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Meeting Date 28 October 2009 Trust Board

    Enclosure P Subject Cancer Services and Palliative Care

    Annual Report

    ? Nature of item For information

    For approval

    For decision


    required (if any)

    General Report Author Maureen Walker Assistant General Manager for Information Cancer Services

    Lead Director Peter Hawker Associate Medical Director for

    Clinical Governance

Received or Meeting Clinical Governance Committee

    approved by Date 8 October 2009

Resource Revenue

    Implications Capital


    Use of Estate

    Funding Source

Freedom of Confidential (Y/N) No

    (if yes, give reasons) Information

    Final/draft format Final

    Ownership Trust

    Intended for release Yes

    to the public

Decision Made

    Cancer and Palliative Care Services

    Annual Report for

    Cancer and Palliative


Version 1

    Job Title of Responsible Manager Maureen Walker, Assistant General

    Manager, Cancer Services Name of Trust Lead Cancer Clinician Dr Peter Hawker, Associate Medical

    Director (Governance) Department Cancer and Palliative Care Replacing Document Annual Report 2008 Agreement Date September 30 2009 Date for Review September 30 2010 Relevant Standards National Cancer Peer Review


    Table of Contents

1. Introduction

2. Aylesford Unit

3. Cancer Targets

4. National Cancer Peer Review Programme

5. Palliative Care developments

6. MDT Update

7. Network Update

8. Data Collection/National/Local Audit

9. Patient and Carer Feedback and Involvement

10. Research

11. Challenges for the coming year



    1. Introduction

    The past year has been a particularly busy one for the Cancer and Palliative Care teams as it fulfilled many of the strategic decisions taken previously. In May 2008 the Trust took the decision to appoint an in house Palliative Care team. We were very fortunate in securing the appointments of Natalie Adams as the Lead Nurse for Cancer and Palliative Care in November 2008, Dr Mandy Barnett, Palliative Care Consultant in May 2009 and Kathy Healy as a Band 7 Palliative Care Nurse Specialist in April 2008. The Palliative Care team are supported by Mrs Angie Jones as the Palliative Care administrator.

    The Aylesford Unit opened in October 2008 and is now delivering chemotherapy and supportive care for patients with breast, colorectal, urological and lung. It is expected that by the end of 2009 all patients requiring chemotherapy will be able to attend their local hospital. The Chemotherapy Suite is nearly up to full capacity and will have to investigate opening for longer hours in 2010. The Clinic Consulting Rooms are used to 75% capacity and will provide some clinic space for the breast follow up patients when the Breast Unit opens.

    The Cancer Reform Strategy, which was published December 2007, set out the plan for Cancer Services until 2012. This plan included the introduction of 6 new cancer targets and a new National Programme for Cancer Peer Review from January 2009.

    2. Aylesford Unit

    The Aylesford Unit opened in October 2008 after several years in the planning and development stages. The Unit includes 4 consulting rooms, a procedure room, an Intrathecal and Stem Cell Harvesting room, a chemotherapy suite, a Macmillan Information and Support Centre, 2 quiet rooms, as well as office space for the Haematology Nurse Specialist, Lung Nurse Specialist, Nurse Consultant, Palliative Care team, Cancer Services Team, MDT coordinators and Haematology and Oncology secretaries.

    Over the past year the Unit has systematically increased the workload to meet the repatriation plan agreed in 2007. All Consultant Oncology appointments now take place within the Aylesford Unit except the joint gynae/oncology clinic which is held fortnightly in the Women‟s Health Unit. The clinics held in the Aylesford Unit are

    oncology clinics x8, Lymphoma clinic, palliative care clinic, new patient chemotherapy clinics x4, chemotherapy review clinics x4, dietician clinic, psychology clinicsx2 and lymphodema clinics x3. These clinics, reception, phlebotomy and all preparation of clinics and notes are undertaken by staff within the Aylesford Unit. The number of attendances for patients treated as a day case during April to June 2009 was 1175 (Data coded on PAS). Of the 1175, 122 were day case procedures such as bone marrow punctures, venesections or line care. The other 1053 were attendances for chemotherapy or supportive therapies. In addition to planned attendances the chemotherapy suite also take emergencies straight to the unit for assessment where patients are reviewed and treatment started or discharged. The bed managers also liaise with the chemotherapy suite for any patient that they may need to admit for blood transfusions. If there are chairs available these patients then receive their blood transfusion in the chemotherapy suite rather than occupying a bed on a ward.



