Going Further on Cancer Waits   Early learning/findings  from the test sites   Patricia Morris  Associate Director  19/09/...
Context  Content:  Progress to date -  Early Learning  Breast – Patricia Morris - Durham  Stretching the goal – Patricia –...
Starting point ……….. <ul><li>Test out ‘what’s possible’ to achieve   </li></ul><ul><li>2 weeks for all breast patients   2...
<ul><li>How the aims can be achieved by a rapid improvement event and ‘lean’ application to urology/ultrasound   </li></ul...
What’s the scale of achieving 2 weeks for all…… <ul><li>Source: Luton data Feb – May 2006 </li></ul><ul><ul><ul><ul><ul><l...
Key Learning from County Durham…….   To be  seen   quickly Value the expertise & Professionalism  of team  Each appointmen...
Durham cont …… <ul><li>Willingness to extend US/mammo radiographers </li></ul><ul><li>Need to have > capacity to manage va...
Luton & Dunstable   <ul><li>Learning </li></ul><ul><li>Takes senior leadership  </li></ul><ul><li>Need to have the data  <...
Luton & Dunstable cont … <ul><li>Outcomes from Rapid Improvement Event  </li></ul><ul><li>To develop a manual data collect...
Key learning from ‘best practice visits ’ <ul><li>Strong clinical leadership </li></ul><ul><li>Value and utilise team to f...
Emerging Common Themes   <ul><li>Understanding the data to realise the scale of the task </li></ul><ul><li>Apply solutions...
Thank you to ….. <ul><li>The clinical & managerial leads  </li></ul><ul><li>The teams  </li></ul><ul><li>The DH Policy Lea...
NOW…… <ul><li>Celia & David! </li></ul>
Going Further on Bowel Cancer Waits Celia Ingham Clark Consultant surgeon, Whittington Hospital and NCL (colorectal) CSCIP
What are we trying to achieve? <ul><li>Patients with bowel cancer should get from referral to treatment as efficiently as ...
Has the TWW system worked? <ul><li><20% of 2WW bowel patients have cancer </li></ul><ul><li><20% of bowel cancer patients ...
What are the numbers? <ul><li>For an average DGH per month - ~ 250 new colorectal referrals - ~ 200 new gastroenterology r...
 
What are the options to improve efficiency? <ul><li>Identify and prioritise patients at highest risk of having bowel cance...
Prioritising high risk patients <ul><li>2WW </li></ul><ul><li>Cade patient questionnaire using Selva score - good discrimi...
A two tier service?
?Two week wait for all?
What works to shorten waits? <ul><li>Demand management at front end </li></ul><ul><li>Pool the queues at all stages </li><...
Outpatient waiting times 12 weeks 12 months Gastro Routine 2 weeks 2 weeks Gastro urgent 7 weeks 6 months Colorectal Routi...
Going further project plan <ul><li>Collate best known practice from CSCIP and specialists in the field </li></ul><ul><li>U...
CSCIP examples of best practice in shortening colorectal access times <ul><li>Streamline pathway – e.g. Blackpool, Mid-Ess...
Test site survey: Whittington Hospital July 2006 <ul><li>4 weeks data collection </li></ul><ul><li>What symptoms? </li></u...
Changes being introduced at test site <ul><li>Demand management work with primary care trust and GPs </li></ul><ul><li>Red...
Challenges <ul><li>Which patients would be better having a colonoscopy and which a flexible sigmoidoscopy as their first t...
?
Screening
Screening <ul><li>Tackling hidden waits </li></ul><ul><li>Fast tracking patients with a high risk of cancer </li></ul><ul>...
Bowel Cancer <ul><li>(2%) positive reading  T = 0 days </li></ul><ul><li>Nurse clinic < 1 week </li></ul><ul><li>Colonosco...
Cervical screening <ul><li>Invasive/Glandular cancer suspected on slide T=0 </li></ul><ul><li>Direct referral to colposcop...
Breast screening <ul><li>First report of abnormal mammogram T=0 </li></ul><ul><li>Assessment appointment 14-21days </li></...
Testing <ul><li>5 screening centres </li></ul><ul><li>It can be done </li></ul><ul><li>Need to clarify definitions  </li><...
