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Cancer Contributions to QIPP. Dr Janet Williamson National Director, NHS Improvement The Beeches Conference Centre, Birmingham 4 November 2010.
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Cancer Contributions to QIPP Dr Janet Williamson National Director, NHS Improvement The Beeches Conference Centre, Birmingham 4 November 2010
“We must keep a relentless focus on improving quality and productivity. The QIPP programme and the need to achieve £15 - £20 Billion inefficiency savings by 20/03/14 are now more pressing than ever. We need to build on the excellent planning work you have all done”. Sir David Nicholson, NHS Chief Executive 2010
Political Context for Cancer • Election Campaign (April 2010) – cancer featured prominently in Leader’s debate • Coalition Government agreement (May 2010) • White Paper: Equity and Excellence – Liberating the NHS (July 2010) • Announcement of Cancer Reform Strategy ‘Refresh’ • To be completed by Winter 2010 • Emphasis on improving outcomes
Equity and Excellence: Liberating the NHS • Key messages • Information and choice: ‘No decision about me without me’ • Emphasis on outcome measures, not process targets • Commissioning: NHS Commission Board and GP consortia • Ring fenced public health budget
Aims of ‘Refreshing’ the Cancer Reform Strategy To align cancer strategy with the White Paper To set the direction for the next 5 years – taking account of progress since 2007 To show how outcomes can be improved despite the cold financial climate
Last 15 years: Huge investment in quality, equipment, manpower and redesign in cancer • Prevention: screening • Care: cancer waits, access, centralisation surgery new drugs • Clinical infrastructure – MDTs networks, clinical teams, facilities Mortality reduces by 2% pa under 75s
Gap in service provision remains … • Early Diagnosis • 10,000 avoidable deaths p.a. • Survivorship • Over 3 million survivors • Service provision based in OPD • Inpatient – increasing emergency admissions (52%) • 14,000 occupied bed (60% non elective • Inequalities – variations UK wide
Where the difference can be made • How many trips to the GP before diagnosis? • Why do 40% blood samples have defects? • Why does a woman needing breast surgery for cancer stay in hospital for 6 days when 23 hours is available? • Over 12 weeks from smear to result in hand for a test that takes 5 hours to process.
Rationale • Patients do not wish to be in hospital more often or longer than necessary • Bed utilisation in England for cancer patients is higher than elsewhere • Inpatient care accounts for around half of all cancer expenditure • Inpatient bed utilisation varies widely between PCTs (even when cancer incidence has been accounted for) • We need to improve productivity if we are to introduce new life saving technologies
If all cancer services adopted the winning principles &the key improvements this can save a million bed days
Variation in mean LOS and activity by provider. Total excision of breast (B27) • Most providers have a mean LOS between 1 and 7 days. • Providers of few cases have been omitted.
Day Case/23 Hour Breast Surgical Pathway • Primary care – optimising pre- • operative health • Blood pressure • BMI, diabetes etc. • Lifestyle advice • Patient choice • Patient information • **Pre-operative surgical assessment • Full clinical & risk assessment eg thrombolysis prophylaxis • Default booking as day case – overnight booking as the exception not the rule • Specialist advice… anaesthetic/co-morbidity management • Check patient informed surgical consent • Inform patient of admission time, length of stay & discharge date • Patient education: self management e.g. arm mobility exercises - physiotherapist/nurse/DVD • Prosthesis advice/fitting • Prescribe TTO’s • Plan theatre scheduling and timing • Intra-operative • Drains the exception not the norm • Anaesthetics: short acting/ local anaesthetic • Analgesia: non steroidal/non opiate • Minimal intra operative fluids • *Sentinel node Biopsy • Surgical follow-up options • No follow up required • Patient activated e.g. telephone call/questionnaire • Pro-active follow up call • Outpatients appointment • GP follow-up • Open Access: seromas/drain management and complications • Joint clinic: e.g. • further treatment options: chemotherapy/radiotherapy • Palliative care 7/10/2010 • Continuing care for cancer patients • Continuing cancer care assessment care plan (including referral as appropriate to AHPs) • Education – self care management