Blueprint v1.0 Final 310316

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Mid Notts Cancer Programme – Redesign Service Blueprint Final 310316
Better Together Mid Nottinghamshire Cancer Programme
Blueprint
30th
March 2016

2
Foreword
“We have a bold vision for health and care services for the next five years, based on our
population needs and public and staff feedback about current services.
Whole system integration of hospital, community, social and primary care is central to the
vision because people tell us that services are currently too fragmented and difficult to
navigate. We are building on our model of proactive care, to move more people from a
reliance on reacting to their illnesses to one of where we can intervene earlier in their care.
This will eliminate some hospital admissions as a default for people who are not acutely
unwell but need help and support. Delays will be reduced significantly by changing the way
that people work in partnership on a day-to-day basis and by removing barriers to cross-
system working. Planned care will be delivered in a more effective and sustainable way,
reducing the complexity for professionals and patients, whilst reinvigorating working
relationships and dialogue between primary and secondary care clinicians. The impact will
be an improvement in the quality of care received and better outcomes for the patient,
overall an improved total patient experience.” 1
In 2014, Mid Nottinghamshire CCGs proposed the whole system transformation of health and social
care services to deliver proactive, patient centred care in order to secure sustainable services to
meet growing demand into the next decade. As part of the vision, it was anticipated that Cancer
would be included within the transformational programme, although the vision and evidence to
underpin the developments was just emerging at that point and required further development of
the vision.
Over the past 2 years, the Mid Nottinghamshire CCGs with key stakeholders including Sherwood
Forest Hospitals, Nottingham University Hospitals, Macmillan Cancer Support, patients and carers
have defined the vision and strategic plans for the transformation of Cancer Services across Mid
Nottinghamshire. The strategic plans were approved by both CCGs in March 2015, and the Mid Notts
Cancer programme was established as a component of the Elective Care Workstream within the
Better Together programme.
The models of care described in the Blueprint have been developed in partnership and alignment
across the system and agreed at the Mid Nottinghamshire Cancer Programme Steering Group and
shared with respective partners.
1
Mid Nottinghamshire CCGs Urgent Care and Proactive & Long Term Conditions Proposal 31st January 2014

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Executive Summary
“The health and social care system in the Mansfield, Ashfield, Newark and Sherwood area is facing
some very significant challenges. Namely, how does the system deliver care to the quality /
outcomes required within the limited (but still very substantial) funds available? The current models
of care are not delivering best health outcomes and are not affordable if scaled up to address the
anticipated growth in population demand.
Phase one developed a future blueprint for how the physical health and social care services should
look in 3 to 5 years’ time, driven by:
 A desire to deliver better health and social care outcomes for the population and an
improved experience of the services people receive; and
 Recognition that the way care is currently delivered is not sustainable for the expanding and
ageing population2
Diagram 1. Model to deliver Integrated Care
Key features of the interventions that made up the blueprint included:
 A proactive, co-ordinated multidisciplinary and properly resourced team based in the
community to help maintain wellbeing – particularly for frail and elderly people;
 Maintain personal independence and increase community care
 Support allowing people to return to their normal place of residence sooner and reduce the
risk of losing the ability, support structures and confidence to live independently;
2
A Blueprint for a safe and sustainable health and social care economy for Mid Nottinghamshire, ICTP, April
2013

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 Integrated urgent care services centred around the patient, with care professionals working
seamlessly between acute, primary, community and social care under a single structure;
 Care professionals able to access the right services at all times – with social, community and
primary care as accessible and responsive as A&E;
 Elective care focussed on those patients most likely to benefit from it, and provided where
there are enough patients to run a high quality, sustainable service; and
 Maternity and paediatric services that provide access to expert opinions earlier and only
admit where necessary.
When aggregated together, these interventions create a strategically different model of care, with a
greater proportion of care provided out of acute hospital settings, with care professionals working
across organisational and professional boundaries”3
.
The ICTP Blueprint provides the local strategic context for the development of the Mid
Nottinghamshire Cancer Programme and provides the framework, drivers and opportunities
required to support a transformational change in the way Cancer Services across Mid
Nottinghamshire are delivered and accessed, and the same values, attitudes and behaviours needed
to deliver sustainable services delivering person centred cancer care.
3
A Blueprint for a safe and sustainable health and social care economy for Mid Nottinghamshire, ICTP, April
2013

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Contents
Page
1. Strategic Case for Change of Cancer Services 6
2. Cancer Programme Priorities 8
2.1. Earlier Diagnosis 9
2.2. Review and redesign of Common Cancer Pathways 16
2.3. Living with Cancer 25
2.4. Emergency Care, including Late Presentation through Accident and
Emergency
32
2.5 Workforce Review 36
2.6. IM+T 37
2.7. Communications and Engagement 39
2.8 Programme Team Resource Requirements 40
Appendix 1.

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1. Strategic Case for Change of Cancer Services
1.1. Incidence and prevalence
As people are living longer, treatments improve and people are diagnosed earlier, the incidence of
cancer across England and Mid Nottinghamshire is increasing at more than 3.8% per annum4
. Earlier
diagnosis and improvements in treatment are demonstrated as survival rates at 1, 5 and 10 years are
increasing. This good news does mean, however, that prevalence set to double from 2010 levels by
20305
placing a significant burden on existing models of care.
The increase in prevalence of all cancers and increased complexity of needs of those living longer
with their cancer, has produced a significant and sustained increase in demand on secondary care
services, which is not sustainable for health services, nor meeting the needs of patients.
While overall, cancer outcomes are improving, for most cancers, outcomes for some cancers across
Mid Notts remain worse than the England average and that of the Area Team.
1.2. Earlier Diagnosis- increase in demand and costs
While more people are living longer and survival rates are improving, England has some of the
poorest survival rates for cancer in the world. Screening Programmes, Be Clear on Cancer
Campaigns and Cancer Waiting times all contribute to improving cancer survival rates at 1 year. In
2015, NICE reviewed and revised guidance for suspected Cancer. The revised guidelines make
recommendation for a lower threshold for investigations of concerning symptoms and anticipate
and increase in demand for key diagnostics. It is anticipated that the increased demand will increase
costs nationally by between £18 -£36m and referrals for some tumour sites to increase by 15% over
and above the existing annual growth in referrals for 2ww (currently between 10%-18% in Mid
Nottinghamshire).
The cost benefits of earlier diagnosis, over late diagnosis at stage 4, are described in Appendix 2 Cost
Comparisons
The Mid Nottinghamshire Cancer Programme proposes the development of new models and
pathways for earlier diagnosis, with an increased role for primary care services in pre-diagnostic
testing, Direct to Test (DTT) diagnostics and safety netting of patients.
1.3. Outcomes and Expenditure across existing cancer pathways (excluding diagnostic
pathways)
In May 2014, Greater East Midlands Commissioning Support Unit (GEM CSU) presented the findings
of the commissioned ‘Cancer Deep Dive’ to Mid Nottinghamshire Health community. The report and
presentation confirmed that across Mid Nottinghamshire, cancer outcomes and spend when
compared against comparator CCGs, demonstrated potential opportunity to improve cancer
4
Cancer Research UK (2015)
5
Macmillan Cancer Support (2015)

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outcomes and release resources from secondary care. While the report defined particular
interventions, it also confirmed, with further discussion during the presentation, the added benefit
of commissioning across ‘whole pathways of care’ with specific focus on primary prevention, early
detection, improved cancer treatments, survivorship pathways and end of life care.
The report defined key tumour site outliers, for outcomes and spends, by CCG, in particular but not
exclusively, lung, breast, prostate and Lower Gastro-Intestinal across Mid Nottinghamshire. The
findings were further substantiated by the RightCare Commissioning for Value Packs presented to
the CCGs during 2014, identifying that Lung Breast and colorectal cancers are outliers for quality and
expenditure, when compared to comparator CCGs. In addition, the Deep Dive report identified that
further development of the pathways can improve the survival rates at 5 years for prostate cancer.
During 2015, the Independent Cancer Taskforce, commissioned by the Department of Health,
published its Cancer Strategy for England6
. The strategy made numerous recommendations to CCGs,
providers and NHS England on the actions required to deliver sustainable services and improve the
outcomes for cancer patients. The recommendations, which reflected those described within the
NCSI report7
published in 2013, are mandated through the Planning Guidance for 16/17 with aims
defined to be achieved by 2020.
The NCSI Report suggests resources tied up in secondary care follow-up, are estimated to be £1554
per patient over 5 years (excluding inpatient costs). For low and medium risk patients, the use of
follow up can be reduced, by unlocking of this resource and redirecting it to support self-
management interventions, care planning and coordinated care. A study in Manchester suggests
that once inpatient, outpatient and emergency costs are considered, it should be possible to unlock
savings of £1,000 per patient through a stratified approach to follow-up, pathway;
“Current face-to-face out-patient follow up is not meeting patients’ needs, isn’t good value for
money, and won’t cope with increasing numbers. Routine follow up appointments are not effective
in terms of detection of recurrence. In practice the large majority of recurrences are detected either
by patients themselves or on investigations which can be planned without a patient having to attend
a clinic.” “Models of aftercare support for the majority of cancer survivors are generic with other
long-term conditions. In some areas, specialist cancer specific services and programmes are
needed.”
(NCSI 2013).
1.4. Patient Experience
The National Cancer Patient Experience Surveys (NCPES) findings from 2010 onwards for NUH and
SFHFT, supported by local patient, carer and public engagement, identifies that while some aspects
of patient care are improving, less than 28% patients received a written care plan during their
treatment or follow up, less than 60% reported having insufficient information about what to expect
6
Achieving World Class Cancer Outcomes: A Strategy for England 2015
7
NCSI 2013: Living with and Beyond Cancer – Taking Action to Improve Outcomes’

