Awareness & Early Diagnosis Clinical Advisory Group (CAG) FINAL MEETING Output from Workshop Discussions on Implementing the Cancer Strategy.

1. FINAL AEDI CAG
12/07/17
Programme Overview
By Dr Tina George
Clinical Lead for Cancer, Horsham and Mid Sussex CCG
Clinical Network Lead for Awareness & Earlier Diagnosis (South East)

2. Projects & Work Streams
 The AEDI Dashboard
 Emergency Presentation Audits
 Primary Care Education
 Supporting roll-out of NG12
 Raising Awareness of Cancer in Schools
 Promoting the ACE programme
 Hosting and supporting CRUK Facilitators

3. The AEDI Dashboard
The Challenge
CCGs requested easily accessible data that would allow them
to benchmark their performance against comparator CCGs and
identify variation in order to support robust planning.
Commissioned, designed, updated and maintained the
AEDI dashboard for 3 years
The Intervention

4. The AEDI Dashboard
Outcome
 A bespoke AEDI Dashboard for CCGs, updated quarterly and
accessible on the CN website was developed with the support
of the Quality Observatory.
 The dashboard brings together a number of awareness and
early diagnosis measures on one page at both CCG & GP
practice level. A variety of AEDI-related measures are included
(including CCGOIS measures)
 Allows GPs to review numbers of 2 week wait referrals &
conversions, trends in emergency admissions and screening
uptake and coverage rates

5. Red Sky Practice

7. 2ww referrals per 100, 000 population Q4 16/17

8. The AEDI Dashboard
Going forward…
The South Region have asked the Quality Observatory to
produce a new Cancer Alliance Dashboard

9. Emergency Presentations Audit
The Challenge
 Three CCGs in Sussex (Hasting & Rother, Eastbourne,
Hailsham & Seaford and Coastal West Sussex) were
identified as having high emergency presentation and
emergency admission rates
 These CCGs agreed to participate in an incentivised
Primary Care Emergency Presentations Audit
 A 2nd audit was undertaken in ASPH & North West Surrey
CCG (2017) to explore the interface between Primary &
Secondary Care

10. The Intervention
 The CN supported CCGs In undertaking the audits by;
• creating the audit proposal,
• incentivising the audits,
• designing the proformas based on RCGP templates &
• supporting analysis of the results
 CCG and CN level reports
produced, containing analysis
of the results & learning

11.  A total of 199 individual patient cases were audited.
 The audit results were discussed within each practice and
changes in practice were identified.
Outcomes
 The CN submitted an abstract
for a poster presentation of the
results at the CRUK Biennial
Early Diagnosis Conference
(2017) which was accepted!

12. Emergency Presentations Audit
Going forward…
 Results of the audit at ASPH and North West Surrey CCG to be
presented here today
 The national focus on emergency presentations continues
(recommendation 25: all GPs should be required to undertake
a Significant Event Analysis for any patient diagnosed with
cancer as a result of an emergency admission)

14. Primary Care Education
The Challenge
 90% of patient interactions with the NHS are in Primary Care
 The vast majority of patients diagnosed with cancer are
symptomatic and most will present to Primary Care
The Intervention
 Funding offered to each CCG for high-quality GP education
 Facilitated & co-ordinated educational events with GP update

15. Outcomes
 The courses were very well attended and highly valued
“As usual with GP Update, it [the course] was excellent, relevant,
evidence based and practical”
“The course was well planned and delivered. The whole course
was outstanding”
Feedback Surrey
Content 3.8
Relevance 3.9
Presentation 3.7
Quality of handbook 3.9
Recommend the course 100%
(1 is poor, 4 is excellent)

16. Roll-out of NG12
The Challenge
 NG12 was published in June
2015 with many changes to the
criteria for suspected cancer
referrals
 National proformas were
anticipated but not delivered

17. The Intervention
 Designed new template referral
proformas based on NG12 with
robust primary care engagement
 Produced a supporting guidance
document with
recommendations for appropriate
governance routes.
Roll-out of NG12

