Cancer Networks Inception to Completion:Cancer Networks Inception to Completion Anna Gregor Lead Clinician for Cancer in Scotland


Why is change necessary …….:Why is change necessary ……. Numbers in SCAN 8000-9600 NP 4200-3900 death Patient power ££, technology, WTD Sustainability Status quo not an option


Lung Cancer:Lung Cancer


Cancer in ScotlandInvestments in Lung Cancer:Cancer in ScotlandInvestments in Lung Cancer (£) 2001-02 2002-03 2003-04 North 52,000 75,000 33,000 South-East 140,000 724,500 462,000 West 106,000 465,000 465,000 Sub-Totals 298,000 1,264,500 960,000 TOTAL = £2,522,500


Cancer care process:Cancer care process Outcome determined by weakest link Patients experience and outcome Multidisciplinary Multiple sites Long term Evidence based Coordinated and explicit


Regional Cancer Networks:Regional Cancer Networks MEL (1999)10, HDL(2001)71 Lead Clinician & manager, structure, RCAG Improvements expected, documented evidence base Multidisciplinary & patients QA programme, education, audit, Effective, value for £ Annual Report NoSCAN WoSCAN SCAN


Networks are……:Networks are…… Groups of people aligning their action to particular purpose Bridges between people as well as organisations Safety nets for patients and professionals


Networks like bridges………:Networks like bridges……… Strong foundations Flexibility Rigidity A system of traffic management To lead somewhere attractive


Foundations:Foundations EB guideline Local protocols National service standards Audit Quality improvement


