SWAG Prostate, Lung and Colorectal Pathway Transformation Report

1. SWAG Prostate, Lung and Colorectal Pathway Transformation Report August 2019

2. SWAG Prostate Pathway Transformation Report August 2019

3. SWAG Cancer Alliance: Q2 2019/20 Prostate Pathway Transformation Report 2019/20 Deliverable - to achieve a demonstrable improvement in the number of prostate cancer patients diagnosed in 28 days by implementing National Rapid diagnostic Pathway (NRDP) The service developments' for the 2019/20 deliverable compliments the pathway transformation work undertaken over 2017/18/19 as directed by the SW prostate clinical leads via the prostate cancer pathway transformation network: Faster Diagnosis Standard (FDS) We are implementing a new diagnostic standard for cancer that emphasises the importance of receiving a diagnosis or ruling out of cancer within 28 days. For patients who are diagnosed with cancer, this means treatment can be offered earlier. For those who are not diagnosed with cancer, this communication of an ‘all clear’ reduces the anxiety felt at a very stressful time. The focus for 2019/20 is now to develop services to deliver on the timings of the NRDP and implement the following best practice recommendations. • Pathway Timelines • The timelines in the national best practice pathway should be the standard. Specifically: • Referral to biopsy by day 9. • Referral to diagnosis to patient by day 28 • South West Cancer Managers have agreed that referral to decision to treat should happen by day 44 to allow scheduling of treatment within 62 days. • The development of one stop clinics is recommended (MRI and biopsy on the same day). • There are only two aspects of clinical order that remain for us to address in the SW prior to 2020: • clinical triage instead of outpatient appointment in all Trusts (the majority are now clinical triage but some have opted out) • mpMRI prebiopsy (as opposed to bpMRI) • Funding • The South West Cancer Alliances have funding to support sustainable developments in the prostate pathway. Proposals will be tested against the recommendations in this report and review by the clinical leads. • Data Collection • Providers should continue to collect and report the South West dataset monthly. This data set should detail all 2ww patients entering the pathway. This will allow providers to benchmark their pathway and activities against providers in the South West and demonstrate progress in implementing agreed best practice. A dashboard tool has been developed to support this and all providers have access to the database and 2019/20 funding to support data collection. .This information is required to demonstrate the impact of funding provided by the Alliance for pathway developments • Data is due on the third Friday of the month. • A data report is due to be published mid-September 2019 which will be used to identify provider specific targeted interventions to support delivery of the RDP and best practice pathway recommendations.

4. SWAG Cancer Alliance: Q2 2019/20 Prostate Pathway Transformation Report • Background: • The Prostate Cancer Pathway Transformation Steering Group are leading a range of transformation work for the prostate pathway. This report describes the range of work that has taken place over the last year and provides updated recommendations in light of the work carried out in the South West. • Pathway Audit • Questionnaires were sent to 14 providers across the South West to understand the variation that exists across pathways in the region and how patient experience might vary. Using the feedback from the questionnaires, a gap analysis against the national pathway has been produced for the region. Each Trust has an action plan in place against the national timed pathway, the delivery of which is being monitored by the CCG’s. • The NHS England national timed prostate cancer diagnostic pathway sets out a standard of 28 days to diagnosis by 2020. Information from the Trust visits allowed analysis of pinch points in the pathway. The findings showed that the average TRUS biopsy pathway from referral to diagnosis varied in length between 13-139 days and the average Template biopsy pathway varied in length from 33-189 days. • The greatest constraints to achieving the timed pathway are radiology reporting, biopsy, and histopathology reporting. • A summary of the findings identified is detailed in the presentation below: • http://www.swscn.org.uk/wp/wp-content/uploads/2018/06/Transforming-the-South-West-Prostate-Cancer-Diagnostic-Pathway.pdf • The key pathways variations identified across the South West, including differences in: • Referral Criteria (age adjusted PSA and suitability criteria). • Clinical order of the pathway -telephone triage and straight to test. • Capacity constraints impacting on 28 / 62 day standard caused by radiology reporting backlogs, template biopsies, histopathology turn-around times. • Workforce - 73% of trusts experiencing reporting backlogs during holiday periods. • Variation in the biopsy, radiology and histopathology techniques deployed. • Type / age of scanning equipment (5 trusts with scanners over 10 years old). • Implementation of the national timed pathway remains a priority for next year.  

