology
80.7%
52
13
75.0%
44
11.5
74.0%
59.5
7.5
87.0%
171
35
79.5%
Urology
78.7%
240.5
65
73.0%
240.5
34
86.0%
171
29.5
83.0%
721
152.5
78.8%
Lower GI
75.2%
76
21
72.0%
76
10.5
86.0%
77.5
15
81.0%
253.5
56.5
77.7%
Upper GI
75.4%
54.5
17
69.0%
46.5
11.5
75.0%
40.5
7
83.0%
158.5
38
76.0%
Lung
75.2%
93
36.5
61.0%
68.5
11
84.0%
76
19
75.0%
263.5
69
73.8%
Head and Neck 70.3%
41.5
15.5
63.0%
37
15.5
58.0%
54.5
5
91.0%
148
40
73.0%
Sarcoma
74.6%
5
1
80.0%
14
5.5
61.0%
2.5
0.5
80.0%
22.5
7.5
66.7%
Total
83.4%
887
190
79.0%
834
117
86.0%
754.5
101
87.0%
2766.5
468.5
83.1%
•
•
Target met in both NWL & SWL
Tumour comparisons of note
• Gynaecology – NWL 87% vs SEL/SWL – 74%
• Head and Neck – NWL – 91% vs SEL – 63%, SWL – 58%
• Lung – SWL – 84%, NWL – 75%, SEL – 61%
• Urology – SWL – 86%, NWL 83% - SEL – 73%
The London Cancer Alliance West and South
Breakdown of Urology into tumour types
Urology performance – LCA providers Q3 2015/16
Tumour type
Number of
accountable
cases
Number of
accountable
breaches
Performance
Prostate
517
131
75%
Bladder
81.5
6
93%
Kidney
79
29
63%
Testicular
36
1.5
96%
Penile
7
1
86%
Total
720.5
168.5
77%
The London Cancer Alliance West and South
Analysis by 2 week wait referral type
Haematology 62 day urgent GP referral to 1st treatment performance by 2 week wait referral
type 2014/15
2 week wait referral type
Haematology
Head and Neck
Upper GI
Lung
Breast
Urology
Lower GI
Skin
Gynaecology
Sarcoma
Brain/CNS
Total (non-haematology)
Total
% of total
haematolo
gy patients
treated on
Number of Number of
62 day
patients breaches % in target pathway
366
35
90%
72%
57
16
72%
11%
18
6
67%
4%
17
4
76%
3%
16
4
75%
3%
13
1
92%
3%
8
4
50%
2%
6
1
83%
1%
6
1
83%
1%
3
1
67%
1%
1
0
100%
0%
145
38
74%
28%
511
73
86%
100%
The London Cancer Alliance
Overview
• Overview of Cancer Waits performance within LCA
• Embedding cancers waits within cancer metrics
• Clinical engagement – wider CWT context
• Examples of data improvement work
• Examples of performance comparisons
• Pathway specific initiatives to improve performance
The London Cancer Alliance West and South
Prostate best practice pathway
Case for change - Prostate 62 day Urgent GP referral to 1st treatment performance by
1st seen trust - 2012/13
Site
St Mary’s Hospital - Imperial
Charing Cross Hospital - Imperial
Croydon University Hospital
Chelsea and Westminster Hospital
West Middlesex University Hospital
Central Middlesex Hospital – The North West London Hospitals NHS Trust
Queen Elizabeth Woolwich - SLHT
St George’s Healthcare NHS Trust
Northwick Park Hospital – The North West London Hospitals NHS Trust
St Helier Hospital
Hillingdon Hospital
Princess Royal University Hospital - SLHT
Guy’s and St Thomas' NHS Foundation Trust
Epsom Hospital
East and North Hertfordshire NHS Trust
King's College Hospital
London Cancer Alliance Overall
Number % in
of
target
breaches (62 day
Number Median
62
standard
of cases Wait standard
)
29
81
18
37.9%
39
75
24
38.5%
96
58
32
66.7%
13
58
5
61.5%
55
55
14
74.5%
13
50
1
92.3%
129
48
27
79.1%
84
46.5
19
77.4%
88
45
2
97.7%
55
45
14
74.5%
12
44
2
83.3%
99
43
27
72.7%
211
42
33
84.4%
71
42
13
81.7%
50
39.5
2
96.0%
88
39.5
8
90.9%
1138
48
243
78.6%
The London Cancer Alliance West and South
Prostate best practice pathway
Prostate best practice pathway
• Already in place at King’s and Guy’s and St Thomas’ which had
relatively good performance
• Main issue highlighted 4-6 weeks required between TRUS biopsy
and MRI scan due to prostate swelling
• Main elements of pathway are:• 1st OPA within 7 days
• MRI before TRUS biopsy where clinically appropriate
• Biopsy by day 14
• Biopsy results & MDT by day 21
• Staging completed and treatment decision by day 42
• Treatment by day 62
The London Cancer Alliance West and South
Prostate best practice pathway
Prostate best practice pathway
Metrics defined to support delivery
Metric No.
Metric
What are we measuring?
LCAPP1
Date from referral to first
appointment is to be <8 days
LCAPP2
First 2ww appointment
for prostate cancer
patients
62 day first treatment
LCAPP3
Decision to treat
Date from referral to decision to
treat <31 days
LCAPP4
First 62 day treatment
modality
% of patients receiving active
monitoring as their first treatment
LCAPP5
Biopsy
Date from referral to biopsy <20
days
LCAPP6
MRI
Date from referral to MRI <10 days
LCAPP7
Pre biopsy MRI
Date of MRI to be before date of
biopsy
LCAPP8
% complete for all COSD
items
To assess the validity of the data
received as the COSD dataset is likely
to be incomplete
Date from referral to first treatment
<63 days
http://www.londoncanceralliance.nhs.uk/media/109454/lca-best-practice-prostatepathway-december-2013-updated-september-2015-.pdf
The London Cancer Alliance West and South
Colorectal straight to test pathway
Standard pathway without straight to test model for patient starting radiotherapy
Treated on day 68 if all timescales met !!!
The London Cancer Alliance West and South
Colorectal straight to test pathway
With straight to test
Treated on day 58 if all timescales met
The London Cancer Alliance West and South
Colorectal straight to test pathway
• LCA has been aiming to role this out across sector
• In July 2015 survey identified that
• 7/15 had fully implemented pathway
• 2/15 had partially implemented pathway
• 6/15 had not implemented
• Main challenges
• Resource to undertake telephone consultation to triage patients
• Difference in agreements with commissioners for telephone
consultation
• Do you roll this out just for 2 week wait patients or for all referrals
Next steps
The London Cancer Alliance West and South
Next steps
• Work to continue through delivery units of National
Cancer Vanguard
• Potential replication nationally by Cancer Alliances
• Challenges
• Increased demand on system
• Including increase in usage of 2 week wait target
• Competing demands with other targets
• New targets (e.g 28 days from referral to diagnosis)
• Access to Cancer Waiting Times data
The London Cancer Alliance
Questions?
Contact details
Stephen Scott – [email protected]
Hilary Wilderspin – [email protected]