ACE project closure: results

1. ACE project closure: results Dr Paola Di Nardo

2. ACE project • January to June 2015 • Aimed to develop the Acute Oncology and Cancer of Unknown Primary Service • Target population: all patients suspected to have cancer, but for whom it is currently unclear which cancer pathway they should be referred to • Bristol CCG lead commissioner, but strongly supported by South Glos and North Somerset CCGs

3. ACE project: key aims • Improve patient outcomes and experience for those patients in whom cancer is suspected but the specific cancer site is unknown • To improve the time from referral to symptom management, diagnosis and care plan for those patients with suspected cancer for which the specific cancer site is yet unknown • To improve patient outcomes through planned referrals to a single service rather than “bouncing” them around the system or having to be diagnosed in an emergency setting • To reduce the number of unnecessary investigations undertaken on patients whose care plan will not change irrespective of more accurate diagnosis • To develop the services with strong patient and carer input to ensure it is best meeting the needs of this patient population.

4. ACE project: key strands • CUP Urgent Referral Pathway - Development and commissioning of a single approach across BNSSG for urgent referrals with evidence of cancer where there are no signs/symptoms to suggest the location of the primary cancer (CUP); • Vague Symptoms Pathway Proposal- Clarification of the unmet need for patients with vague symptoms where cancer may be a differential diagnosis amongst other serious diseases and development of a service proposal for how this could be resolved locally; • Acute Oncology Service Specification - Refining and formalising of Acute Oncology Services across all three BNSSG providers, including support for patients with toxicity issues and formalising this in a single service specification for inclusion in provider contracts.

5. Project Closure: CUP Urgent Referral Pathway /1 …To improve the time from referral to symptom management, diagnosis and care plan for those patients with suspected cancer for which the specific cancer site is yet unknown… • CUP Urgent Referral Pathway • Two pilot approaches available: UHBristol’s 2WW CUP Referral and WAHT’s Urgent CUP Referral. • Need to meet national requirements for 2WW: patients were being seen without appropriate diagnostics being done first. This actually created delays • Small numbers being referred through this route: questionable need to commission 3 separate clinics by 3 separate providers across BNSSG.

6. Project Closure: CUP Urgent Referral Pathway /2 • “…The providers already have a robust pathway for treating patients where the specific cancer site is unknown and it is recommended that the 2ww process for these patients is downgraded to accept urgent referrals instead. This would allow for appropriate diagnostics/tests to be implemented prior to consultation. This process is already in place in WAHT and allows for more informed and accurate consultation with patients upon receipt of diagnostic/test results. UHBristol would also like to adopt this process. “ • Recommendation to the BNSSG cancer board to remove the 2ww for these patients: • ensure robust process to ensure patients do not slip through the net and once cancer is diagnosed, patients can be appropriately upgraded..

7. Phase 2: CUP • CUP Urgent Referral Pathway • With the BNSSG agreement to adopt the proposed approach to the CUP Urgent Referral Pathway there would be minimal project management support required • Providers should be able to take this forward within the own organisations • The pathway can be captured and included in an appendix to the Acute Oncology Service Specification and progress in delivery of the service can then be managed through normal contract monitoring routes.

8. Project Closure: Vague Symptoms Pathway Proposal • Clarification of the unmet need for patients with vague symptoms where cancer may be a differential diagnosis amongst other serious diseases • Development of a service proposal for how this could be resolved locally • CCGs to consider how to resource the recommendation from the pathway redesign for a service to accept the patients requiring a broader clinical review

9. Project Closure: Vague Symptoms Pathway Proposal/2

10. Project Closure: Vague Symptoms Pathway Proposal/3 • Patients with clusters of vague symptoms where there is no specific diagnostic identified cancer but there is still a reasonable suspicion. Not easy access to diagnosis and appropriate secondary care management in a timely way. • A number of services were spoken to regarding potential siting of the broad experience clinician but no specific existing service met the needs of this group of patients, these included: • CALS (complex adult liason service) which was felt would not be appropriate for these patients; • patients with unidentified medical symptoms – this clinic was purely for psychology patients and again not appropriate; • Rapid access diagnostic service at UHBristol – this was felt to be focused much more on same day urgent care and not appropriate for this pathway.

11. Project Closure: Vague Symptoms Pathway Proposal/4 • If an existing service cannot have its referral criteria extended, initial thoughts for how the provision of broad experience clinician appointments could be developed are: • Creation of an MDT that includes GP with special interest, Geriatrician, Medical Consultant and Medical Oncologist; • Use of a HOT Clinic approach to ensure that urgent access is available whenever required; • Development of an advice and guidance option to allow GPs to discuss the patient in a timely manner to avoid unnecessary emergency admissions.

12. Project Closure: Vague Symptoms Pathway Proposal/5 • However, whilst repeatedly seeking evidence of the numbers of patients that fit the hypothesis and trying to find cases to understand more about this cohort of patients, the project group has been unable to identify who these patients are. • It is recommended that prior to further work on pathway design, commissioning and implementation, a new approach is agreed for identifying this patient cohort and information is collected on the age range and symptom clusters that this cohort are presenting with in primary care • It is recommended that once a patient cohort has been identified prior to being formally commissioned this pathway is tested with GP Referral Management Service Leads, potential future clinic speciality leads, patients and carers and further refined.