5. SWAG Cancer Alliance: Q2 2019/20 Prostate Pathway Transformation Report Recommendation - MRI Audit In 2018 The Prostate Cancer Pathway Transformation Steering Group (PCPTSG) commissioned an audit of mpMRI images across the South West. The aim of this audit was to assess compliance with recognized standards and to evaluate image quality. Each hospital was asked to share a small sample of scans. These images were assessed by two radiologists, Dr Tristan Barrett, University Lecturer, Honorary NHS Consultant Radiologist, Addenbrooke’s Hospital, University of Cambridge and Dr Paul Burn, Consultant Radiologist, Taunton and Somerset NHS Foundation Trust. A summary of the audit can be viewed at: http://www.swscn.org.uk/wp/wp-content/uploads/2019/01/South-West-Prostate-Audit.pptx The results of the MRI audit showed variation in compliance with standards and image quality across the region. The individualised results for each Trust were reported to the lead prostate radiologist and superintendent radiographer, in November 2018. Each Trust was asked to consider if the sample was representative of their service, and discuss their results with commissioners. The PCPTSG radiologists have supported trusts with poor image quality to optimise their scan parameters. A specialist MRI physicist from UCL has been identified to support our regional physicists to modify protocols, and optimise scanners to achieve the best quality image possible in collaboration with local MRI physics experts. This will lead to optimisation of prostate MRI at all sites (who wish to be supported) to ensure that the current MRI systems are operating to maximum potential for prostate imaging. Following MRI optimisation, lead physicists for each Cancer Alliance will work with the PCPTSG radiologists to visit each Trust and assess whether prostate MRI imaging is of acceptable diagnostic quality and determine whether there are some MRI systems that cannot deliver acceptable image quality even following optimisation. Outcomes of MRI audit per provider to be confirmed Following the latest NICE guidelines(NG131, 1.2.2 ) published on the 9th May 2019 and also in line with the PROMIS trial, the Prostate Cancer Pathway Transformation Steering Group are advocating the use of a Likert score in the assessment of prostate MpMRI. This will be an essential requirement and will be incorporated into a revised copy of our Radiology Standards document. • Recommendation –MDT Streamlining Standards of Care (SOC) • Standard of Care that have been distributed to MDT leads for discussion: already been piloted by Guys and Clatterbridge •  It has been agreed that this can happen outside of the SSG /CAG meetings to save time, with the intention that these are then ratified by the CAG/ SSG membership. We will need to produce an audit and put metrics in place to ensure we have safety netting / are able to quantify the difference made. • Trusts are already trialling SOCs to be confirmed and share learning

6. SWAG Cancer Alliance: Q2 2019/20 Prostate Pathway Transformation Report • Recommendation - Biopsy training • The Cancer Alliance has funded education and training on targeted and systematic transperineal biopsy procedures under local anaesthetic. This technique reduces the risk of sepsis, is better for the patient, and can be undertaken in an outpatient setting (instead of theatre). This technique will remove the need for template biopsy under general anaesthetic in the majority of patients and should improve the timeliness of the pathway; LATP BX will make the biggest difference to reducing breaches • The course teaches the principles of freehand local anaesthetic transperineal targeted and systematic prostate biopsies. It introduces the Precision Point Transperineal Access System TM and explains how it can be used to enhance the prostate diagnostics, particularly in relation to the two week wait pathway. • Initial funding (HEE 74K and SWAG 18/19 funding- approx. 2500 per provider) offer was for 1 consultant and 1 CNS and the model for deployment was that the trained consultant would oversee the training of his colleagues / other CNS / to support the move to surgical care practitioners delivering biopsies. • The Cancer Alliance has identified 17 consultants and 8 Clinical Nurse Specialists (CNS) or Surgical Care Practitioners (SCP) in Providers across the South West to receive training. Professor Raj Persad is the regional lead and providers now delivering the technique include NBT, TST, PHT and RDE. • SWAG places funded to date: • Nick Burns-Cox and Angus Maccormick from TST were trained prior to the roll out of this training. • Graeme MacCormick from TST - 26th July 2019 • Ramesh Vennam from TST – still to arrange training date with training provider. • Sanjit Das and Mohammed  Khawaja YDH - 26th July 2019 • Beatriz Mora from NBT – February 2019 • Stefanos Bolomytis from NBT – 28th & 29th June 2019 • Hugh Gilbert from NBT – 27th October 2019 • Salah Albuheissi from NBT - still to arrange training date with training provider. • Jaspal Phull (and Jon McFarlane – awaiting verification) from RUH 27th September 2019 • David Dickerson from Weston - 25th October 2019 • Karen-Anne Shelley from Weston – 8th November 2019 • Amr Hawary from Great Western - still to arrange training date with training provider. • Jonathan Borwell from Salisbury has requested that they would like 2 places on the training. Still to arrange training date with training provider. • Gloucestershire are using a different technique – camprobe and do not wish to take up the offer. • NB LATP requires a biplanar or triplanar probe that is attached to the US machine. However, it has come to our attention that only newer versions of the US machine support these. Older versions can’t be adapted. Some trusts will have the newer versions or have managed equipment services so will not be affected. Those that are may need to use CA funding to support leasing of a newer machine or may be able to ‘swap’ an older machine if there are newer ones available elsewhere in the service. • Increase histopathology capacity to improve turnaround times and reduce variation by histopathology standardisation (no of cores).