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or where to get support following discharge, and over 30% reported they received inadequate
support from Practice staff with their condition.
Local stakeholder events underpinning the programme of integration of services for Long Term
Conditions (LTCs) across Newark and Sherwood during the past 2 years clearly articulated the case
for change; a move towards integrated patient centred services that proactively support self-
management, access to timely information and support, care coordination and shared decision
making.
1.5. Sustainable Services
Traditional models of care are under increasing pressure and will not be sustainable in the near
future. As people live longer, more are experiencing the consequences and late effects of cancer and
its treatment, with many people experiencing complex health and social care needs that are not
currently systematically addressed by existing services.
Current service models require a transformational approach to delivery of sustainable cancer
services, with a focus on primary prevention, delivery of earlier diagnosis with a stronger role for
Primary Care, delivery of evidence based reviewed and risk stratified pathways with information
sharing across Primary and Secondary Care to provide coordinated and proactive care.
Improvements in both quality and cost effectiveness are aimed at all people with cancer, with 5 key
tumour sites specifically targeted that account for more than 54% of all cancers. There is increasing
evidence that improved outcomes and cost effectiveness can be achieved specifically for Lung,
Prostate, Lower Gastro Intestinal, Upper Gastro Intestinal and Breast Cancer pathways. Targeting
these tumour sites will improve outcomes for patients and release investment in secondary care to
support development in community and primary care services.
2. Cancer Programme Priorities
The Blueprint proposes new models of care from diagnosis through to follow-up and aftercare for
cancer patients, underpinned by on-going care coordination across the patient pathway. The
developments will support delivery of improved cancer outcomes at years 1, 5 and 10 years, as
earlier diagnosis pathways and implementation of the EMSCN approved pathways and follow-up
arrangements are embedded and full benefits realised.
Interventions will support the delivery of proactive planned care for patients, reducing avoidable
planned and unplanned activity, improved patient experience and outcomes, and support the
effective use of resources in the right place at the right time first time.
The proposals place an increased role for Primary Care in the diagnosis and coordination of care of
patients from their first contact, diagnosis, through to follow-up, and aftercare; Community and Self
Care Services will provide supportive services for patients across the pathway, determined by

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regular holistic assessment and care planning of patients’ needs to meet the on-going unmet needs
through the cancer pathways.
2.1. Earlier Diagnosis
Delivering services that diagnose more patients at an earlier stage of their cancer (i.e. more
at stages 1+2, rather than later at stages 3+4) is central to improving patient outcomes and
reducing the rate of increased expenditure of cancer services.
Late presentation to services is a poor prognostic indicator, and therefore service
developments are aimed at reducing late presentation through a range of interventions:
2.1.1. Two Week Wait Referral Pathways.
Approximately 28% of all cancers are diagnosed through the 2ww pathway8
. The number of 2ww
referrals to SFHFT for suspected cancer have continued to increase by more than 10% between
2013/14 and 2014/15, while NUH has seen referrals increase by 18%9
(See Appendix 1)
While referral rates are increasing, the proportion of positive cancer diagnoses (Conversion Rates)
for all cancers remains about the same at about 8%, reflecting the increased incidence of cancer in
the population:
Table 2. SFHFT 2WW and Conversion rates by Tumour site
The Planning Guidance for 2016/17 mandates delivery of the 28 day to diagnosis standard to be
delivered by 2020. In addition, the NICE Guidance for Suspected Cancer released in 2015 reduced
the threshold for investigation for suspected cancer, with anticipated increase in referrals for key
tumour sites in addition to the existing 10-18% annual increase in total 2ww referrals:
It is anticipated that referrals in the following tumour groups will increase by
 Lower GI 5-15%
8
NCIN: Routes to Diagnosis (Mar 2014 vb)
9
Increased referral rates on 2ww pathways are in line with national findings

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 Urology 5-10%
 Lung 10-15%
Lower GI, Urology and Lung cancer are three of the four top cancers, they account for 38% of all
cancers diagnosed in Mid Nottinghamshire and approximately 46% of all 2ww referrals.
During 2014/15 there were approximately 26,000 2ww referrals to NUH and SFHFT.
Nationally, the NICE Costing Report10
suggests that implementation of the Guidelines will cost the
NHS between £17.8 and £36.3m to implement. Costs are derived from additional FOPA and
increased demand on Diagnostics.
Table 3. Anticipated 2WW referral rates for NUH and SFHFT
2ww referrals to NUH and SFHFT 2014/15 and estimated 2015/16
NUH SFHFT Combin
ed
Expected
growth @
10%
+ NICE
Guidelines
Expected
growth @
18%
+ NICE
Guidelines
All
referral
s
15,428 10,730 26,158 28,774 - 34,406 -
Lower
GI
1,496 1,744 3,240 3,564 @ 15% 4,099 3,823 4,399
Urology 1,961 1,350 3,311 3,642 @ 10% 4,006 4,298 4,728
Lung 892 521 1,413 1,554 @ 15% 1,787 1,834 2,109
The guidelines assume
 Greater focus on pre-diagnostic work up of patients with low risk but not no risk symptoms
 Increased Primary Care access to direct diagnostic tests:
o Lung CT
o Abdominal CT
o MRI Head
o Non-obstetric Ultrasound scan
o Colonoscopy/ Flexi Sigmoidoscopy and OGD
The Achieving World Class Cancer Outcomes: A Strategy for England describes the need to;
 Move towards diagnosis within 28 days. (by 2020)
 Commission direct access diagnostics for Primary Care.
The Cancer Programme will work with local, regional and national colleagues where they exist, to
undertake the modelling required determining the impact on diagnostic services and capacity and
informing the development of new service models to support delivery of the 28 days to diagnosis
standard, with an initial focus on Urology, Lung and Lower GI symptoms. The developments will be
aligned to the emerging Primary Care Model and Diagnostic Workstream.
10
NICE (2014): Costing Report to support NICE Clinical Guideline on Suspected Cancer

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Table 4. Cost Impact of increased 2WW referrals on FOPA only.
(Effect of annual increase and NICE guidance)
Cost Impact of 2ww referrals only FOPA to "WF01B First Attendance - Single Professional" 2015/16
Combined
NUH and
SFHFT
referrals
Expected
growth @
10%pa
+ NICE
Guidelines
Cost
Increase for
total activity
growth
£s
Expected
growth @
18%pa
+ NICE
Guidelines
Cost
increase for
total activity
growth
£s
All
referrals
26,158 28,774 - - 34,406 - -
Lower GI 3,240 3,564 @ 15%
4,099
154,620 3,823 4,399 208,620
Urology 3,311 3,642 @ 10%
4,006
91,045 4,298 4,728 185,627
Lung 1,413 1,554 @ 15%
1,787
67,320 1,834 2,109 125,280
Total 313,260 519,527
(Assume tariff: Gastroenterology 301 @ £180, Urology – 101 @ £131, Respiratory 340 @ £180).
The Earlier Diagnosis Workstream has identified and agreed a number of developments to address
the challenges identified above and below in the tables shown.
Currently, approx. 28%11
patients are diagnosed through the 2ww pathway, with increasing numbers
diagnosed late through Emergency Routes including 23% through A+E. Presentation at A+E with
undiagnosed cancer is an indicator of late diagnosis, poor prognosis and low survival rates at 1 year.
Many patients who present at A+E with undiagnosed cancer have a history of vague but concerning
symptoms that may not have triggered a 2ww referral for further investigation.
2.1.2. Review of existing 2ww processes
The Clinical Reference Group (CRG) membership (Site Specific Leads) will review the site specific
templates, proforma and protocols against the NICE Guidance (2015) to ensure that they reflect
current guidance and best practice. The group will also explore the possibility of including site
specific pre-diagnostic tests that can be undertaken in Primary Care to support expedition of the
pathways and early exclusion from the pathways.
2.1.3. Increased access to Direct Access diagnostic testing
The CRG will review the existing access and make recommendation for further direct access
diagnostics for Primary Care to support the delivery of 2ww and towards 28 days to diagnosis.
11
National Cancer Intelligence Network: Routes to Diagnosis (2006-10)v2b 2014