13. Phase 2: Vague Symptoms Pathway • Identify the patient cohort for progression of this pathway • Before moving forwards with this project future resourcing for this element of the project needs to be decided by BNSSG Cancer Working Group. • Potential options for proceeding are: • Capture information from inappropriate referrals to CUP Urgent Referral Pathway and review this in 1 years’ time when there is critical mass of information.. • Do a retrospective audit on the referrals that were moved from the original MDT through 2WW pathways to another MDT,. • Request example patient cases from GP practices based on the outline pathway described above to test if the types of patients identified by practices and consider the trends around symptom clusters and patient demographics.

14. Project Closure: Acute Oncology/1 • Aims and objectives of service • The aim of an Acute Oncology Service is to improve the care of patients presenting at secondary care services with cancer-related emergencies. • Provide a model of care that will deliver improved patient outcomes • in line with National Chemotherapy Advisory Group (NCAG) Guidelines, • to exceed where possible the National Peer Review Standards for Acute Oncology. • On this basis, the aim of the overall service is to provide rapid specialist clinical input into the care of patients who are acutely unwell as a result of: • Complications relating to chemotherapy/radiotherapy treatment • Disease progression • Suspected but unconfirmed malignancy

15. Project Closure: Acute Oncology/2 • Acute Oncology service offered by each of the 3 providers for several years • The current service specification did not reflect everything that the service currently offered and had not built in developments to the service for the future • Therefore, the Service Specification has been updated by the identified clinical leads within the project team. It identifies future service developments which require further scoping/resourcing.

16. Project Closure: Acute Oncology/3 • Local defined outcomes • It is anticipated that the following outcomes will result from the implementation of an Acute Oncology Service: • Improved patient experience of services • Improved patient outcomes • Reduction in emergency admissions • Reduced length of stay for Acute Oncology patients • Reduction in unnecessary diagnostic tests • Reduction in non-beneficial curative treatment when palliative care would be more appropriate • An increase in the number of patients with suspected neutropenic sepsis receiving antibiotics within 1 hour of contacting the hospital • An increase in the proportion of patients with suspected malignant spinal cord compression receiving appropriate investigation and treatment within nationally agreed timeframes

17. Project Closure: Acute Oncology/4 • National measures: • An Acute Oncology Team for each acute hospital • Protocols for the treatment of Acute Oncology presentations • Patients to be seen within 24 hours (1 working day) by the AO team • at least one designated consultant assessment session each day, Mon–Fri • at least two designated nurse triage sessions each day, Mon–Fri • 24/7 Telephone Advice Line for known cancer patients currently on treatment • Rapid access to fast track outpatient clinic appointments • Patient flagging system • AO training for A&E, medical admissions unit and acute medical staff • Policies and protocols • ‘1 hour to antibiotics’ pathway for patients with neutropenic sepsis • Audits of the treatment of neutropenic sepsis and MSCC

18. Project Closure: Acute Oncology/5 • Future Acute Oncology Service initiatives (as agreed by BNSSG Cancer project board who will designate teams to take plans forwards) • Direct patient access to acute oncology services for those with known malignancy (off treatment) with complications of cancer, for example: • Ascites • Pain • symptoms of progressive disease • blood transfusions • Daily urgent access clinics for patients with suspected cancer of unknown primary requiring urgent investigations • Increasing move to community based assessment and management of patients with acute oncology presentations via: • primary care • chemotherapy satellite units • community nursing and palliative care services

19. Phase 2: Acute Oncology • Implementation should be managed by a cross-provider working group consisting of the key stakeholders from each provider • Once contracts and the BNSSG Cancer Working Group have signed off the service specification, any additional resources required to implement this should be negotiated through contracting routes. • Progress on delivery of this element of the project can be overseen through contract management meetings, exception reporting shared with BNSSG Cancer Working Group through provider members to the group.

20. Phase 2: ACE National Requirements • Cross-provider team to ensure commitment for national requirements is continually met • GP clinical leadership linked to the group – it’s recommended that a GP lead from BNSSG Cancer Working Group is identified to work with the cross-provider project team to continue this work.

21. Evaluation of changes • PROMs: patient outcome measure to be agreed upon to allow comparison with other projects • Patient Activation Measure (PAM) to be considered and developed into clinical practice • Basic data collection: • length of time from initial visit to GP to diagnosis • length of time into appropriate alternative service • the number of patients accessing the service • the number of diagnostic tests undertaken by the service – split by tests before and after referral to the service • performance status of the patients referred to the service • impact of PS and tests on the management approach • time to agree a management approach with the patient

22. Evaluation of changes/2 • Baseline work –retrospective data collection on a percentage of patients who have accessed the service in the last 12 months • Patient and carer experience –very short pre/post patient and carer experience survey (no more than 5 questions). • Work is being done by the national cluster team to develop something that could be used, based on a number of cancer PES questions. • Referrer experience survey – very short referrer survey sent with each feedback letter/email • Use of peer review scores to see the impact that the changes to the service have had over time.

23. Questions?