7. SWAG Cancer Alliance: Q2 2019/20 Prostate Pathway Transformation Report LA TP Status August 2019

8. SWAG Cancer Alliance: Q2 2019/20 Prostate Pathway Transformation Report • Prostate Cancer Clinical Study Day – Wednesday 18 September, 2019 at the Peninsula Radiology Academy, Plymouth. • Dr Simon Freeman, Consultant Radiologist, University Hospitals Plymouth. • On 18th September 2019 the South-West Cancer Alliance and NHS England will be hosting a study day at the Peninsula Radiology Academy in Plymouth. • The theme for this event will be “Advances in Prostate Cancer Imaging and Biopsy Techniques” and will also include an update and discussion on the information obtained from the prostate database, into which all the sites in the Peninsula and SWAG are contributing. • The final program will be distributed nearer the date but talks will include: • A summary of prostate MRI; PI-RADS and pitfalls for non-radiologists • An update on modern prostate pathology • The roles of PSMA PET and whole body MRI in prostate cancer • New biopsy techniques: local anaesthetic trans-perineal biopsy and MRI/US fusion biopsy • What have we learned so far from the regional database? • The shifting sands of prostate cancer risk stratification • The day will include lunch and, a manufacturer’s exhibition. • This study day is aimed at all healthcare professionals (Urologists, radiologists, CNS, radiographers, regional radiology SpR’s) who are involved in the prostate cancer pathway. • PLEASE REGISTER YOUR INTEREST USING THE LINK BELOW: • https://www.bmus.org/meeting-booking/south-west-prostate-study-day/

10. SWAG Lung Pathway Transformation Report August 2019

11. SWAG Cancer Alliance: Q2 2019/20 Lung Pathway Transformation Report Deliverable - to achieve a demonstrable improvement in the number of lung cancer patients diagnosed in 28 days by implementing National Rapid diagnostic Pathway (NRDP) The service developments' for the 2019/20 deliverable compliments the pathway transformation work undertaken over 2017/18/19: implementation of the diagnostic phase of the National Optimal Lung Cancer Pathway (NOLCP); this enabled all CXR to be reported promptly (preferably within 24 hours) and where suspicious of lung cancer direct escalation to CT. The lung cancer timed pathways draw on the National Optimal Lung Cancer Pathway (NOLCP), which was produced by the NHS England Clinical Expert Group for Lung Cancer in August 2017 and sets out how to deliver the pathway from referral to diagnosis. Faster Diagnosis Standard (FDS) We are implementing a new diagnostic standard for cancer that emphasises the importance of receiving a diagnosis or ruling out of cancer within 28 days. For patients who are diagnosed with cancer, this means treatment can be offered earlier. For those who are not diagnosed with cancer, this communication of an ‘all clear’ reduces the anxiety felt at a very stressful time. The focus for 2019/20 is now to develop services to deliver on the timings of the NRDP. Funding and Metrics £217,200 allocated to support improvement in speed of diagnosis. The following methodology is proposed for spending these funds: • Providers who currently do not have CT scans completed and reported by day 7 of the 62 day pathway (based on median from quarter 3 2018/19) are eligible for funds • All providers who are sending patients for curative treatment to demonstrate that all appropriate locally delivered tests are requested at first OPD and undertaken and reported in reasonable timeframe working towards national timings of NOLCP. Assurance – • Monitored through quarterly pathway data returns to the Cancer Alliances. Principals - A condition of accepting the funding is providers are required to prove by end of 2019/20 financial year that they had made permanent changes that enabled CT scans to be reported by day 7 of the 62 day pathway (median) and that for an increasing number of lung cancer patients all required tests available to refer to locally will be requested at the first OPA. Successes' - South West Cancer Alliances Lung Cancer Pathway Transformation project evaluation 2018/19 demonstrates 2 providers who have delivered consistent reduction in waiting times from CXR to OPA. RUH Bath have reduced this early part of the pathway by 15 days and Salisbury District Hospital by 7 days during 2018/19 Risks to achievement of NRDP timelines are diagnostic turnaround times, OPA capacity, sustainability of reporting timeframes, multiple MDT attendances, PET CT digital referral and performance delays, molecular pathology waiting times. Addressing these challenges forms the core priorities of the SW Cancer Alliances Lung Cancer Pathway Delivery Group