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2.1.4. Vague and Concerning Symptoms – The Third Pathway
During the summer of 2015, Vedsted and Olesen12
published their findings of developing a ‘Three
Legged Pathway’ to support Primary Care in the earlier diagnosis of cancer in Denmark, with a
particular focus on vague symptoms. Their findings have gained significant interest nationally and
locally the Cancer Programme has developed a draft ‘Third Pathway and model’ to test across Mid
Notts for 3 groups of symptoms – Lower GI, Lung and Vague Symptoms.
It is important to note that these groups of symptoms are vague in nature are not ‘red-flag’ and
therefore do not meet the 2ww referral criteria, but do require further investigation. The
development of a Third Pathway to enable further investigation may be beneficial for this group of
patients in diagnosing cancer earlier and also, reducing avoidable referral onto 2ww or late
presentation to A+E.
The Pathway is timed and aims to support Specialist teams to review and potentially confirm a
diagnosis within the proposed 28 days, based on the findings of the Danish model.
 Day 1 – 4: patient attends GP. Pre-diagnostic work-up and GP review of results.
 Day 4 – 12: Direct to test diagnostics. Results reviewed by GP if inconclusive or
non/malignant. Potential development for Diagnosticians to escalate to Specialist MDT /
Consultant upgrade if results suggestive of malignancy.
Screening patients through pre- diagnostics and direct to test diagnostic investigation may
potentially reduce demand on the existing 2ww referrals and FOPA, through increased routine and
tumour marking testing and increased Direct to Test CT, Endoscopy and MRI. The potential for a
One-Stop Shop for diagnostics will be explored to ensure appropriate testing.
The proposed model for Mid Nottinghamshire is described below. The testing of the model has been
be developed in partnership across Primary and Secondary Care colleagues and has been shared
with the EMSCN to secure a grant to support the development of testing the model, alongside other
sites in the East Midlands. Currently there is no proven approach or model nationally to support
local developments. The national ACE Earlier Diagnosis Pilot Programme is yet to publish findings
from Phase 1.
12
Vedsted and Olesen, A differentiated approach to referrals from general practice to support early cancer
diagnosis – the Danish three-legged strategy (2015)

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Diagram 5. Draft Mid Notts. Early Diagnosis Pathway for Vague and Concerning Symptoms
To maximise cost efficiency, it may be necessary to consider unbundling of diagnostic procedures to
support increased Primary Care investigations and diagnostics.
2ww referral YES
NO
YES
PRIMARY CARE RESPONSIBILITY
2ww referral YES
SECONDARY CARE RESPONSIBILITY
NO
Clear 'Red flag' symptoms or signs
History & Examination
MID-NOTTS PROPROSED EARL DIAGNOSIS PATHWAY
GP review Alternate diagnosis / watchful
wait / refer for further
investigations or speciality
(Fast-track)
(Consultant upgrade)
As agreed with Trust based on local priorities & agreed protocols for pathway selection
YES
Malignancy
YES
NO
Referral back to GP with summary
of investigations, advice & guidance
NO
GP reviewAbnormal results
NO
Clear evidence of specific tumour site
NO
Alternate diagnosis
YES GP review
Abnormal results
Patientpresentswith vague or non-specificsymptoms.Eg:-
- Nonspecificabdominalpain
- Unexplainedweightloss
- Tiredness
- Appetite loss
- UnexplainedDVT
- GP gut feeling/concernedaboutunderlyingmalignancy
- Bloodtestanomalies –unexplainedhyponatraemia,raisedplatelets,
highESR, abnormal LFTs,unexplainedhypercalcaemia
- Run Cancer RiskAssessmente.g.QRisk/eCDS
Primary Investigations:
- Bloods
- Urinalysis
- CXR
- Abdominal USS
- Tumour markers? PSA/ CA125/ CA19-9
(Investigation sets to be agreed with secondary-
care)
Lung Pathway
- Direct access
Lung CT
GI Pathway
- Direct access CT
Abdomen
- OGD +/- Colonoscopy
MDC
(Vague sxs
Pathway)

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The model will be further developed and tested in Mid Notts in the context of the emerging Primary
Care Model and Diagnostic Work-streams.
2.1.5. Primary Care Screening for Familial Breast Cancer
The FaHRAS Genetic Breast Cancer Risk Screening Tool is an evidence based tool aimed at
determining the risk of familial breast cancer and enable preventative measures to be considered by
the patient and consultant. The tool is currently used within secondary and will be tested and rolled
out in Primary Care to reduce avoidable referral to hospital, increase detection of familial breast
cancer in the local population and improve 1 year survival rates.
The FaHRAS team suggest that successful implementation of the tool may potentially lead to further
innovations in Primary care for familial colorectal cancer in the near future.
2.1.6. Improved pick up of the Cancer Screening Programmes for Breast Bowel and Cervical
Cancers.
Working with the PHE Screening Programmes, the Cancer programme is exploring the opportunities
to improve pick up of the existing screening programmes, which are shown to increase identification
of pre-cancerous changes and early diagnosis of cancers, improving cancer outcomes and reducing
demand on complex treatment and follow-up resources.
2.1.7. Earlier Diagnosis Outcomes
Development and implementation of the Earlier Diagnosis pathways aims to deliver both quality and
financial benefits;
a. Quality
 Improve the 1 year survival rates for all cancers
 Reduce late presentation of cancer including through A+E of key cancers through
increased rates of earlier diagnosis. (Domain 1 Population Health – reduction in U75
mortality from Cancer).
 Support the delivery of the CWT standards with particular reference to the 2ww and 62
day standards.
 Support the delivery of 28 days to diagnosis standard by 2020.
 Reduce avoidable demand on diagnostics and secondary care capacity through the
robust delivery of pre-diagnostic screening and Direct to Test diagnostics, led by Primary
Care.
 Improve the experience of care people receive (Domain 3 – Quality of Care – improved
access to timely and responsive services
 Improve the Effectiveness of Care (Domain 4 – Services are effective and reduce the
need for readmissions)

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b. Finance
Referral rates are increasing at a significant rate (10-18% pa). The implementation of the NICE
guidelines is likely to increase referral rates by more than 30%pa for some tumour sites. (See Table 4
above).
The development of revised Earlier Diagnosis pathways will
 Reduce the rate of demand on secondary care FOPAs for 2ww
 Improve access to Primary Care pre-diagnostic investigation and potential to screen out
non cancer earlier in the pathway
 Improve access to Primary Care Diagnostics in:
o Lung CT
o Abdominal CT
o Flexi sigmoidoscopy / OGD
o Head MRI
o Non-obstetric Ultrasound Scan (USS)
Further detailed work up is needed to understand the impact of the NICE Guidelines for Suspected
Cancer (2015) including
 Increased demand on Diagnostics – pathology, endoscopy and radiology13
 Impact of screening patients in Primary Care (Routine and tumour marker blood testing)
 Access to and maximising capacity of Primary Care and ‘other providers’ of USS, CT and
endoscopy in particular.
Delivery of the Earlier Diagnosis work-stream for Cancer will contribute to Better Together Financial
Outcomes:
 Objective 1: 15.1% reduction in ED attendances
 Objective 2: 19.5% reduction in ED Admissions
 Objective 3: 30.5% reduction in Acute bed days
Improving the numbers of patients diagnosed at stages 1+2 cancer will reduce treatment costs along
the pathway, as more patients will be treated with curative intent.
Fewer patients will be diagnosed with advanced disease requiring complex treatment plans and
associated health consequences of treatment.
Implementation of the FaHRAS Breast Screening Tool:
Initial roll out of the tool will incur no cost to the CCGs. At the end of the roll out timeframe, costs
will be incurred for risk analysis licences which will be offset against the projected savings achieved
through reduced referrals to secondary care:
 Costing (100% uptake):
 Current cost of Primary Care Referral: £218.40
13
NICE Costing Report to support NICE Clinical Guideline for Suspected Cancer (2015)