Fast tracking patients <ul><li>Some feedback from national leads </li></ul><ul><li>Sheffield about to pilot some work with...
JCCO targets (1993) 28 days  -  D Post-operative  14 days  2 days  C Palliative  28 days  14 days  B Radical  48 h  24 h  ...
31 day target for subsequent treatments <ul><li>Surgery </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Radiotherapy </li...
The Sheffield experience <ul><li>Concerns that &quot;target-eligible&quot; patients fast-tracked at the expense of those w...
The Sheffield experience <ul><li>Since 1999  </li></ul><ul><ul><li>4 to 7 linear accelerators  </li></ul></ul><ul><ul><li>...
 
 
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  1. 1. Going Further on Cancer Waits Early learning/findings from the test sites Patricia Morris Associate Director 19/09/2006
  2. 2. Context Content: Progress to date - Early Learning Breast – Patricia Morris - Durham Stretching the goal – Patricia – Luton Bowel – Celia Ingram Clark – Whittington Other GFCW - David Levy
  3. 3. Starting point ……….. <ul><li>Test out ‘what’s possible’ to achieve </li></ul><ul><li>2 weeks for all breast patients 2 weeks for all bowel patients </li></ul><ul><li>3 sites </li></ul><ul><li>12 weeks initial testing </li></ul>
  4. 4. <ul><li>How the aims can be achieved by a rapid improvement event and ‘lean’ application to urology/ultrasound </li></ul><ul><li>Streamline processes and pathways to deliver max 18 weeks wait for all </li></ul><ul><li>Stretch the goals for cancer patients </li></ul>All tumors with emphasis on urology & Ultrasound The Luton & Dunstable Hospital NHS Trust <ul><li>Straight to test based on symptoms </li></ul><ul><li>One stop clinics </li></ul><ul><li>No routine follow up in bowel </li></ul>- To achieve a max 2ww for new patients referred with bowel symptoms by testing new operational models of services to test what’s possible Bowel The Whittington Hospital NHS Trust <ul><li>Process/capacity </li></ul><ul><li>Triage into structured clinic </li></ul><ul><li>Ultra sonographer led clinics for under 35 yrs </li></ul><ul><li>One route for all breast service patients </li></ul><ul><li>Compress targets for breast cancer patients to 52 days </li></ul>Breast County Durham & Darlington Acute Hospital NHS Trust Testing Aims Focus Test Site
  5. 5. What’s the scale of achieving 2 weeks for all…… <ul><li>Source: Luton data Feb – May 2006 </li></ul><ul><ul><ul><ul><ul><li>Referral routes for all patients with suspicion of cancer (regardless of route) recorded </li></ul></ul></ul></ul></ul>
  6. 6. Key Learning from County Durham……. To be seen quickly Value the expertise & Professionalism of team Each appointment kept to minimal delay Patient Perspective Extend roles /develop skills (fully supported) Second nurse practitioner required Training time for 2nd practitioner Nursing Perspective
  7. 7. Durham cont …… <ul><li>Willingness to extend US/mammo radiographers </li></ul><ul><li>Need to have > capacity to manage variation </li></ul><ul><li>Challenges – local aims to be met </li></ul>
  8. 8. Luton & Dunstable <ul><li>Learning </li></ul><ul><li>Takes senior leadership </li></ul><ul><li>Need to have the data </li></ul><ul><li>Need to involve all the team </li></ul><ul><li>Need to be clear about outcomes </li></ul><ul><li>It takes time ! </li></ul>Distilled Analysed Collected the data Ultrasound Urology Rapid Improvement Event 26/27/28 September Foundation for 18 weeks ‘ Stretching the goals A different approach