12. SWAG Cancer Alliance: Q2 2019/20 Lung Pathway Transformation Report – CXR to OPA wait times 2018/19 report

13. SWAG Cancer Alliance: Q2 2019/20 Lung Pathway Transformation Report – Q1 2019.20 Phases of Lung Pathway by Provider

14. SWAG Cancer Alliance: Q2 20/19 Lung Pathway Transformation Report Update on Cancer Alliance Lung Cancer Pathway Work Programme 2019/20 •SWCSU completion of South West NLCA Organisational survey benchmarking report anticipated w/b 2nd September to be followed by Clinical lead visits to providers to discuss required resourcing for NOLCP delivery •Collaboration with NHS Improvement IST finalise reporting requirement by providers using adapted pathway analyser tool anticipated 16th September •Pathologist representation of the SW Cancer Alliance Lung Cancer Pathway Delivery Group secured •Neck biopsy training for Respiratory Physicians at Peninsula Lung Educational Event 22nd November at Roadford Lake, Broadwoodwidger, Lifton, Devon, PL16 0RL. Open to all SWAG Lung Cancer MDTs •Sharing, Support and Training Event for Pathway Navigators working in Cancer Care at Dillington House, Ilminster, TA19 9DT on 26th September. Open to all Cancer Pathway Navigators across South West

15. SWAG Colorectal Pathway Transformation Report August 2019

16. SWAG Cancer Alliance: Q2 2019/20 Colorectal Pathway Transformation Report Deliverable - to achieve a demonstrable improvement in the number of colorectal cancer patients diagnosed in 28 days by implementing National Rapid diagnostic Pathway (NRDP) Faster Diagnosis Standard (FDS) We are implementing a new diagnostic standard for cancer that emphasises the importance of receiving a diagnosis or ruling out of cancer within 28 days. For patients who are diagnosed with cancer, this means treatment can be offered earlier. For those who are not diagnosed with cancer, this communication of an ‘all clear’ reduces the anxiety felt at a very stressful time. The focus for 2019/20 is now to develop services to deliver on the timings of the NRDP. . Funding and Metrics £143,000 allocated to support improvement in speed of diagnosis (indicative allocation per provider 19,863. The following methodology is proposed for spending these funds: Turnaround times for radiology and endoscopy are identified as the main barriers to achievement, along with patient compliance with taking bowel preparation. To share the funding the following methodology is suggested: Providers who currently do not have endoscopy or CT colonoscopy performed by day 14 of the 62 day pathway (based on median from quarter 3 2018/19), or those who do not have staging CT and/or MRI scan reported by day 21 of the pathway (based on median from quarter 3 2018/19) would be eligible for funds Funds then split between eligible providers proportionally based on numbers of lower GI two week wait referrals at the provider Providers would have to prove by end of 2019/20 financial year that they had made permanent changes that enabled endoscopy/CT colonoscopy to be performed by day 14 of the 62 day pathway (median) and staging CT and/or MRI scan reported by day 21 of the pathway, on an ongoing basis. Assurance – • Monitored through quarterly pathway data returns to the Cancer Alliances. Principals - A condition of accepting the funding is providers are required to prove by end of 2019/20 financial year that they had made permanent changes that enabled CT scans to be reported by day 7 of the 62 day pathway (median) and that for an increasing number of lung cancer patients all required tests available to refer to locally will be requested at the first OPA.