16
 Estimated number of Annual Referrals: 182
 Annual Referral Cost: £39802.88
 Cost of Risk Analysis: £95
 Annual Risk Analysis Cost: £17313.52
 Savings (100% uptake):
 FaHRAS Referral Rate: 25%
 Saved referrals: 136
 Annual Referral Savings: £29767.59
 Net Annual Referral Savings: £12454.07
Net Annual Referral Savings: £12,454.07
c. Risks and Constraints
 Significant pressures currently exist within the current 62 day pathways at both NUH
and SFHFT – changes to the diagnostic pathways may create a ‘surge’ in demand that
could negatively impact on the 62 day CWT standards.
 Both Trusts have developed and implemented 62 day Recovery plans. Potential
reduction in referrals through the 2ww and demand on avoidable diagnostics through
increased pre-diagnostics and Primary care DTT for Lung CT, OGD and Flexi
sigmoidoscopy in particular, may support delivery of the 62 day recovery plans.
 Guidelines suggest increased demand of diagnostics and additional capacity will be
needed and procured. Initial pilot of the pathway and review of existing evidence will
inform capacity requirements. National and regional scoping of existing diagnostic
capacity suggests insufficient capacity, in particular, radiology.
 Close monitoring of the pathway and referral patterns will be essential to avoid
negative impact on delivery of the 62 day pathway.
 Capacity within Primary Care to deliver increased pre-diagnostic work-up and ‘safety
netting’ of patients (i.e. monitoring the patients pathway through initial screening
and on referral to the Multi-Disciplinary Diagnostic Centre (MDC)
 The development of the Model, and demand on diagnostics will also be in
consideration of the wider RTT pathways, also under significant pressure at both
SFHFT and NUH.
 Potential to review / innovate shared models of care and support with emerging
community / Primary Care teams.
 Potential need to unbundle tariff for some diagnostics to avoid double payments of
DTT and pre-diagnostic work up in Primary Care.
 Potential need to work with surrounding health communities to maximise potential
diagnostic capacity
 Impact of the changes to the Primary Care workload and skills base. Need to review
the existing skills and capacity with recommendation for skills development needed
in Primary Care within the emerging Primary Care model

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2.2. Review and redesign of Common Cancer Pathways
Traditional cancer pathways and models of follow-up have remained largely unchanged over the
past 40 years. The incidence and prevalence of cancer and the needs of cancer patients have
considerably changed as described above and existing models are no longer the most clinically or
cost effective.
Diagram 7 Median Cancer Survival Times14
Since the early 1970s the demand on cancer services has continued to increase, and it is expected
that by 2020, 50% people living with cancer will survive for more than 10 years, many with more
complex needs due to the consequences and late effects of cancer and treatment.
In response to increasing demand, growing evidence base and need for sustainable services, Cancer
pathways from the point of diagnosis have been under increasing review and scrutiny through
 National Cancer Survivorship Initiative (2013)
 Cancer Deep Dive (Mid Notts 2014)
 RightCare Commissioning for Value (2014)
 EM Strategic Clinical Network Expert Clinical Advisory Groups (On-going)
With recommendations made for CCGs to
 Implement High Value Population Pathways (as approved by the EMSCN, e.g. Prostate and
Upper Gastro Intestinal pathways) Including 62 day treatment pathways and surveillance
protocols
 Review and redesign common cancer pathways and introduce stratified follow-up ( as
approved by the local network)
14
Macmillan Cancer Support (2011)

18
 Review and redesign existing defined tumour site pathways to reduce variations in clinical
and cost effectiveness, e.g. move to day care, ambulatory care and OPA interventions where
clinically appropriate to do so.
 Redirect cost efficiencies to deliver community based services to support people living with
cancer (including community based surveillance, monitoring and support for unmet needs)
 Development of Self Care Services to support cancer patients to maximise and maintain
optimum levels of health and wellness
 Implementation of the NICE Guidelines for follow- up (e.g. Nurse Led Follow-up for Lung
Cancer)
The reports collectively suggest that review and redesign of cancer pathways will support improved
patient outcomes and reduction in geographical variations for patients with Lower Gastrointestinal,
Prostate, Upper Gastro Intestinal and Lung cancers and support greater cost efficiencies.
2.2.1. Review and redesign of pathways to reduce variation in cost and outcomes
Diagrams 10 and 11 are excerpts from the M+A and N+S Deep Dive ‘Opportunities Table’ which the
authors suggest should be investigated further locally to identify further cost benefits.
Many of the figures appear to be aggregated across the whole tumour specific pathway and require
deeper understanding of the scale of opportunities that can be realised. The Pathways workstream
will undertake a review of the data and make recommendations to the Mid Notts Cancer
Programme Steering Group.
The RightCare Commissioning for Value Packs focus on the variations in Breast, Upper GI and Lower
GI and recommend further investigation.
a. Risks and Dependencies
 The defined assumptions need to be tested locally and financial impact assessed.
 Base-lining of the existing pathways has started and further work is needed over the
coming weeks
 Agreement across Secondary and Tertiary Services of the current EMSCN approved /
developing pathways. (Challenge exists re shared care FU protocols for Breast and
prostate cancer )
 Capacity within the system to deliver concurrent / subsequent pathway redesign and
impact of other developments within the programme e.g. Earlier Diagnosis
 NUH has progressed some risk stratified pathways ahead of SFHFT creating potential
inequity. SFHFT and DFT to agree to adopt EMSCN pathways (e.g. prostate)Alignment
with other programmes of work within the Cancer Programme, e.g. Pathways review in
response to the Commissioning for Value Packs15
and Cancer Deep Dive.
15
Commissioning for Value – Pathways on a Page NHSE, RightCare PHE. 2014 (N+S and M+A)

19
Diagram 10 Mansfield and Ashfield Deep Dive Opportunities excerpt.
Diagram 11 Newark and Sherwood Deep Dive Opportunities excerpt
Further detailed scoping of individual pathways is needed and locally interpreted to confirm the
ambitious cost savings and outcomes described for the CCGs to achieve the minimum benefits of the
comparator groups.
Pathway Step/
Cancer Type
Indicators in the bottom quintile (ranked <=20) in the benchmark cluster group
CCG value against benchmark group average value shown in brackets
Opportunity if CCG
were to equal the
benchmark cluster
group average
Cancer incidence: Female (PCT) (409.4 per 100,000, 376.7 per 100,000) 51 fewer cancers
Patients diagnosed with cancer in last 18 months with patient review within 6 months (CCG) (89.71%, 92.8%) 19 more reviewed
Cancer secondary care spend per 1000 population (CCG) (£39,030 per 1000, £30,344 per 1000) £1686618 reduction
Cancer secondary care admissions per 1000 population (CCG) (27 per 1000, 21.4 per 1000) 1071 fewer admissions
Cancer secondary care admissions Mean LOS (CCG) (7 per 1000, 6.2 per 1000) 1439 fewer bed days
Cancer Inpatient spend per 1000 population (CCG) (£15,139 per 1000, £12,851 per 1000) £445123 reduction
Cancer Inpatient admissions per 1000 population (CCG) (5.2 per 1000, 4.6 per 1000) 121 fewer admissions
Cancer Inpatient admissions Mean LOS (CCG) (4.3 per 1000, 4 per 1000) 382 fewer bed days
Cancer Daycase spend per 1000 population (CCG) (£10,501 per 1000, £8,531 per 1000) £381528 reduction
Cancer Daycase admissions per 1000 population (CCG) (18.1 per 1000, 14.3 per 1000) 739 fewer admissions
Cancer Emergency spend per 1000 population (CCG) (£11,251 per 1000, £8,352 per 1000) £562814 reduction
Cancer Emergency admissions per 1000 population (CCG) (3.2 per 1000, 2.4 per 1000) 150 fewer admissions
Breast cancer incidence: Female (PCT) (143.5 per 100,000, 119.5 per 100,000) 38 fewer cancers
Mortality Breast: Female (PCT) (31.4 per 100,000, 24.72 per 100,000) 10 fewer deaths
Cancer Inpatient spend - Lung per 1000 population (CCG) (£1,665 per 1000, £525 per 1000) £225236 reduction
Cancer Daycase spend - Lung per 1000 population (CCG) (£516 per 1000, £301 per 1000) £42494 reduction
Colorectal cancer incidence: Male (PCT) (68.8 per 100,000, 58.4 per 100,000) 16 fewer cancers
Colorectal cancer incidence: Female (PCT) (45.3 per 100,000, 33.9 per 100,000) 18 fewer cancers
Cancer Inpatient spend - Upper GI per 1000 population (CCG) (£1,232 per 1000, £855 per 1000) £74199 reduction
Cancer Emergency spend - Upper GI per 1000 population (CCG) (£1,599 per 1000, £1,143 per 1000) £88905 reduction
Cancer Inpatient spend - Lower GI per 1000 population (CCG) (£2,807 per 1000, £2,208 per 1000) £117287 reduction
SHMI: Colorectal (CCG) (149.6 obs:exp ratio, 109.6 obs:exp ratio) 8 fewer deaths
Prostate cancer incidence: Male (PCT) (118.3 per 100,000, 94.4 per 100,000) 37 fewer cancers
Mortality Prostate: Male (PCT) (28.8 per 100,000, 24.1 per 100,000) 7 fewer deaths
Prostate survival 5yr Male (PCT) (64.9%, 76.6%) 65 fewer deaths
All Cancers
Breast and Cervical Cancer
Lung Cancer
Colorectal Cancer
Prostate Cancer
Pathway Step/
Cancer Type
Indicators in the bottom quintile (ranked <=20) in the benchmark cluster group
CCG value against benchmark group average value shown in brackets
Opportunity if CCG
were to equal the
benchmark cluster
group average
Cancer incidence: Female (PCT) (409.4 per 100,000, 376.7 per 100,000) 35 fewer cancers
Patients diagnosed with cancer in last 18 months with patient review within 6 months (CCG) (89.78%, 93.4%)16 more reviewed
Two-week referrals with cancer (% of all TWW referrals with cancer) (CCG) (9.2%, 11.7%) 448 more diagnosed
Cancer secondary care spend per 1000 population (CCG) (£33,237 per 1000, £30,150 per 1000)£446529 reduction
Cancer secondary care admissions per 1000 population (CCG) (24.2 per 1000, 22 per 1000) 315 fewer admissions
Breast cancer incidence: Female (PCT) (143.5 per 100,000, 119.5 per 100,000) 26 fewer cancers
Mortality Breast: Female (PCT) (31.4 per 100,000, 24.72 per 100,000) 7 fewer deaths
Cancer Inpatient spend - Lung per 1000 population (CCG) (£771 per 1000, £476 per 1000) £44126 reduction
Cancer Daycase spend - Lung per 1000 population (CCG) (£323 per 1000, £239 per 1000) £12544 reduction
Colorectal cancer incidence: Male (PCT) (68.8 per 100,000, 58.4 per 100,000) 11 fewer cancers
Colorectal cancer incidence: Female (PCT) (45.3 per 100,000, 33.9 per 100,000) 12 fewer cancers
Cancer Inpatient spend - Lower GI per 1000 population (CCG) (£2,625 per 1000, £2,270 per 1000)£52634 reduction
Prostate cancer incidence: Male (PCT) (118.3 per 100,000, 94.4 per 100,000) 26 fewer cancers
Mortality Prostate: Male (PCT) (28.8 per 100,000, 24.1 per 100,000) 5 fewer deaths
Prostate survival 5yr Male (PCT) (64.9%, 76.6%) 65 fewer deaths
All Cancers
Breast and
Cervical Cancer
Lung Cancer
Colorectal
Cancer
Prostate Cancer

