Lower Gastrointestinal Cancers. Wrexham Maelor Hospital (WMH) Date of review: 15 September 2017

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1 Peer Review: Sub-site: Health Board/Region: Main Hospital Base: Cycle: Cancer Betsi Cadwaladr University Health Board Ysbyty Glan Clwyd (YGC), Ysbyty Gwynedd (YG), Wrexham Maelor Hospital (WMH) Second Date of review: 15 September 2017

2 REVIEWEES SERVICE DESCRIPTION KEY THEMES STRUCTURE AND FUNCTION OF THE SERVICE brief overview, including objective of the service The Health Board serves a population of approximately 700,000 and diagnoses approximately new colorectal cancers per annum. Colorectal cancers are managed by colorectal cancer multi-disciplinary teams on each of the 3 main hospital sites ie Ysbyty Gwynedd in Bangor, Ysbyty Glan Clwyd near Rhyl and Ysbyty Wrexham Maelor. The core and extended team members of all three MDTs meet regularly as a Colorectal Cancers Clinical Advisory Group to ensure consistent practice across North Wales. PATHWAY describe links between primary care, diagnostics, MDT and treatment Colorectal cancers are diagnosed and staged at each of the main hospital sites of Bangor, Glan Clwyd and Wrexham. All cases are discussed at the local MDT meetings. Surgical and chemotherapy treatment is carried out at each of the three main hospital sites with radiotherapy delivered at the North Wales Cancer Treatment Centre at Ysbyty Glan Clwyd. Patients with liver metastases are managed in conjunction with the hepatobiliary MDT in Aintree Hospital, Liverpool. IMPROVEMENTS/CHANGES SINCE LAST REVIEW refer to last Action Plan An updated action plan was submitted by the Health Board to the Peer Review team as part of its self-assessment. In summary: A new cancer management structure and Health Board Cancer Steering Group have been established The number of consultant pathologists in post has increased and reporting turnaround times have reduced The high emergency admission rate in Ysbyty Glan Clwyd has been audited and reviewed The CaNISC MDM module is used by all 3 MDTs although to a varying degree at present; staging is now recorded at al MDTs All surgeons in Ysbyty Gwynedd are now substantive and attend the MDT meeting; a fourth substantive consultant has been appointed in Ysbyty Glan Clwyd Endoscopy waiting times have reduced 15 September

3 MDT SERVICE Specifics Local / Regional VC Used with whom? Details Three local MDTs providing a service for the regional population of Betsi Cadwaladr University Health Board, including a proportion of patients north of Bronglais General Hospital within Hywel Dda University Health Board due to Bronglais not having a colorectal surgeon. Three separate local MDTs: YGC Separate MDT, no videoconferencing required. YG Videoconferencing input of pathology provision from Ysbyty Glan Clwyd WMH Videoconferencing input of pathology provision from Ysbyty Glan Clwyd Membership / attendance YGC Histopathology and oncology provision within the MDT has improved since the submission data. The MDT are actively looking to address gaps; however, no succession planning evident to cover the impending temporary decrease of colorectal surgeons. YG A well-functioning MDT addressing gaps in the core provision of MDT members as they arise. WMH Increased CNS capacity within Wrexham. Adequate time for discussion MDM Module used Not raised by the MDTs YGC MDM module used during the MDT YG MDM module used during the MDT and also hold data review meetings every 2-3 months consisting of the MDT Co-ordinator, Lead Surgeon, Oncologist and Clinical Nurse Specialist. WMH MDM module used during the MDT 15 September

4 PATIENT CENTRED CARE AND EXPERIENCE Specifics Named Key Worker / contact details Details YGC Named key worker from a point of diagnosis that continues through the site specific team to oncology and/or palliative care. Communication via a referral form sitting on Canisc, with letters and written communication to primary care. YG Key workers are allocated upon diagnosis and communicated to primary care. Key worker not identified throughout the entire patient pathway, for instance where a metastatic case is managed by the oncologist, the nurses are identified as the key worker, but in practice the oncologist fulfils this role. WMH Key worker communicated to GPs within 24 hours. The MDT highlighted an improvement where the cancer key worker needs to be written within all letters communicated. No administration support provided overall. A band 4 role has been identified within one of the MDTs to take on administrative duties, which releases the CNSs to develop a nurse led follow up service and free up consultant time. This does not address the gaps in YGC and YG around metastatic disease and oncology support. Care plans / holistic needs assessment YGC HNAs are not being completed and communicated for patients within this service. Care plans are not communicated to primary care. YG HNAs are not being completed and communicated for patients within this service. Care plans are not communicated to primary care. Reportedly said to be down to limited capacity. WMH The formal process is not in place, however commenced e-hna in the last month and still need to develop further, but the clinical nurse specialists provided assurance that needs are being met and communicated. The team are looking at formalising this process. Follow up process YGC Nurse led follow up clinics. YG No nurse led follow up clinics. Consultants carry out follow up for colorectal cancer patients. WMH Nurse led follow up clinic by Advanced Nurse Practitioner (ANP). 15 September

