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Commissioning Patient Centered Care
& Improving Outcomes for People with
Cancer
Di Riley
Associate Director, Clinical Outcomes
NCIN
To cover:
• Improving Outcomes
• Long Term Conditions in Cancer
• Commissioning Patient Centred Services
What are Outcomes
Clinical v Patient
Survival
Quality of Life
Stage of disease
Return to normality
Co-morbidity
Treatment
Toxicity & side effects
Role of
National Cancer Intelligence Network?
NCIN Goal
Goal for NCIN: To develop the best cancer
information service of any large country in the
world
Why?
•
•
•
•
To provide feedback on performance to clinical teams
To promote stronger commissioning
To provide informed choice for patients
To provide a unique opportunity for health services
research
i.e. To improve outcomes
NCIS Example: Trends in one year
cancer survival, breast cancer, females,
England, 1985-2004 (five-year moving
average)
1985-1989
1986-1990
1987-1991
1988-1992
1989-1993
1990-1994
1991-1995
1992-1996
1993-1997
1994-1998
1995-1999
1996-2000
1997-2001
1998-2002
1999-2003
2000-2004
Number in
Cohort
115,172
119,114
124,244
129,482
133,081
135,249
137,167
138,737
140,591
143,894
148,009
151,320
153,862
155,571
158,404
160,007
Cumulative
Deaths Crude Rate
15,559
15,547
15,370
15,379
15,422
15,064
14,890
14,829
14,485
13,911
13,696
13,222
12,835
12,546
12,306
11,947
86.5
86.9
87.6
88.1
88.4
88.9
89.1
89.3
89.7
90.3
90.7
91.3
91.7
91.9
92.2
92.5
Relative
95%
Survival Confidence Interval
88.9
88.7 89.1
89.3
89.1 89.5
89.9
89.7 90.1
90.4
90.3 90.6
90.7
90.6 90.9
91.2
91.0 91.4
91.5
91.3 91.7
91.7
91.5 91.9
92.1
91.9 92.2
92.7
92.6 92.9
93.1
93.0 93.3
93.6
93.5 93.8
94.1
93.9 94.2
94.4
94.2 94.5
94.7
94.5 94.8
95.0
94.8 95.1
100
90
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70
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Year
NCIN Publications
Cancer Incidence by Ethnicity **June 2009**
Cancer Incidence by Deprivation, England, 95-2004 **NEW**
Cancer Prevalence (undertaken by Thames Cancer Registry)
Cancer Incidence and Mortality by Cancer Network, UK, 2005
1 Year Survival Trends (incl. 1 year Survival by Cancer Network), Eng, 1985-2004
Improving Outcomes
• Public awareness
• Stage at diagnosis
• Co-morbidities
– at & after diagnosis
• Children and Young Peole
• ‘Outcomes Measures’
– clinical
– patient reported
• International Benchmarking
Long Term Conditions:
....... A condition that cannot at present be cured,
but can be controlled by medication and other
therapies
e.g. Diabetes
Heart Disease
Chronic obstructive pulmonary disease
Over 15.4 million people in England with a LTC
(~30%)
UK Population
Between 1983 & 2008 % >65 and over, inc. from 15% to16%,
an increase of 1.5 m people.