20
The East Midlands Strategic Clinical Network has developed and approved the costed pathway for
Upper Gastro Intestinal Cancer. The pathway aims to reduce inequality of cancer care across the East
Midlands.
b. Quality
 Improved cancer outcomes for patients in Mid Nottinghamshire, to the comparator
group average
 Reduce avoidable admission to hospital
 Reduce avoidable unplanned care
 Domain 2 – Quality of Life Indicators, Improved quality of Care – closer to home,
good experience of care;
 Domain 3 Quality of Care Improved effectiveness of care – responsive to changing
patient needs – Domain 4 Effectiveness of care
c. Activity and Finance
 Cost efficiencies as defined within the Opportunities Tables (excerpts above)
Total cost benefits for Mid Notts £324,400 – £491,842 (requires further investigation and evidence)
2.2.2. Risk stratification of cancer pathways
Cancer follow up pathways will be delivered based on the patients assessed clinical needs, choices
and ability to manage their cancer and related conditions
Diagram 7. NCSI Risk Stratified Model of Cancer Care (2013)
Risk stratified pathways will provide individualised packages of care based on regular assessment
and review of patient clinical and holistic needs:

21
 Self-Care and open access. Patients are assessed as on a ‘curative intent pathway’ and are
assessed as suitable for on-going surveillance of their condition in line with NICE Guidelines
(or regionally agreed protocols), with additional support to self-care.
 Shared Care Protocols. Patients are assessed as requiring on-going surveillance that can be
provided through Primary Care, with on-going support and advice from the specialists on a
less frequent basis.
 Specialist Led Follow up. These patients may continue to have active or advanced disease,
but not at end of life. Their needs may be highly complex, requiring on-going specialist
surveillance or intervention. While support from Primary Care and Community services for
this group of patients may be essential, clinical responsibility remains with the Oncologist or
other consultant leading the patients care.
Diagram 8 below is the NCSI Breast Risk Stratified Pathway. It is a representative pathway for risk
stratification for all common cancers with minor amendments needed to reflect the specific needs of
patients with particular tumour types.
The NICE Proven case studies support the work of the NCSI and suggests that risk stratification of key
cancer pathways, delivering ‘tailor made’ follow-up based on assessed patient need will improve
outcomes for patients and release resources from secondary care, while improving productivity.
Released resources will be available to reinvest in community and primary care services, and those
supporting Self-Care.
a. Stratification and Quality
Risk stratification, supported by the delivery of the Recovery Package (see Living with Cancer below)
and support from Primary and Community Care aims to provide improved patient outcomes and
experience of care. A system wide transformational approach is essential to support the redesign of
cancer pathways.
Implementation of Risk stratified pathways aims to;
 Deliver tailor made follow-up based on their needs and preferences – Domain 1
Population Health – People are able to stay physically and mentally well, Domain 2
Quality of Life - People can remain independent, with or without support, and are
able to manage the risks associated with this, people are able to have choice and
control over their condition and the services they receive, people can manage their
condition and/or frailty to prevent complications. Domain 3 Quality of Care – people
have access to timely and responsive services. People who use services have a good
experience of care.

22
Diagram 8.

23
 With the recovery package, deliver proactive tailor made follow up and proactive
assessment and care planning, promote health and wellness through support to self-
care and rapid access in the event of recurrence or late effects.
b. Stratification and Finance
Table 9 below describes the potential financial and productivity benefits of stratifying key tumour
sites, described in the NICE Quality and Productivity Proven Case Study for Risk Stratification of
Cancer Pathways16
and applied to local cancer incidence.
Table 9. Financial and Productivity Benefits of Risk Stratification
NB. The majority of lung patients are assessed as needing palliative or end of life care. However,
increasing numbers of patients are living longer with lung cancer and not assessed as at need of End
of Life care and may benefit from additional support not traditionally provided by community
services.
16
NICE Quality and Productivity Proven Case Study, Stratified Cancer Pathways; Redesigning Services for those
living with and beyond cancer. NHS Improving Quality 2013

24
The modelling for Mid Notts to achieve maximum financial benefit makes several assumptions:
 The existing cancer pathways through SFHFT are comparable with those used elsewhere,
nationally
 Local pathways are based on NICE guidance and no local / regional pathways are in
place.
 Local patient staging and grading profile is comparable to the areas included within the
studies and that similar levels of risk stratification are achievable.
 Costs are based on the OPPROC tariff identified (Not described in the NICE paper).
Contributing to the Better Together Objective 3: 30.5% reduction in acute bed days.
c. Benefits Realisation
Nationally, risk stratification of pathways takes between 18- 36 months. EMSCN has approved a
number of pathways for local implementation and base-lining of existing pathways has been
undertaken at SFHFT and NUH.
The Cancer Programme reviewed the local and national evidence and recommend review and
redesign of the following pathways
 Breast
 Lung
 Prostate
 Lower Gastro Intestinal
 Upper Gastro Intestinal
From the point of diagnosis through to follow-up and aftercare to ensure the optimum clinical and
cost effectiveness as compared to comparator CCGs.
The Programme Steering Group has agreed the priorities as
1. Prostate Cancer
2. Lung Cancer
3. Breast
4. Lower and Upper Gastrointestinal
Prostate and Lung Cancer review is underway and redesign will commence within 2016/17. It is
anticipated may take 2 years or more for full implementation of revised pathways and maximum
benefits to be realised. Discussions are underway with SFHFT and NUH to agree the timelines and for
review and redesign of the 3 remaining pathways. Base lining against 62 day pathways has been
undertaken.
The existing pathways span 2 or 3 secondary care providers including NUH, SFHFT and DFT. The work
of the Pathways workstream will link with and build on the existing work-plans developed across the
Network to maximise benefits realisation and reduce avoidable variation in pathway delivery

25
models. NUH and SFHFT have established the Cancer Clinical Partnership Board, which will be the
vehicle to drive many of the changes required across the local network.
The diagram below represents the new generic cancer pathway demonstrating regular points for
holistic assessment and care planning, MDT review and stratified follow-up that will inform the
development of primary and community care based support services.
d. Benefits realisation
Nationally, risk stratification of pathways takes between 18- 36 months. Across Mid Notts,
significant work has started to risk stratify existing pathways, particularly at NUH.
Key pathways for risk stratification will include:
 Breast
 Prostate
 Colorectal
 ?Gynaecology – endometrial Cancer
Timelines for delivery of Benefits will be dependent on the review of each of the pathways, and
system capacity to delivery concurrent pathways developments.
e. Risks and Dependencies for combined pathways redesign
 The defined assumptions need to be tested locally and financial impact assessed.
 Base-lining of the existing pathways needed to confirm patient flow, and existing
models of care.
 Agreement across Secondary and Tertiary Services of the current EMSCN approved /
developing pathways. (Challenge exists re shared care FU protocols for Breast cancer)
 Capacity within the system to deliver concurrent / subsequent pathway redesign and
impact of other developments within the programme e.g. Earlier Diagnosis
 NUH has progressed some risk stratified pathways ahead of SFHFT creating potential
inequity. SFHFT to agree to adopt EMSCN pathways (e.g. Gynaecology pathway for
endometrial cancer, not included in above financial modelling).
Alignment with other programmes of work within the Cancer Programme, e.g. Pathways review in
response to the Commissioning for Value Packs17
and Cancer Deep Dive.
2.3. Living with Cancer
The 2016/17 Planning Guidance, recommends stratifying Cancer follow-up for the common cancers
by 2020 to enable the resources to be reinvested into services that support people to ‘live well’ after
cancer.
17
Commissioning for Value
– Pathways on a Page NHSE, RightCare PHE. 2014 (N+S and M+A)