programme • Palliative care • Post-operative • Analgesia: avoid PCA/opiates • Provide nutrition and mobilise • Nurse led discharge • Patient discharge summary with 24/7 contact information and wound care advise • Discharge day case (85% of patients) • 23 hour discharge (1 night stay, 15% of patients) • GP discharge summary • Drain management information (if required) • Fitting permanent prosthesis • Dispense TTO’s • Admission (Day Unit, Treatment Centre, Surgical Ward) • Admit day of surgery • Starvation – the ‘2 and 6’ rule • fasting time 6 hours for food and • clear fluids 2 hours prior to surgery (consider carbohydrate drink) • No pre med • Pre-op analgesia (paracetamol/ • non steroidals) • Diagnosis(Triple Assessment Clinic) • Full clinical assessment • Mammogram/ultrasound/ +/-MRI +Chest X-ray • Core/fine needle biopsy • Bloods • Discuss informed consent • Pathology reporting • Outcomes • Discuss results • Involve patient in choice of treatments/trials/reconstruction • Obtain patient informed surgical consent • Confirm treatment/surgery date • ** Pre-operative assessment • Provide patient information prescription, hand held record/care plan/patient diary • Inform patient of next steps • Inform GP positive results within 24 hours/negative within 10 working days *Intra-operative - Sentinel Node Biopsy: In centres where adequate training has been provided. Extra theatre time e.g. 40mins is required for this procedure **Pre-operative - Surgical assessment at diagnosis clinic or minimum 7 days prior to surgery ‘Patient involvement & Choice Guarantee’ ‘Professional & Patient Outcome Audits’ Patient informed decision making
Supporting Spread: www.improvement.nhs.uk
Transferring the lessons from Birmingham An exemplar in improvement
13 National Clinical Spread Networks Lancashire & South Cumbria Humber & Yorkshire Merseyside & Cheshire Greater Manchester East Midlands Pan Birmingham Anglia Arden North London Three Counties Thames Valley ASW South West London
Potential for Breast Day Case/23 Hour Model • National average Los 2.8 days (HES 09)= 95,200 bed days • Approx 34,000 new case registered per annum • 1 day stay = 34,000 bed days
Cytology screening • 14 day standard delivery by end 2010 (baseline 12 weeks+) • Delivery of standard requires: • Understanding of process and redesign • First in, first out principles • Single queues • Small batches • Daily problem resolution
The Result (QIPP) across 10 pilots • Q. 100% delivery of the 14 day standard • 80% in 7 days • I. New processes • P. £100K savings per site • 14% re-work eliminated • National impact £18million per annum
Cytology : Phase 1 Turnaround position
Sample taken in primary care Result received by patient Report issued from lab Processing and printing Laboratory Test Result issued by call/recall agency Time taken to reach laboratory Laboratory process- Liquid based cytology End to end TAT- 14 day max Training of smear takers Inconsistent use of NHS numbers Transport-delivery times/ routes Left at surgery Incorrect info/ demographics Illegible forms Missing/wrong smear taker codes 25% out of scope samples Skill mix/ staffing Processor down Data entry issues Over- printing labels Double look-up/ printing from open-exeter Matching forms/slides Writing on forms Excessive checks Backlogs Morale Sending out processing/screening Returned samples/cards Report running weekly Non-matches Enveloping- leaflets Postage ‘Abnormals’ sent out by GP Route to Colposcopy (direct referrals) Manual checking of electronic data Print jobs not believed Other IT issues Multiple results centres across PCT’s 5 hours 30 minutes value added time
Innovation ‘The best way to improve services is through healthy plagiarism’. National Clinical Lead, Heart • Diffusion of innovation is critical • ‘Adaption’ not adoption is central • Open networks not closed alliances • No need to totally reinvent wheel • Define in terms of value added • Headspace for innovation • Defining ‘What to do’ and ‘How’
The biggest enemies of improvement are: • ‘Not invented here’ • ‘We don’t work like that’ • ‘It’s easy for them. They have 6 nurse specialists and a couple of GPwSI.’ • ‘We can’t do more work without more staff/ equipment’ • ‘Jumping straight to solutions’ • ‘Not taking time to understand the process’ Source National Clinical Leads NHS Improvement
The big opportunities • Early diagnosis and prevention • New models of care • Long term conditions • Self and supportive care • Transforming ‘inpatients’ • Diagnostics
How quality can save money…… www.improvement.nhs.uk