18. SUSSEX SUSPECTED CANCER REFERRAL FORM
UROLOGY
Trust Name Method of Referral Telephone/email
Conquest Hospital Hastings Fax: 01323 438157 01424 757060
Eastbourne DGH Fax: 01323 438156 01323 414941
Brighton and Sussex University
Hospitals NHS Trust
e-mail:
FirstContact.Cancer@bsuh.nhs.uk
Queen Victoria Hospital, East
Grinstead
Fax: 01342 414114
Western Sussex Hospitals NHS
Foundation Trust
e-mail: cancer.appointments@nhs.net 01903 205111 x 84997
Patient Demographics
Surname: First Name: Title:
DOB: NHS Number: Gender:
Ethnicity: Language: BMI:
Patient Address: Postcode:
Tel: Home: Mobile: Email:
GP Practice Details
Usual GP Name:
Practice Name:
Practice Address: Practice Code:
Telephone: Fax: Email:
Referring Clinician: Date
Supporting Patient Information
History of cognitive impairment (e.g. dementia/learning disability/etc): Y N
Please give details:
History of sensory impairment (e.g. deafness/visual impairment/etc): Y N
Please give details:
If the patient has a mobility impairment please describe:
Preferred language: Interpreter required Y N
Carer attending Y N
Patient Engagement and Availability
I have discussed the possibility that the diagnosis may be cancer, I have provided the patient
with a 2WW referral leaflet [insert web hyperlink to the patient information leaflet] and advised
that they will need to attend an appointment within the next two weeks.
Please detail any dates the patient is NOT available for an appointment in the next 2 weeks:
Patient’s WHO Performance Status:
0 Able to carry out all normal activity without restriction
1 Restricted in physically strenuous activity, but able to walk and do light work
2 Able to walk and capable of all self-care, but unable to carry out any work. Up and about more
than 50% of waking hours
3 Capable of only limited self-care, confined to bed or chair more than 50% of waking hours
4 Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair.
Discussion with a specialist (for example, by telephone or email) should be considered where there is
clinical suspicion and uncertainty about the interpretation of symptoms and signs, and whether a
referral is needed.
Reason for Suspected Cancer Referral – to be seen within 2 weeks
Cancer Type suspected: Bladder Renal Prostate Testicular Penile
Bladder/ Renal Cancer
Aged ≥45yrs and have:
Unexplained visible haematuria without urinary tract infection or
Visible haematuria that persists or recurs after successful treatment of urinary tract infection
Bladder Cancer
Aged ≥60yrs have unexplained non-visible haematuria (UTI excluded) and either:
Dysuria or
Raised white cell count on a blood test
Cancers Arising Anywhere within Urinary Tract
Soft tissue mass found on imaging arising from urinary tract (please attach report)
This includes solid renal masses, complex renal cysts (i.e. cysts containing septa, calcification or
soft tissue elements) and soft tissue bladder masses.
This does not include distended bladders of urinary retention.
Male specific
Prostate Cancer
(NB: the ‘Further Information & Guidance’ page advises when to organise a PSA & DRE)
Refer urgently if the prostate feels malignant on digital rectal examination (DRE) or
If the PSA level is above age specific reference range (consider factors which affect PSA)
Guidance: 40-49y 0-2.5ng/L; 50-59y 0-3.5ng/L; 60-69y 0-4.5ng/L; 70-79y 0-6.5ng/L
If PSA raised in context of UTI, repeat PSA after 6 weeks to confirm if it is truly raised and whether
further investigations are required.
Consider the impact of referring patients with significant co-morbidity and the very frail
elderly. If in doubt consult your local specialist and carefully counsel the patient.
Testicular - consider
with any of the following testicular changes:
Non-painful enlargement
Change in shape
Change in texture
Suspected testicular cancer on USS (report attached)
Consider direct access USS in men with unexplained or persistent testicular symptoms
Penile – consider (after STI excluded/treatment completed)
Mass or
Ulcerated lesion or
Unexplained or persistent symptoms affecting the glans or foreskin
Investigations
Please ensure the following recent blood results are available (auto-populate):
FBC eGFR U&E PSA
Additional Clinical Information
Please ensure that you include as much clinical information as possible to support the referral
If this case has been discussed with the secondary care clinical team, please specify with
whom, when and the advice given:
Please use this area to auto-populate a patient summary to include: recent consultations,
current diagnoses; past medical history; recent investigations; recent blood test results; medication;
any other fields which might be helpful to secondary care.
Hospital Admin Usage Only Consultant comments:
Date received: Date 1st appt:
Further Information and Guidance
Site-specific information and advice for Primary Care:
Consider a non-urgent referral
Patients aged 60yrs or over with recurrent or persistent UTI that is unexplained.
Urgent referral/ Discussion with secondary team
Hydronephrosis of unknown cause or symptomatic renal/ ureteric colic
PSA testing
Consider arranging a PSA test (with counselling) and a digital rectal examination (DRE) in men with:
 Lower urinary tract symptoms (LUTS) (nocturia, frequency, hesitancy, urgency or retention)
 Erectile dysfunction
 Visible haematuria
Haematuria
Safety net patients following positive haematuria result.
Consider the possibility of gynaecology pathology in females with haematuria.
Urine dipstick testing
Ensure urine dipstick testing in primary care is in accordance with manufacturer’s guidance.
Ensure urinary tract infections are treated appropriately (in accordance with local guidelines and
results of culture).
Useful websites:
CRUK main
CRUK learning
e-CDS
Genetics and Family History
Macmillan
Macmillan learning
Map of Medicine
NICE
Q-Cancer
RAT
RCGP learning (members only)
Wessex Clinical Network
Exampleofareferralproforma

19.  Template proformas were circulated to all CCGs and Trusts
 The CN recommended that the forms be reviewed, discussed
and adapted according to local services.
 Robust governance processes via TSSGs with senior CCG
clinical and managerial representation were recommended.
 AEDI Clinical Lead spoke to GPs at educational events about
use of NG12 in clinical practice
Outcomes

20. Raising Awareness of
Cancer in Schools
 Proposal suggested by a patient
representative on the AEDI CAG
 By providing information at a
formative stage in their lives, the
initiative encourages teenagers to
make healthy lifestyle choices and
informed decisions about their health.
 More information to follow…

21. Supporting the ACE Programme
 There were two ACE Wave One projects in our region related to
lung cancer diagnostics
 Horsham and Mid Sussex CCG and
Crawley CCG worked with their local
Acute Trusts to ensure compliance with
CN commissioning recommendations
produced in 2014 (advocating
streamlined access to CT scans for
patients with suspicious CXRs)

22. Hosting the
CRUK Facilitation Programme
 The Health Professional Engagement Programme provides
face-to-face tailored support to GP practices and health
professionals to promote cancer prevention, early diagnosis
and improve cancer outcomes
 The CRUK Facilitator work plan was developed in collaboration
with the CN to; • Provide education and training
• Improve understanding of practice profiles
• Promote prevention, screening resources & initiatives
• Support audits/ SEAs
• Raise awareness of Clinical Decision Support Tools
• Promote NICE guidance
• Provide evidence, information and resource

23. Thank you for listening!
Discussion / feedback / comments welcome…