26
Patients consistently report more than 5 unmet needs at the end of treatment: A person with a
cancer diagnosis is twice as likely as the wider population to use A&E services, 30% more likely to
see their GP and report poorer quality of life than the wider population. 49% people with a cancer
diagnosis also have at least one other long term condition, and unplanned use of services increases
as patients have more LTCs.
Diagram 9. Unmet needs of Patients living with Cancer18
Stratification of pathways alone will not deliver the improvements to sustainability, capacity or
patient outcomes without the implementation of the ‘Recovery Package’, with access to information
and support services for on-going health and social care needs of patients.
Comprehensive Holistic Needs Assessment, care planning and care coordination are essential to
supporting patients to maximise their health and wellness, reduce risk of recurrence and improve
their quality of life.
Care and support is needed into the long term as more patients live longer following cancer and
experience late effects, consequences and recurrence of their disease. Increasingly being considered
as a long term condition, proactive care planning and assessment can help cancer patients
understand how to reduce risk of these events, manage symptoms effectively, access the right help
when needed and reduce avoidable unplanned care activity, while improving patient experience and
outcomes.
Self-Care is central to supporting people living with Cancer, enabling people to make the life style
choices that are best for them and their life and is a central theme of the Living with Cancer work-
stream.
18
Macmillan Cancer Support (2011) Health and Wellbeing Survey

27
The Living with Cancer work-stream will
 Develop pathways that provide integrated and holistic care for people living with and
beyond their cancer diagnosis, providing support for cancer as a Long Term Condition.
 Deliver services that are coordinated, proactive and based on individual assessed needs and
preferences, underpinned by shared decision making and empowerment.
 Implement interventions of the interventions of recovery package across the cancer
pathways
o Holistic Needs Assessment
o Treatment Summary
o Cancer Care Review
o Health & Wellbeing Event
 Ensure that assessments, care plans and treatment summaries are shared across providers
to support on-going proactive patient centred care through community and primary care.
 Promote and actively support the development of Flo applications that support patients
across pathways (in particular, consider prompts for appointments, psychological
interventions, self-care prompts, etc).
 Develop and coordinate services which work collaboratively to support the patient across
the pathway.
 Ensure that self-care and shared decision-making underpin the delivery of cancer care.
 Establish access to comprehensive training and development as part of initial workforce
training as well as continuing professional development.
 Support patients and their carers to access information, support and learning to empower
them through their cancer journey and beyond.
Living with Cancer workstream developments assumes:
 Regular holistic needs assessment and care planning at key points along the pathway
 Care coordination for patients and carers
 Regular information sharing between primary and community care services to support
proactive care
 Access to a range of therapies and support services to support patients’ preparation for or
recovery from cancer and its treatments. (e.g. Rehabilitation services, continence,
psychological support, information and support).
 Risk stratification of follow-up arrangements based on clinical needs and patient preferences
 Most patients complete treatment with on-going needs requiring coordinated care and rapid
access to secondary care in the event of recurrence, acute oncological complications
metastatic disease.
Active promotion and delivery of support to Self- Care to maximise health and wellness and reduce
the risk of disease recurrence.
The NCSI19
makes recommendation to introduce systematic assessment and care planning across
secondary and Primary Care (Recovery Package) with a strong focus on coordinated care and
support to self-manage, funded by the resources locked in secondary care and re-invested in
19
NCSI Living with and Beyond Cancer – Taking Action to Improve Outcomes 2013

28
community, primary and self-care services to enable to proactive care planning, improved patient
experience and outcomes, and reduction in avoidable unplanned care activity.
2.3.1. Recovery Package20
The Recovery Package is a series of interventions aimed at improving the outcomes and coordination
of care for people living beyond their cancer diagnosis. During 2015/16 Mid Nottinghamshire CCGs
commissioned SFHFT to deliver Holistic Needs Assessments, care plans and Treatment summaries (at
the end of each definitive treatment), with a full roll out plan across all tumour sites to be agreed by
the end of 2015/16.
Diagram 10. The Recovery Package Model
During 2016/17, the Workstream will work to further embed the components of the recovery
package building on the progress to date, to deliver comprehensive assessment and care planning
pathways from the point of diagnosis through treatment to aftercare.
NUH and SFHFT are working in partnership to coordinate the approach to HNAs and care plans. In
addition, both Trusts are working with Macmillan Cancer Support to test and roll out electronic
HNAs and care plans to support ease of use and time effectiveness for both patients and carers and
staff. The e-HNA pilot is expected to launch during the summer of 2016.
A Cancer Care Review, (CCR) conducted by the patient’s GP is a key intervention within the Recovery
Package and is currently incentivised through QOF. Further development is needed to ensure that
20
NCSI Living with and Beyond Cancer – Taking Action to Improve Outcomes 2013 – Recovery Package

29
the CCR meets the patients proactive care needs and is included within the emerging Primary Care
Model as part of the Long Term Conditions workstream.
“The ‘recovery package’ is potentially the most important building block for achieving good
outcomes. Providers and commissioners who wish to achieve good patient outcomes will want to
implement these measures. These interventions can deliver immediate benefits to patients, as well
as supporting improvements in care further down the survivorship pathway. Re-allocate any cost
efficiencies, achieved through follow-up, to other areas of the survivorship pathway, such as
assessment and care planning, or community support.” NCSI 2013
a. Quality
Implementation of the Recovery package ensures that patients are offered a Holistic Needs
Assessment and Care plan, at key points along their pathway that is based on shared decision
making and shared with Primary Care to support continuity and coordinated care. It ensures that the
GP is aware of the patient’s needs and wishes relating to their holistic needs, and provides the
patient and carer with the information they need to support them to meet their needs.
The Recovery Package aims to support delivery of each of the 4 domains of the Outcomes
Framework:
 Domain 1 Population Health: Ensuring patients and carers know how to access
services in the event of recurrence or new symptoms, and what to do to maintain
personal health and wellness.
 Domain 2 Quality of Life: People are able to have choice and control over their
condition and services they receive.
 Domain 3 Quality of Care: People have access to timely and responsive services
 Domain 4 Effectiveness of Services: Services are effective and reduce the need for
readmission.
b. Activity and Finance
 Holistic Needs Assessment and Care planning are existing components of community
and Self Care Services. The Living with Cancer Workstream is working to align the
recovery package into existing care planning systems and processes where possible.
Treatment Summaries will be included within the Pathways redesign through
Secondary Care, while Cancer Care Reviews will be included within Primary Care
Model negotiations.
 Delivery of the Health and Well-being Events is included within the Self-Care Hub
Service Specification, with specialist support to be negotiated within the redesigned
cancer follow-ups pathway design.

30
Holistic Needs Assessments, Care planning and Treatment Summaries have been delivered at SFHFT
for defined tumour sites through a CQUIN during 2016/7, and work is underway to explore the
potential use of HNA and Care planning in Primary Care.
Good progress has been made in embedding the practice, and the Living with Cancer Workstream
will build further on the foundations through their workstreams.
The Cancer Care Review is being offered at a number of Practices by GPs and Practice Nurses, and
further work is needed within the context of the Primary Care Developments to embed Cancer care
and coordination as if another Long Term Condition. Proactive Care Planning and coordination of
patients with Cancer is subject to the Primary Care Development Plan that describes the aims and
objectives of cancer care in Primary Care and the support required to deliver those aims.
d. Risks and dependencies
 Appointment of the M+A PCCL and Macmillan GPs to support Primary Care Clinical
Engagement to support the Cancer Programme as a whole, and Primary Care Cancer
care in particular.
 Self-Care Hub – development of the Cancer Self Care Pathways that meet the needs
of people affected by cancer
 Development, approval and delivery of the Primary Care Development Plan to
support Primary Care cancer care and management consistently across the patch
 Primary Care capacity to deliver the Recovery Package and other elements of the
Cancer Programme – workforce review to take into account role of Primary Care and
the changing context of Primary Care delivery.
 Timely progression of the Pathways review and risk stratification to support the
patient flow.
 Workforce Review to be undertaken to determine the skills and workforce
requirements to support the Cancer Programme Redesign and Primary Care Model.
 IT Interoperability – the impact of the Recovery Package is maximised when shared
between providers. IT systems across the Health and Social Care Community need
to be able to communicate in order to share data and information.
2.3.2. Support to Self-Care.
The Self Care Hub, commissioned through the Better Together Proactive and Urgent work-stream is
testing the model for self-care with Cancer and Diabetes during 2015-17. Evidence from the NCSI
suggests that patient and carer outcomes are improved when they have access to self-care
resources and interventions. The Mid Notts Cancer Self Care pathway21
is an integral element of the
cancer pathways for all cancer patients and their carers.
21
Pathway developed, based on the Mid Notts. Self Care Strategy and NCSI Generic Cancer Pathways (2013)