Service maps, protocols, information:Service maps, protocols, information Certainty and choice for patients Preplan and pre-schedule Reduce delays and restrictions Improve patient satisfaction Best care, in the best place, by the best person/team Northern Cancer Network ·        To place the GP urgent referral proforma on GP computer software in Sunderland and to introduce an e-mail referral system to the chest clinic for urgent cases. ·        To carry out a random MDT audit of 10 patients at three sites to compare outcomes. ·        To create a dedicated space and common list across the Trust for pleural aspiration.     JACOB (Birmingham Hospitals Cancer Network) ·        To co-ordinate efforts within Heartlands on prevention and to find out what city council/health authority initiatives are in progress. ·        To improve GP referrals by organising a further GP meeting with PGEA points to increase involvement, and repeat in March 2001. The British Lung Foundation and BACUP to be invited. ·        To test out a nurse specialist seeing some patients and ordering investigations at the first clinic visit. ·        To produce a first draft of a ‘passport leaflet’ on complementary therapies.   Mid-Anglia Cancer Network ·        To strengthen the MDT and involve the radiologist. ·        To reduce waits of 4–6 weeks for CT by acquiring a second scanner and process redesign. ·        To tackle delays in palliative radiotherapy by organising a workshop on capacity and demand. ·        To PDSA a drop-in follow-up clinic run by a specialist nurse to provide supportive care for outpatients and to set up a support group for carers. Merseyside and Cheshire Cancer Network ·        Agreed that project managers would not have to take time out from project commitments in July and August. ·        Each project will do work over the next action period in at least one area of constraint to ensure improvement. ·        One project will concentrate on patient information and satisfaction. ·        More detailed mapping of tertiary services to be carried out.   South East London Cancer Network ·        Programme managers to write to PCG chairs to try to engage GPs in the Collaborative. ·        Further discussions to be held with clinicians, project managers and Greenwich Hospital about incorporating Greenwich in the Collaborative. It is currently the only Trust in the Network that is not involved. ·        Accelerating the patient information project – currently awaiting delivery of the Personal Information File.       Spreading the Improvements from the CSC Professor Helen Bevan, National Patients' Access Team   The CSC’s approach has been to create improvements across the whole process of care for a small slice of patients, to spread these improvements across the tumour specific groups and then to other cancers within the network. Up till now the CSC has concentrated on delivering improvements at a local level. It is now starting to develop plans for regional and national spread and hopes to have a definitive plan by November. The spread plan of the CSC will be a key component of the National Cancer Plan, which is due to be published in the autumn.   As well as spreading these changes regionally and nationally, the CSC also aims to spread them over other services. Dermatologists have already shown an interest in the CSC’s collaborative process and are adopting its methods. A similar approach is also planned for CHD.   Around 2–3% of people are innovators. When any innovation is introduced only 13–14% of people will be early adopters. These individuals are clinical champions who are seeking to improve practice. One of the criteria used in selecting the nine participating networks for the CSC was the presence of early adopters. Around a third of people will be keen to adopt the change once positive results have been demonstrated (the early majority), another third will adopt these changes later (the late majority) and the remaining 16% will be laggards. If 10–20% adoption can be achieved this provides a starting point for spread to take off.   People have to be convinced that there is a problem with the old way of doing things and that there are advantages of adopting the new practice. They need to be shown examples of practical benefits. The more simple the change the more likely it is to be taken up. The language used is also important and jargon should be avoided.   Approaches to spread can be ‘optional’ where the decision to adopt new practice is made by an individual, ‘collective’ where there is a consensus decision or ‘authority’ where the leadership makes the decision. Initially, the CSC plans to use the optional approach but may use the other approaches later on. Although national goals are needed, spread should be regionally led and it is important to have very strong local ownership.   Measurement of spread and a system for regular progress reporting are essential, as is good communication. Leadership, however, is the most critical aspect of a spread programme. Clinical leaders and managers need to work together and someone needs to be accountable for each stage of the spread programme. The CSC hopes that it will be able to retain key individuals to help support the spread process.   Summing Up Professor Helen Bevan   Several key themes emerged from the programme team meetings where action needed to be taken over the next period, said Professor Helen Bevan. The first was capacity and demand in 3 key areas: radiotherapy, diagnostic radiology and pathology. Another was prebooking and prescheduling systems in radiology.   There was a strong emphasis on developing MDTs. Links with primary care and also with supportive and palliative care need to be strengthened. Work is needed on systems for improving information and choice for patients especially at the primary care/secondary care interface.   Plans are needed to spread examples of new practice systematically. The CSC should be linked to mainstream planning and improvement activities. Improvements achieved by the CSC need to be linked to health improvement plans and service and financial frameworks.   Tasks for the next 4–5 months ·        To make the connections across the patient journey. ·        To rethink what is possible – it is important to keep testing new ideas and implement what works. ·        To engage leaders such as chief executives. ·        To achieve the target for November of more than 90% of teams scoring themselves at 4 or more (4 = significant progress, 5 = outstanding sustainable progress).   Critical areas to be developed together ·        Primary/secondary care interface. ·        Diagnostic radiology and radiotherapy – may have national workshops. ·        The patient experience – to take it forward locally and nationally. ·        Contribute to the national cancer improvement programme. ·        Take the patient journey forward. ·        Develop a national, regional and local spread programme. ·        CSC should be an integral part of the National Cancer Institute programme.   Mr Hugh Rogers said he felt that there had been a “tremendous growth in confidence” since the last meeting. There was a realisation that small changes could make a large difference to the patient journey. More attention should be paid to the GP’s perspective and a more formal dialogue established with primary care.   There has been interest in rolling out the programme from early adopters, outside the collaborative. The improvements need to be spread to other geographical and clinical areas.   The gold standard pathway should not be considered the outer limit. “We need to aim higher,” said Mr Rogers. “It will be important to keep the momentum going over the summer when key members of the teams are on holiday”.   The Fourth Learning Workshop will be held at the Imperial Hotel, Blackpool on November 16–17, 2000.


CSBS Standards 2001/2 :CSBS Standards 2001/2 90% seen by respiratory physician within 2 weeks of referral Met in 3 hospitals out of 31 90% considered for curative treatment to receive CT scan within 2 weeks Met in 2 hospitals out of 31 90% resected within 6 weeks of diagnosis Met in 2 hospitals out of 31


1st Treatment (ISD):1st Treatment (ISD) Surgery Radiotherapy Chemotherapy Scotland 10.1 35.7 17.7 North 10.7 46.0 20.4 South-East 8.9 37.0 17.4 West 10.5 31.3 16.9


Trends:Trends Factor 95 98 2000 Histology 61 73 74 Surgery 11 9 11 RT 36 36 33 CT 16 19 21


Impact of multi-disciplinary working in patients >70 with NSCLC:Impact of multi-disciplinary working in patients >70 with NSCLC 8% increase in patients 4 fold CT 4 fold curative RT 10 fold HD PRT I year survival up by 6% p=0.023


Clinical change :Clinical change Possible Needs data Buy-in through investment + service development May improve outcomes Will improve experience


Organisational benefits:Organisational benefits Strategic Informs clinical governance – targets, audit reports; Performance Assessment Framework Peer review + clarity Clinical & managerial partnerships Reduces variations Improves effectiveness


Slide 17:Great health professionals do not make great health care Great health professionals inter-acting well with all of the other elements of the health care system make great health care…… Don Berwick,, BMJ, Vol 314, 1564 –1565.