By 2033, 23% of population will
be >65 years of age
By 2033, only 18% will be
<16 years
Population by age, UK, 1983, 2008 and 2033, ONS
In 2008, median ages
Women 40 years
Men 38 years
Population aged 65+ years
Cancer Incidence
Figure 6.1: Age-standardised (European) incidence rates, all cancers
males
450
females
persons
400
300
250
200
Since 1977, incidence rate for cancer
has increased in Great Britain, by 25%
150
100
14% increase in men
32% increase in women
50
Year of diagnosis
2005
2002
1999
1996
1993
1990
1987
1984
1981
1978
0
1975
Rate per 100,000 population
350
Number of new cases and rates, by age and sex,
all malignant neoplasms (exc NMSC), UK, 2006
3,500
50,000
3,000
Female cases
Male rates
40,000
2,500
Female rates
2,000
30,000
1,500
20,000
1,000
10,000
500
Age at diagnosis
75+
65-74
55-64
45-54
35-44
25-34
0
15-24
0
under 15
Number of new cases
Male cases
Rate per 100,000 population
60,000
Lung Cancer Incidence
Prostate Cancer Survival
5 year relative survival rates
Increased by an average of 12%
every 5 years between 1986 & 1999
42% to 65%
Breast Cancer Survival
For women diagnosed
with breast cancer in
2001-2006 (England)
5-year relative survival
rates - 82%
compared with only 52%
thirty years earlier in
1971-75
CR-UK
Incidence and Mortality
Figure 6.3: Age-standardised (European) incidence and mortality rates, all
400.0
350.0
300.0
250.0
200.0
150.0
100.0
Persons Incidence
50.0
Persons Mortality
Year of diagnosis/death
2007
2005
2003
2001
1999
1997
1995
1993
1991
1989
1987
1985
1983
1981
1979
1977
0.0
1975
Rate per 100,000 population
450.0
UK Cancer Prevalence
UK 2008 estimates
(based on diagnoses 1971-2004 applied to 2008
population; Thames Cancer Registry, 2008)
Breast (female)
Large bowel
Prostate
Lung
Other
All cancers
550,000
250,000
215,000
65,000
920,000
2,000,000
So.....the implications!
• Ageing population
• Increasing presence of long term conditions
•
•
•
•
•
Increasing risk of cancer
Increasing cancer incidence
Increased survival
Reductions in mortality
More living with cancer
So, more people with LTC will also have cancer
What about treatment effects?
Treatment Effects
Treatment
Long-term side effects
Late side effects
Chemotherapy
Fatigue
Menopausal symptoms
Neuropathy
Heart failure
Kidney failure
Infertility
Liver problems
Radiotherapy
Fatigue
Skin sensitivity
Cataracts
Infertility
Liver problems
Lung disease
Osteoporosis
Reduced lung capacity
Second primary cancers
Cataracts
Cavities and tooth decay
Heart problems
Hypothyroidism
Infertility
Lung disease
Intestinal problems
Memory problems
Second primary cancers
Surgery
Scars / Chronic pain
Lymphoedema
Commissioning considerations
Long term conditions
(Ageing population)
Inc. cancer incidence
Increasing survival
Increasing prevalence
Late effects
Long term effects/conditions
What drives Commissioning – cancer or condition?
Patient Centred Commissioning
Strong cancer commissioning is vital to
ensure:
• high quality services are delivered
• reflect needs of local populations
• reflect national priorities
• cost effective
Commissioning is Complex?
• Many types of cancer
• Many different care pathways
• Clinical teams in the community, DGHs and
specialist centres.
• Some aspects require highly specialised
commissioning at a national or SHA level.
• Other aspects overlap with non-cancer services
(diagnostics & ?LTC) and commissioned at a
more local level.
An example?
• A known cancer patient visits GP with
breathlessness
– Refer back to oncology team?
– Refer to a cardiologist?
– Refer to a respiratory physician?
• Commissioners view:
–
–
–
–
Commission patient pathways
Underlying cause identified and treated
Establish a ‘MDT breathlessness clinic’
Cancer MDT involved
The Cancer Commissioning
Toolkit (CCT)
Programme Budgeting
Cancer Commissioning Guidance was
launched in January 2009 as a ‘sister’
product to the CCT
Sets out the key issues and
questions for commissioners for:
 Assessing health needs
 Reviewing services
 Monitoring performance
 Service specifications
• Easy to
use
format
• Interactive
• Quick
links
25
Each section of the Cancer
Commissioning Guidance contains
Key Questions for commissioners –
and where to find the answers
Patient Centred Care
Late Effects
Long Term Effects
Holistic Needs
Survivorship
Long Term Conditions
Pat. Reported Outcomes
Rehabilitation Services
Commissioning considerations
Long term conditions
(Ageing population)
Inc. cancer incidence
Increasing survival
Increasing prevalence
Late effects
Long term effects/conditions
What drives Commissioning – Patient Pathways?
Any Questions?
www.ncin.org.uk