31
Where cancer specific interventions are needed, the service is working closely with the Macmillan
Information and Support Services at Kings Treatment Centre and other Macmillan Projects in place
across Mid Nottinghamshire, with a view to maximising utilisation and monitoring of unmet needs.
Through the Macmillan Cancer Partnership (Nottinghamshire) partners are working together to
develop a range of comprehensive services to support people with cancer at no additional set –up
cost to the CCGs. Interventions include but not limited to:
 Self Help and Support Groups
 Volunteer schemes to provide emotional, practical and social support
 Education and information resources – physical and on-line
 Development of protocols for FLO for cancer patients
 Health and wellness information and activities.
 Peer to peer support
 HOPE programme (cancer specific programme based on an Expert Patient Programme)
Unmet needs will be collated through the Self Care Hub for regular reporting to the CCG.
a. Quality, Activity and Finance and KPIs
The Quality, Activity and Finance and KPIs for the Self Care Hub are monitored through the contract
and will not report to the Cancer Programme to avoid double counting. Progress updates, risks and
milestones will continue to be reported to the Steering Group
The cancer self-care pathways will contribute to the overall KPIs for the Hub, the KPIs for which are
included within the Service Specification.
The Living with Cancer Workstream has defined the expected outcomes from the Workstream, in
addition to those defined for the Self Care Hub and in the process of determining the KPIs to
measure the impact of the Cancer pathways.
The Pathways Workstream has agreed that Prostate and Lung pathways will be reviewed during
2016/17 with the potential for Breast to be included in the same year. It is anticipated that 100%
newly diagnosed patients (2015/16 2332 new patients) will be signposted to the Self-Care Hub, with
a proportion of those referred for needs based intervention or support. (To be determined through
the HNAs and Care planning outputs delivered by the existing and then redesigned cancer
workforce).
2.3.3. Primary and Community workforce development
Delivery of the Transformational Cancer Services is dependent on a suitably skilled,
knowledgeable and placed workforce. The emergent workstreams identify a series of
interventions that require skills in secondary, primary, community and voluntary services - a

32
significant shift from current models of care provision requiring a behavioural and cultural
shift for professionals and patients.
The programme has commissioned a Workforce Review across the system that will inform
the workforce requirements to deliver the aims and outcomes of the Cancer Programme.
Further details are described in section 2.6 below.
Diagram 11. Mid Notts Cancer Self-Care Pathway
2.4. Emergency Care, including Late Presentation through Accident and Emergency
Patients with cancer attend A+E for several reasons related to their cancer:
 Late presentation with significant symptoms, to later be diagnosed with cancer.
 Presentation with Acute Oncological emergencies requiring urgent intervention including
MSCC and neutropaenic sepsis
 Management of symptoms as a consequence of cancer or its treatment.
The interaction of the interventions described in this paper aims to contribute to the reduction in
avoidable A+E attendances. While it is essential that people with oncological emergency do access

33
care to meet their needs, it is clear that for many patients, A+E is inappropriate for their presenting
needs.
Acute Oncology Services (AOS) were established at NUH and SFHFT during 2012/13, following the
publication of the National Chemotherapy Advisory Group22
recommendations for every emergency
department to have AOS to improve the outcomes for cancer patients in A+E. The development of
the Acute Oncology Teams at both NUH and SFHFT aim to ensure that patients with a cancer
diagnosis are seen by a cancer specialist and receive appropriate care within defined parameters.
AOS services are non-commissioned. The service models at SFHFT and NUH differ in scale and skill
mix. Notably, oncology support is provided by NUH to SFHFT on a sessional basis. (SFHFT as a cancer
unit does not have resident oncology). The Acute Oncology service at NUH has recently expanded as
part of the Admissions Avoidance Scheme at City Campus. Charts 14 and 15 demonstrate the trends
for emergency cancer admissions at both trusts;
Chart 14 NUH Cancer Admissions
22
National Chemotherapy Advisory Group: Chemotherapy Services in England- Ensuring quality and safety.
(2009).

34
Chart 15 SFHFT Cancer Admissions
The reasons for the variation between the two trusts needs further exploration and understanding
to ensure equity of services for patients attending either hospital and related support, e.g. access to
AOS advice and support, triage, information and education to the wider community and primary
care services.
The Cancer Clinical Partnership Board between NUH and SFHFT was established to address the
Oncology provision issues between the two Trusts and are actively addressing the issues of equitable
Oncology Service provision including for AOS. The Cancer Programme Clinical Lead attends the
meeting on behalf of the programme, and the Partnership Board reports minutes to the Cancer
Programme Steering Group.
The impact of Acute Oncology Service Improvement and the development of the Earlier Diagnosis
pathways and model are the interventions that will deliver improvements to the Cancer Emergency
Admissions rates for both CCGs.
At this point, the Programme has integrated emergency care into existing workstreams and will
monitor emergency care rates at the Steering Group. However, should the Emergency Admissions
rates continue to diverge, the Programme will review the need for a separate Emergency Care
workstream.
2.4.1. Emergency Care Outcomes
a. Quality
The Cancer Programme aims to improve the quality of life, quality of care and effectiveness of care
as:
 People are able to have choice and control over their condition and the services they
receive
 Users are safeguarded against unintended or potential harms
 People have access to timely and responsive services

35
 People who use services have a good experience of care
 Services are effective and reduce the need for readmissions
Review of current Emergency Presentations of the 5 key tumour sites suggests that both CCGs A+E
activity is currently over the SARS of 100 and that potential savings are possible from current activity
(see diagrams 16 and 17 below):
The key areas for improvement to support the Emergency care pathways include
 Lung Cancer, suggesting the need for earlier diagnosis, proactive management and rapid
referral to specialist palliative care services.
 LGI, suggests the need for earlier diagnosis and improved pick up of Bowel screening.
The Cancer Deep Dive suggests between 150 -218 less admissions are possible for all cancers, (M+A
only) saving between £562,814 and £773,889. This may suggest that people with ‘other’ cancers
account for more than 2/3 of all admissions and needs further investigation.
Further investigation of the potential reductions in A+E admissions will be undertaken through the
workstream.
Development of the Earlier Diagnosis workstream and Acute Oncology Service improvements will
deliver improvements in the SARS rates for cancer admissions. Review of the variation between
SFHFT and NUH readmission rates is underway currently and reporting due before the end of March
2016 which will inform the development of action plans aimed at providing equitable service
delivery and improvement in SARS at both sites.
d. Risks and Dependencies
 Capacity within the system to effectively impact on earlier diagnosis in particular for Lung
and GI cancers. ( in particular, CT and endoscopy)
 Further detail is needed to understand the 2/3 of patients admitted with ‘other cancers’
 Capacity for NUH to provide SFHFT with consistent Oncology cover to support the service
delivery of AOS services and support roll out to community and primary care services.

36
Diagram 16. Cost benefit if Mid Notts achieves A+E SAR of 100 Diagram 17 - Cost benefit if Mid Notts achieves A+E SAR of 90
Financial Benefit of achiving SAR's of 100 for each Cancer diagnosis and each CCG
Emergency Admissions July 2014 to June 2015
Mansfield & Ashfield CCG
Cancer Diagnosis
Spells
Expected
Spells
SAR
Reduction in
Spells to achive
SAR of 100
Av cost of
Spell
Cost Saving if
SAR of 100
achieved
Breast 9 22 40.6 0 £2,575 £0
Lung 105 64 164.1 41 £2,705 £110,905
Prostate 19 19 101.6 0 £4,005 £0
Upper GI and HpB 40 36 111.6 4 £3,126 £12,504
Lower GI 62 63 99.1 0 £6,709 £0
Total 45 £123,409
Newark and Sherwood CCG
Cancer Diagnosis
Spells
Expected
Spells
SAR
Reduction in
Spells to achive
SAR of 100
Av cost of
Spell
Cost Saving if
Sar of 100
achieved
Breast 6 16 38.3 0 £2,575 £0
Lung 38 48 79.4 0 £2,705 £0
Prostate 9 14 62.4 0 £4,005 £0
Upper GI and HpB 25 36 69.4 0 £3,126 £0
Lower GI 59 49 121.1 10 £6,709 £67,090
Total 10 £67,090
Mid Notts Total
Cost saving SAR of 100 £190,499