    Chemotherapy and supportive therapies are given to patients with oncological and

    haematological conditions but also to patients with rheumatology or general medical

    conditions. Raw data collected by the clinical team in the Aylesford Unit stdemonstrates that since the 1 quarter of 2009/10 there has been an increase in the

    workload with approximately 22 patients receiving treatment in the Chemotherapy

    Unit every day.

    This increase in workload has resulted in a waiting list for chemotherapy developing,

    breaches in the 31 day drug treatment cancer target, several critical incidents, and

    extra pressure on staff as they work longer hours and an increase in sickness. The

    Cancer Team are looking at how these issues can be addressed and whether the

    Chemotherapy Suite needs to open longer hours to match the demand. Even if the

    hours stay as they are there needs to be an uplift in staff to cope with the workload.

    As the number of patients receiving chemotherapy treatments increase the likelihood

    of patients experiencing complications of chemotherapy will also increase. It is

    expected that approximately 6 patients per week may need to be admitted due to

    possible neutropenic sepsis.

    3. Cancer Targets

    The NHS Cancer Plan 2000 set out the original targets

    ? 2 week standard from urgent GP referral for suspected cancer to first hospital

    appointment by 2000

    ? 31 day standard from decision to treat to first treatment by 2005

    ? 62 day standard from urgent GP referral to first treatment by 2005 These targets are still in place but we now have additional targets to meet since the

    publication of the Cancer Reform Strategy 2007. These extra targets include:-

    ? The existing 2 week standard has been expanded so that any patient with

    breast symptoms will be seen within 2 weeks whether cancer is suspected or


    ? The existing 31 day standard has been expanded to cover subsequent

    treatments including those who have recurrent disease

    ? The existing 62 day standard now includes patients who are referred through

    a National Screening Programme

    ? The existing 62 day standard now includes patients who the consultant deems

    to be highly suspicious of cancer regardless of the route of referral Currently we are not collecting data for the 2 week standard for patients with breast

    symptoms but the Trust is working with other colleagues across the Arden Cancer

    Network to ensure a co-ordinated approach to meeting this target.


    ??????Targets year to date April to August 2009

    Target Target percentage Achievement 2 week wait 93% 95.5% 31 day 96% 98.9% 31 day 96% 99.3% subsequent/recurrences

    62 day (2WW) 85% 85.7% 62 day (Screening) 98% 92% 2 breaches as a

    result surgical capacity in

    August 62 day (Consultant TBC 98.4% Upgrade)

Looking at these percentages it would appear that our percentage of achievement

    has reduced since last year. This is not the case. Since January 2009 the

    methodology for processing the cancer targets has changed to be more in line with

    the 18 week methodology. Previously the cancer targets allowed Trusts to take time

    out of the pathway where a patient requested later appointments, or as a result of

    clinical requirements which delay investigations. This is no longer the case. If a

    patient chooses to have a month‟s holiday rather than attend for an appointment that

    results in us trying to see, diagnose and treat the patient within 1 month as opposed

    to 2. To allow for these patient choices and reasonable delays the Government has

    increased the tolerances to the targets.

    SWGHT is struggling to meet the 62 day target as a result of these changes in

    methodology. As a Trust we treat a higher than average proportion of prostate

    patients. The prostate pathway dictates that patients have a prostate biopsy to

    diagnose the presence of cancer and an MRI to stage the level of disease. There is

    a legitimate clinical reason why one can‟t undertake an MRI until at least 4 weeks

    after the prostate biopsy. This is to ensure any effects of the biopsy don‟t obscure

    the MRI picture giving a false positive and thereby requiring a different mode of