17. SWAG Cancer Alliance: Q2 2019/20 Colorectal Pathway Transformation Report SW Improvement Project Approach: The Peninsula and SWAG Cancer Alliances are joining forces to deliver a South West England quality improvement project designed to support colorectal teams with the delivery of the 28 day timed pathway and the standards set out in the 2017 publication Clinical Advice for the Provision of Bowel Cancer Services. We have appointed 2 clinical leads, Mel Feldman and Mike Thomas as the SW Alliances’ clinical leads for this project. This project is intended to be a peer review formative exercise inspired by the 2016 Peer review of Emergency General Surgery in the South West led by Paul Eyre's; sharing good practice and pragmatic solutions assisting you to do the very best for your cancer patients. This project will run during the Autumn and Winter 2019. We will be liaising with MDTs and cancer services team to gather data and then will make a site visit on. This was one of the great strengths of the EGS peer review – an opportunity for us to talk to colleagues around the region and share ideas. Doubtless the competing demands of cancer services, benign services and emergency services make change management complex and it is important to avoid breaking one service in order to improve another. We can only dig deep into the way these issues impact on your service by visiting you. The peer review itself will involve talking to a group of patients and a group from the MDT. We would welcome speaking with patients, CNSs, managers, and the consultants involved in delivering care and reviewing your data together. At the end of the site visit we would also ask that we present the provisional report to the Medical Director and/or chief executive or their representative at 4pm. We will contact you again 6 months after your visit to give you an opportunity to report back on improvements you have been able to implement.  Data: Baseline of current practice to get a snapshot of the current practice across the South West. This will allow us to understand challenges, drawbacks and good practice in a standardized approach to identify data driven areas of improvement and allocate funds to support Trusts in prioritized/identified areas. Thus, the sent out request (enclosed in this email), seeking support from trusts to fill out templates with two primary outcomes: 1 )Scenarios template – To develop process maps of current processes at each trust from the moment patient  were referred through 2WW to treatment. Based on the referral form we have a possibility of 420 different scenarios, 6 scenarios were generated with the support of the clinical lead and cover most of them(they were not selected randomly) . This allows us to evaluate best practices/drawbacks across SWAG and assess how would each provider manages different cases with their current resources. 2) Timeline Template- Get a baseline data for patients referred in February & March through 2WW at every trust. Those templates will enable to create a standardized data portfolio for all trust across the South West identifying primary gaps & best practices. Site visits which are expected to start in October, 2019. The site visit is one of the most crucial areas of this project as it is an opportunity to maximise all the ‘grey’ outcomes across the SW through peer group networking, sharing of ideas & shared learning. A portfolio will be shared ahead with the outcome of the templates that were completed to guide us through the visit, there will be an interview with the MDT which is an opportunity to hear stories, successes, concerns, and to hear what the team have been doing to try to deliver the service. We will be speaking with patients, CNSs, the consultants involved in delivering care and reviewing their data together. After the discussion a preliminary report will be presented to the team and executives to demonstrate all the things the team are doing great and where challenges requiring managerial and resources support are highlighted. 

18. SWAG Cancer Alliance: Q2 2019/20 Colorectal Pathway Transformation Report Complete this quarter (Q1/2): Project Scope & Data Collection Plan • Identify drawbacks in current pathways and timeliness at provider level. Data portfolio, current pathway + pathway steps mean/median for Feb/Mar 2019 will be developed for each provider. • Access NBOCA report for each trust • Agreement with clinical leads to request data at trust • Information Gathering Plan template developed (outline description of service, protocols, assessment of problems, description of things trusts are proud to do well) to be sent to MDT leads & Cancer Managers to be sent before site visits. To be sent 2nd September 2019. • Most recent NCPES Report • First CRC Steering Group 25th July 2019. Project approach discussed and approved. • Invitations for site Visits sent 19th August 2019. Priorities for next quarter (Q3): • SWAG PCA CL peer visits to meet teams, understand good practice, local challenges/barriers to delivery. Volunteers are welcome to support CL & PM in site visits to maximize networking, sharing ideas & learning opportunities. • Analysis of Information gathering plan (deadline for return 30th Sep, 19) and trust data portfolio. • Identify gaps in practice and proposed change ideas for sustainable improvement fit for future • Site visits scheduled Nov, 19- Feb, 20 • Peer review will include • Meeting with MDT group to review data • Qualitative structured interview with MDT • Patient group • Meeting with MDT and MD/Executives Individual reports will be shared with each trust 2 weeks after peer review.

19. SWAG Cancer Alliance: Q2 2019/20 Colorectal Pathway Transformation Report