37
2.5. Cancer Workforce Review
The Transformation of Cancer Services, and delivery of new ways of working across the system to
deliver coordinated and integrated care pathways, requires a significant shift in skills, knowledge and
behaviours.
Key changes to service delivery include:
 Increased role for Primary Care teams in delivery of Earlier Diagnosis of Cancer and safety
netting of patients undergoing pre-diagnostic investigation and Direct to Test Diagnostics.
 Primary /Community care delivery of some diagnostic tests and investigations to support
earlier diagnosis (e.g. USS, endoscopy within the context of wider diagnostic workstream)
 Increased role of specialist cancer teams in Secondary Care to deliver on-going assessment
and care planning at key points along the pathway
 Delivery of coordinated care from the point of diagnosis with access to specialist support at
all points along the pathway, including supporting health and wellbeing events as part of
stratified follow-up pathways
 Increased role in Primary / Community services to deliver on-going surveillance as defined
within tumour site specific follow-up protocols ( e.g., community based Prostate Monitoring
Services)
 Development of cancer capacity within community services will provide ongoing opportunity
for further cancer service improvements to be delivered in the community that are currently
secondary care based e.g. Delivery of oral chemotherapy and IV treatments in the patients
home
 Development of Acute Oncology outreach services as part of on-going service improvements
at both SFHFT and NUH
The Cancer Programme has reviewed the scope of the transformational changes and commissioned
an external Organisational Development expert to deliver a workforce review across the Cancer
pathways. The review will align with the Primary Care workforce planning and is being planned in
partnership with SFHFT, HP, and other partners.
The transformational change to the cancer pathways will require a significant culture shift across the
system. The review will consider the outcomes of the programme and make recommendation for
the skills and learning required to ensure delivery of the system wide outcomes and benefits
including sustainable and integrated services.
The system wide Cancer workforce review will be designed by the Cancer Programme Steering
Group membership in partnership with Macmillan Cancer Support. The Partnership Agreement
between the Mid Notts CCGs and Macmillan has secured a series of grants that were reviewed and
as part of the process, it was agreed that the existing grants will contribute to the review costs. The
Cancer workforce review will be undertaken in the context of the wider Primary Care Workforce

38
review that is currently being considered and planned. Recommendations will be prepared by the
Cancer programme for consideration by the Elective Care Steering Group and respective CCGs.
2.6.1. Primary Care Development Plan for Cancer
In recognition of the increased role and demands for Primary Care within the Cancer Pathways, the
Cancer programme has drafted a Primary Care Development Plan that details the key deliverables
and outcomes needed from Primary Care to support the transformation of Cancer Services.
The Plan describes the impact and demands on Primary Care in addition to the resources required to
support Primary care in their delivery.
The Cancer Programme recognises the development of Primary Care that is now underway, and
plans are in place to support the development of the Primary Care Model and the Primary Care
Cancer Plans in tandem.
Both CCGs have committed to invest in Primary Care Cancer Lead roles to support the Cancer
Programme development and delivery. Macmillan Cancer Support has also invested in supporting
the role of Macmillan GPs (completed funding in Newark and Sherwood, now picked up by the CCG)
and outline agreement to secure funding for 2 Macmillan GPs in Mansfield and Ashfield (2 x sessions
per week for 2 years) to support Primary Care.
The Programme is currently developing a Primary Care Development Plan to detail the interventions
and developments needed within Primary Care to support delivery of an integrated care model for
cancer across Secondary, Primary and Community Services. The strategy is being consulted upon
currently, and will be aligned to / informed by the emerging Primary Care Strategies for Mid
Nottinghamshire CCGs. As part of the on-going partnership with Macmillan Cancer Support, a grant
will be available to support the Primary Care Developments in the context of the wider Primary Care
Strategy and Model Development.
a. Quality
Implementation of the Primary Care Engagement and Development Plan aims to support delivery of:
 Population health – Domain 1, fewer people will die prematurely and more will be
able to stay well
 Quality of Life – Domain 2 – more people will report an improved quality of life, and
have choice and control over their condition and the services they receive.
 Quality of Care – Domain 3 – people have access to timely and responsive services
 Effectiveness of Care – Domain 4 – services are effective and reduce the need for
readmission.
Review of the workforce aims to ensure that patients are supported in the right place at the right
time, and will reduce demand for avoidable care activity.
KPIs will be revised in line with the Pathways Work-stream Developments and will include:

39
 Avoidable unplanned primary care activity
 Avoidable unplanned secondary care activity
 Reduced length of stay.
The workforce review is expected to start in the spring of 2016. The review process will be on-going
and initial timelines will be agreed over the coming weeks once the scale and scope of the review is
agreed.
d. Risks and Dependencies
 Availability of the required skills and expertise to be recruited to safely deliver the
service
 Timely progress with review and risk stratification of key tumour pathways
 Robustness of the underlying data to support the system benefits.
2.6. IM+T Solutions for the Cancer Programme
Data management and information sharing across the system is managed through the Better
Together Programme. The IM+T and Cancer workstreams are aligned to ensure coordination of
developments and solutions and identify issues and solutions that may fall outside of the remit of
the BT IM+T workstream.
The Cancer Programme has identified a number of tools to support the transformation of Cancer
Services to date:
 e-CDS – Integrated Cancer tool. Currently free to Practices to use and maintained within
SystmOne. Currently delayed to resolve compatibility issues with SystmOne. If unable to
resolve there are potentially a range of other tools that can be trialled.
 FaHRAS assessment tool – currently non-integrated tool, but plans to integrate to SystmOne
in the medium term. Local testing has been completed -No current issues. Free during roll
out period. Costs included above with net savings for this discrete project.
 Data sharing across Primary /Secondary Care interface – mainly being resolved through
existing IM+T work-plans. Cancer Specific issues being identified through the work-streams
and will be addressed by provider IT services or escalated through the programme.
2.7. Communications and Engagement
The Mid Nottinghamshire Cancer Programme has developed its visions and plans through a
comprehensive communications and engagement plan aimed at supporting all stakeholders,
partners and members of the public to be informed, engaged and involved in shaping and defining
the programmes aims, objectives and deliverables.
The Programme is a key work-stream within two change Programmes:

40
1. Better Together Mid Nottinghamshire Transformation
2. Macmillan Cancer Partnership (Nottinghamshire)
The development and delivery of the Cancer Programme Communications and engagement plans
are coordinated with those of the two Change programmes to ensure maximum coverage and
impact across Mid Nottinghamshire and the wider Cancer network of Nottinghamshire.
The Cancer Programme is included within the existing Better Together Communications and
Engagement plans, with support accessed from CCG communications and engagement teams when
needed. Macmillan Cancer Partnership events are funded through the existing grants attached to
the Partnership agreements in place with Mid Notts CCGs.
The development of the Patient Reference Group is currently using underspent funds from the 3Cs
Group through Mansfield and Ashfield CCG.
2.8. Cancer Programme Team Resource Requirements
The Cancer Programme is expected to complete delivery of key outcomes in 2018/19.
Significant costs associated with the programme have been funded through the Partnership with
Macmillan Cancer Support as detailed below.
Existing posts grants expire as detailed in the table 18 below and will require pick up funding from
the CCG to secure the future delivery of the programme.

41
Table 18 – Programme Costs
Post Sessions /
WTE
Costs (including
on costs) per
annum
Funding Source Funding period Pick up costs Pick up
month and
year
Recurrent
Costs
Programme
Clinical Lead /
N+S PCCL
1 session
per week
£200 per session N+S CCG
programme costs
On-going for length
of Programme
- - -
Primary Care
Cancer Lead
1 Session
per week
TBA M+A CCG
Primary Care
Initially for 1 year
and review for
continuation
- - -
Programme
Manager Band 8a
(from the end of
secondment)
1.0 wte Circa £52,000 +
travel
Macmillan Cancer
Support
Secondment ends
June 2016.
Circa
£48,000 +
travel
June 2016 £52,000 for 2
¾ years
Service
Development
Manager Band 7
1.0 wte Circa £45,000 +
travel
Newark and
Sherwood CCG
2 Years to May
2017
Circa
£45,000 +
travel
June 2017 £45,000pa for
1 ¾ years
Service
Development
Manager Band 7
0.8 wte Circa £36,000 +
travel
Macmillan Cancer
Support
3 years to
December 2018
- - -
Macmillan GPs x
2
2 per
week x 2
= 4
sessions
£83,000 +travel Newark and
Sherwood CCG
(from Sept 15/
Jan 16)
On-going for length
of programme
(following 2 years
funding by
Macmillan)
- - -
Macmillan GPs x
2
2 per
week x 2
= 4
sessions
£83,000 +travel Macmillan Cancer
Support
2 years from
recruitment?
March 2016.
Circa
£62,000
March 2018 -

42
Appendix 1
2WW Referrals to SFHFT 2014/15
2WW Referrals to NUH 2014/15

43
Appendix 2 Earlier Diagnosis v Late Diagnostics Cost comparison

Blueprint v1.0 Final 310316

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