    4. National Cancer Peer Review

    The National Cancer Peer Review Programme was introduced as part of the Cancer

    Reform Strategy 2007. The Strategy acknowledged that national guidance will

    continue to play a role as cancer services develop, including guidance from the

    National Institute of Health and Clinical Excellence. There has been a clear

    commitment to establishment of an active and positive relationship with the Care

    Quality Commission and information gathered from the National Cancer Peer



    Review Programme has been shared with the Commission. The Care Quality

    Commission will play an important role in assessing the quality of cancer services

    and peer review continues to be committed to working in partnership with that


    The outcomes of the National Cancer Peer Review Programme are:

    ? Confirmation of the quality of cancer services;

    ? Speedier identification of major shortcomings in the quality of cancers

    services where they occur so that rectification can take place;

    ? Published rep[orts that provide accessible public information about the quality

    of cancer services;

    ? Timely information for local commissioning as well as for specialised

    commissioners in the designation of cancer services;

    ? Validated information which is available to other stakeholders. The National Cancer Peer Review team have adopted a process of annual self

    assessment supported by a targeted visit programme. It was considered that the

    annual process would allow more up-to-date information to be available to support

    the commissioning of cancer services and patient choice.

    This process requires each tumour site to complete an annual self assessment of the

    cancer measures, including the production of an operational policy, an annual report

    and a work programme. The operational policy details the patient pathway, the core

    team membership, how the MDT functions, lines of communication between

    professionals and patients and the clinical guidelines as agreed across the Network.

    The annual report reflects on the previous year and demonstrates the core team

    attendance at the meetings. The numbers of patients discussed at MDT; their

    achievements and challenges. The work Programme demonstrates how the team.

    Internal validation of the self assessment is undertaken by the Cancer Team. Dr

    Hawker as the Lead Clinician then signs the Internal Validation Documentation on

    behalf of the Chief Executive and this report is submitted to CQUINS from where it is published.

    The Trust was informed at the end of December 2008 that the targeted schedule of

    peer review visits would involve the cancer services of skin, upper gastrointestinal

    and urology. This visit took place in June 2009. The Cancer Services Team was

    delighted to be informed that there were no immediate risks or serious concerns

    demonstrated during the visit. The Skin visit highlighted the need for the Trust to

    appoint a Clinical Nurse Specialist to meet the requirements of the Improving

    outcomes Guidance in Skin and ensure that the patient had nursing support

    throughout the pathway. The reviewers recognised the strengths that the Skin MDT

    contained and the dynamic individuals involved. They recommended the need for the

    Warwick MDT to support the establishment of an SMDT at UHCW and begin to refer

    patients to this meeting.



    The report of the visit to the UGI team congratulated the team for their commitment

    and cohesiveness. They acknowledged the vast improvement achieved in the

    appointment of a Trust-wide palliative care team. The challenge for this team and the

    Trust continues to be the lack of radiology and oncology cover for attending the MDT

    meetings. This theme of lack of cover for core team members was continued for the

    urology team.

    Two internal validations have taken place in September 2009, namely breast and

    lung. The breast team demonstrated clear leadership and a functioning MDT,

    unfortunately the lung team experienced difficulty in gathering their evidence but

    after extra support and guidance produced a good operational policy.

    5. Palliative Care and End of Life Developments

    (Taken from Palliative Care and End of Life Report 2009)

    The Specialist Palliative Care team (SPCT) now consists of :

    Natalie Adams - Lead Nurse Cancer and Palliative Care

    Band 8a. 1 WTE. Mon-Fri 08.30-16.30

    (in post October 2008) Dr Mandy Barnett - Consultant in Palliative Medicine

    0.4 WTE. Mon & Wed 09.00-17.00

    (in post May 2009) Kathy Healy - Palliative Care Clinical Nurse Specialist

    Band 7. 0.6 WTE. Tues/Wed/Fri (flexible


    (in post April 2009) At present there is no Out of Hours or weekend palliative care team member on site.

    24hr telephone advice is available from Myton Hospice and/or On Call Palliative

    Care Consultant.


    ??????The Table below details the number of referrals received by the SPCT from October

    2008-Mid September 2009.