  9. 9. Luton & Dunstable cont … <ul><li>Outcomes from Rapid Improvement Event </li></ul><ul><li>To develop a manual data collection system to record clearly demand for ultrasound; this will transfer to the new system in November 2006 </li></ul><ul><li>To develop a scheduling system that maximises capacity of ultrasound staff and equipment </li></ul><ul><li>To review the flow of patients, information and staff in the ultrasound department and look for opportunities for improvement </li></ul><ul><li>To develop timed pathways for the “Green Stream” i.e. haematuria, urinary flow symptoms, testicular and prostate. </li></ul><ul><li>To review protocols for: </li></ul><ul><ul><li>Referral to ultrasound from outpatients </li></ul></ul><ul><ul><li>Urology patients </li></ul></ul>
  10. 10. Key learning from ‘best practice visits ’ <ul><li>Strong clinical leadership </li></ul><ul><li>Value and utilise team to full potential </li></ul><ul><li>Streamlined pathways </li></ul><ul><ul><li>Diagnostics </li></ul></ul><ul><ul><li>Follow-up </li></ul></ul><ul><li>Workforce development for all </li></ul><ul><li>Clear visual patient and information processes </li></ul>
  11. 11. Emerging Common Themes <ul><li>Understanding the data to realise the scale of the task </li></ul><ul><li>Apply solutions to meet local circumstances </li></ul><ul><li>One size will not fit all! </li></ul><ul><li>2 weeks for all will need ‘sign up’ from Royal Colleges </li></ul><ul><li>Workforce issues (eg Nurse Practitioner roles) are important </li></ul><ul><li>Service Improvement – back to basics approach is important </li></ul><ul><li>Clinical buy in is key </li></ul><ul><li>Primary Care is important to success </li></ul>
  12. 12. Thank you to ….. <ul><li>The clinical & managerial leads </li></ul><ul><li>The teams </li></ul><ul><li>The DH Policy Leads </li></ul><ul><li>We’ll continue with testing ! </li></ul>
  13. 13. NOW…… <ul><li>Celia & David! </li></ul>
  14. 14. Going Further on Bowel Cancer Waits Celia Ingham Clark Consultant surgeon, Whittington Hospital and NCL (colorectal) CSCIP
  15. 15. What are we trying to achieve? <ul><li>Patients with bowel cancer should get from referral to treatment as efficiently as possible </li></ul><ul><li>Patients with bowel symptoms who do not have cancer should get from referral to clear reassurance that they do not have cancer as efficiently as possible </li></ul><ul><li>Two week wait was designed to achieve this </li></ul>
  16. 16. Has the TWW system worked? <ul><li><20% of 2WW bowel patients have cancer </li></ul><ul><li><20% of bowel cancer patients come via 2WW route </li></ul><ul><li>Partly due to inappropriate use of 2WW </li></ul><ul><li>Partly because 2WW criteria not robust enough to identify all patients with bowel cancer </li></ul><ul><li>Partly due to emergency admissions (up to 25% of bowel cancers) </li></ul>
  17. 17. What are the numbers? <ul><li>For an average DGH per month - ~ 250 new colorectal referrals - ~ 200 new gastroenterology referrals - < 50 2WW referrals - ~ 12 new bowel cancers </li></ul>
  18. 19. What are the options to improve efficiency? <ul><li>Identify and prioritise patients at highest risk of having bowel cancer </li></ul><ul><li>Aim to get all referred patients through the pathway as quickly as possible </li></ul>
  19. 20. Prioritising high risk patients <ul><li>2WW </li></ul><ul><li>Cade patient questionnaire using Selva score - good discriminator but 70 factors </li></ul><ul><li>G-RAF neural network (Sheffield) </li></ul><ul><li>Screening with FOB </li></ul><ul><li>Consultant triage of letters </li></ul><ul><li>Consultant history-taking in OPD </li></ul>
  20. 21. A two tier service?
  21. 22. ?Two week wait for all?