    October 08 1 April 09 18 November 08 21 May 09 25 December 08 16 June 09 24 January 09 26 July 09 27 February 09 22 August 09 26 March 09 24 17 September 09 8

     TOTAL 238

One of the Macmillan golden standards of care is that all urgent referrals should be

    seen within 2 working days (ex weekends).

    From October 2008 to 17 September 2009 the vast majority of patients have been

    seen in the 2 working day standard. During Oct08-Mar09 the response rate was that

    72 % of patients were seen by the SPCT within 24 hours, 12% within 48 hours and

    16% in 72 hours. However with the appointment of Dr Barnett and Kathy Healy there

    has been an improvement in response time in the second half of the year. 84% of

    patients were seen within 24 hours, 8% in 48hours and 3% in 72 hours. There are

    still 5% of patients who were not seen in this standard time frame, this related to the

    only full-time team member being on holiday.

    Most of the patients who are referred have multiple reasons for referral but the

    majority are referred for symptom control. Please see the Palliative Care and End of

    Life report 2009 for greater detail. The numbers recorded are the primary reason for

    referral. Each individual person seen by the SPCT is fully assessed. The team will

    be working with the Arden Network to adapt our documentation to the “holistic


    6. MDT Update

    The following MDT Update has been taken from the annual reports that have been

    completed as part of the National Peer Review Programme for 2009.

    Upper Gastro-intestinal Service

    The upper GI service continues to operate and provide a diagnostic and local

    treatment service to the majority of patients of South Warwickshire. The team

    continues to work hard to identify the needs of each individual patient and address

    them as best as possible. There is now a new Gastroenterology Nurse Specialist in

    post, whose primary work focus is patients with chronic liver disease, but who

    provides a cover role for the Upper GI Cancer Nurse Specialist at time of annual



    leave or study leave. In addition the Nutrition Nurse Specialist who started in early May will provide many benefits for patients with upper GI cancer.

    The team made a relatively minor adjustment to scheduling of endoscopy services for patients attending the 2WW clinic as a result of the last peer review visit. Patients are now offered an endoscopy appointment the day following their clinic attendance rather than the following week. For those patients that attend the 2WW service this change will therefore potentially shorten the pathway by a few days.

    Electronic communication with our specialist teams (UHCW for gastric and oesophageal cancer and UHB for pancreatic and hepatobiliary cancer) has improved. We are now able to electronically link radiological investigations directly to their radiology systems, enabling radiologists and clinicians at both centres to review images promptly. Referral letters also these days tend to be faxed more often as well as sent in the post, once again enabling specialist teams to contact patients with appointments as promptly as possible.

    The UGI team see the main challenge for their services as being the attendance of an Oncologist at MDT. Currently the oncologist who is scheduled to attend the upper GI MDT works only part time, and therefore, once allowance is made for annual leave or study leave, he is able to attend fewer than 50% of MDT meetings. More appointments of oncologists are planned within the UHCW which should ensure improved attendance at MDT meetings. Once an oncologist comes regularly to the MDT meetings it will also allow the team to more easily demonstrate that all patients are discussed with a member of a specialist MDT.


    In September 2008 plans for the purchase of new Cystoscopes to incorporate Cystodiathermy equipment commenced. The purchase of such equipment will reduce the number of superficial bladder cancer recurrences being admitted to the surgical day unit as well as the need for the patient to undergo general anaesthetic. This should also decrease the number of visits and potential procedures for the patient. The new Cystoscopes are now in place and purchase of the Cystodiathermy equipment is complete, training and use of the later equipment took place in May 09.

    Improvements have taken place with the projection of both imaging and pathology findings, which makes good use of time for all team members. Bone scan imaging results are also accessible and now available for discussion at the MDT. The MDT coordinator, Radiologist and histopathologist have worked together to improve the transfer of information from the pathology / radiology department in time for reviewing pre the Specialist meeting and discussion of patients at the specialist MDT, as a result the system now in place has improved. This should continue to improve further now that the specialist MDT meeting has moved to a Friday afternoon.

    Clearly, whilst there has been some progress / achievements during 2008, there continues to be the ongoing problem of no cover for either the oncologist or


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