  22. 23. What works to shorten waits? <ul><li>Demand management at front end </li></ul><ul><li>Pool the queues at all stages </li></ul><ul><li>Straight to test </li></ul><ul><li>Clear patient pathways </li></ul><ul><li>Reduce follow-ups </li></ul><ul><li>Match capacity to demand </li></ul>
  23. 24. Outpatient waiting times 12 weeks 12 months Gastro Routine 2 weeks 2 weeks Gastro urgent 7 weeks 6 months Colorectal Routine 2 weeks 2 weeks Colorectal urgent 2006 2002 Whittington Hospital
  24. 25. Going further project plan <ul><li>Collate best known practice from CSCIP and specialists in the field </li></ul><ul><li>Use test site to a) survey exact distribution of current outpatient colorectal practice and the work it generates b) test means of shortening waits using validated techniques </li></ul>
  25. 26. CSCIP examples of best practice in shortening colorectal access times <ul><li>Streamline pathway – e.g. Blackpool, Mid-Essex, Good Hope, Taunton </li></ul><ul><li>Nurse-led clinics – e.g. Homerton, Durham, Taunton, N and E Herts </li></ul><ul><li>Straight to test – e.g. Leicester, Nottingham, Gloucester </li></ul><ul><li>Pool the queues – e.g. Blackpool, Durham, Luton </li></ul>
  26. 27. Test site survey: Whittington Hospital July 2006 <ul><li>4 weeks data collection </li></ul><ul><li>What symptoms? </li></ul><ul><li>What referral route? </li></ul><ul><li>Who saw the patient? </li></ul><ul><li>What test requested? </li></ul><ul><li>Test result? </li></ul><ul><li>Patient outcome? </li></ul>
  27. 28. Changes being introduced at test site <ul><li>Demand management work with primary care trust and GPs </li></ul><ul><li>Reduction in follow-up - after tests - after first visits </li></ul><ul><li>Pool the queues </li></ul><ul><li>Straight to test </li></ul>
  28. 29. Challenges <ul><li>Which patients would be better having a colonoscopy and which a flexible sigmoidoscopy as their first test? </li></ul><ul><li>Can you decide this without a specialist taking the history? </li></ul><ul><li>If using straight to test for colonoscopy, how do you know who is fit enough for the procedure and how do you take informed consent? </li></ul>
  29. 30. ?
  30. 31. Screening
  31. 32. Screening <ul><li>Tackling hidden waits </li></ul><ul><li>Fast tracking patients with a high risk of cancer </li></ul><ul><li>Breast 12,000 cancer patients </li></ul><ul><li>Cervix 3,000 patients </li></ul><ul><li>Bowel 3,000 cancer patients </li></ul>
  32. 33. Bowel Cancer <ul><li>(2%) positive reading T = 0 days </li></ul><ul><li>Nurse clinic < 1 week </li></ul><ul><li>Colonoscopy < 2 weeks </li></ul><ul><li>Refer to MDT </li></ul><ul><li>Treatment </li></ul>
  33. 34. Cervical screening <ul><li>Invasive/Glandular cancer suspected on slide T=0 </li></ul><ul><li>Direct referral to colposcopy clinic </li></ul><ul><li>MDTM </li></ul><ul><li>Treatment </li></ul>
  34. 35. Breast screening <ul><li>First report of abnormal mammogram T=0 </li></ul><ul><li>Assessment appointment 14-21days </li></ul><ul><li>MDTM 28days </li></ul><ul><li>Treatment 42 days </li></ul>
  35. 36. Testing <ul><li>5 screening centres </li></ul><ul><li>It can be done </li></ul><ul><li>Need to clarify definitions </li></ul>
  36. 37. Fast tracking patients <ul><li>Some feedback from national leads </li></ul><ul><li>Sheffield about to pilot some work with clinicians </li></ul>
  37. 38. JCCO targets (1993) 28 days - D Post-operative 14 days 2 days C Palliative 28 days 14 days B Radical 48 h 24 h A Urgent Max. acceptable delay Good practice Waiting times for radiotherapy Patient group
  38. 39. 31 day target for subsequent treatments <ul><li>Surgery </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Radiotherapy </li></ul>
  39. 40. The Sheffield experience <ul><li>Concerns that &quot;target-eligible&quot; patients fast-tracked at the expense of those with greater clinical need. </li></ul><ul><li>Only way to address this concern, is to ensure that all patients are treated in a timely fashion </li></ul><ul><li>At Sheffield 90+% success rate of JCCO maximum targets for all radiotherapy patients. </li></ul><ul><li>A key to success has been visionary and sustained investment by commissioners and Trust </li></ul>
  40. 41. The Sheffield experience <ul><li>Since 1999 </li></ul><ul><ul><li>4 to 7 linear accelerators </li></ul></ul><ul><ul><li>0.5 to 1.5 CT simulators </li></ul></ul><ul><ul><li>2 expansions of our facility </li></ul></ul><ul><ul><li>installation of a MRI scanner </li></ul></ul><ul><li>BUT, no doubt that active service improvement programme has significantly contributed to success </li></ul>
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