5 Patient involvement and quality measures Outcomes of the patient survey are planned to be reviewed by the Health Board (CAG), however details are not broken down for each MDT. Teams have individually dealt with outcomes of the survey. MDTs reported no capacity to take forward any improvement work to identify individual differences in quality. There is a plan to introduce a standard questionnaire for the three sites and to be discussed at the next CAG. SUPPORTIVE CARE Specifics Patient Questionnaire Details Generally, the Health Board have explored patient satisfaction within colorectal cancer services. YGC The MDT conducted a patient questionnaire survey seeking the view of patients and have evidenced this within their submission. YG The MDT reviewed the national survey results and acted upon the outcomes, which are identified by Health Board and not MDT or locality. Surveys not currently common practice within the MDT. WMH patient surveys are a rolling programme within the Health Board and WMH Colorectal MDT is next on the schedule. Screening Services are not equipped for the capacity increase with the introduction of the new screening programme parameters (FIT testing). STRATEGIC INTERFACE Specifics Business meeting Details A Cancer Advisory Group (CAG) for colorectal cancers within Betsi Cadwaladr University Health Board YGC MDT business meetings are held and evidenced within their submission. YG A data validation meeting takes place every 2-3 months between MDT Co-ordinator, Lead Surgeon, 15 September

6 Oncologist and Clinical Nurse Specialist. WMH A business meeting is scheduled for the MDT following the peer review visit. Policy Links to organisational strategy / planning MDT policies exist but are not uniformed across the organisation. Links to a strategic cancer approach is evident through the Cancer Advisory Group (CAG). However CAG is an advisory group and not an implementation group of the Health Board. GENERAL OBSERVATIONS The three MDTs having variation in a number of key quality performance indicators within one health care provider. There is good and effective patient pathway management with Ysbyty Gwynedd Oncology team are actively addressing issues of concern All MDTs should acknowledge the progress made against the review outcomes of 2014 Distinctive three teams working separately to achieve common goals and practices for one organisation GOOD PRACTICE GOOD PRACTICE AND SIGNIFICANT ACHIEVEMENTS identify any areas of good practice Colorectal Cancer Advisory Group (Colorectal CAG) full engagement to the group from colorectal MDTs Plan to develop a primary care Cancer Advisory Group (CAG) Pathology improved across the patch since last review Data completion rates including stage at diagnosis have increased across the Health Board and there has been a clear improvement in clinical engagement with the collect5ion and validation of data. Caroline Williams and MDT co-ordinators are seen as instrumental in facilitating improvement of data, services and the pathway Improvement of the services and patient pathways since the 2014 review Engagement of radiology 15 September

7 GOOD PRACTICE GOOD PRACTICE AND SIGNIFICANT ACHIEVEMENTS identify any areas of good practice YGC YG WMH Identified a band 4 role to take on administration duties relieving nurses to explore nurse led follow up and freeing consultant time The MDT have conducted a number of audits to ascertain the relative high emergency admission rates and noted for their proactive approach Very good engagement Access to straight to test Patient experience: The MDT have looked at and responded to patient experience issues Good communication with primary care colleagues Active business and data validation meetings Very good engagement Access to straight to test Good communication with primary care colleagues Very good nursing provision for the MDT Use of PCQ 15 September

8 IMMEDIATE RISKS TITLE Detail of the risk Rationale None None None SERIOUS CONCERNS TITLE Detail of the risk Rationale Surgical cover arrangements Endoscopy capacity Two of the colorectal cancer surgeons at Ysbyty Glan Clwyd will shortly be going on extended sick leave, resulting in a significant cut (50%) in consultant surgical resources. Whilst the Health Board are aware of the issue and are reviewing options to maintain safe services, there are no agreed arrangements in place. The service will be extremely fragile during this time. The emergency closure of an endoscopy room at Wrexham Maelor Hospital, as a result of building maintenance problems, has left only one endoscopy room functional. There are concerns that this will have significant implications for the continuity of colorectal cancer surgical services at Ysbyty Glan Clwyd which could seriously compromise the quality or clinical outcomes of patient care unless there is urgent action. Whilst this a relatively exceptional set of circumstances, the sickness absences are planned rather than emergencies albeit with relatively short notice. With no robust contingency plans in place for the scheduled absences, there remains a risk to patient care. There are concerns that a significant loss of endoscopy capacity could have significant implications in the waiting times for the diagnosis and staging of cancer patients, and in delays for patients undergoing surveillance or having follow-up endoscopies post 15 September

9 SERIOUS CONCERNS TITLE Detail of the risk Rationale treatment to check for recurrence or disease progression It is recognised that this is an emergency situation, and the health board are seeking to implement temporary arrangements to mitigate the loss of capacity. However, in the absence of a more sustainable interim solution, the risk to patient care remains. Relationship of MDT members and Health Board management team of the Glan Clwyd MDT Poor links between MDT clinicians and management was reported within the 2014 review and it would appear that links have deteriorated further in Ysbyty Glan Clwyd. A number of clinicians felt unable to communicate some of their concerns as part of the normal review process, especially with regard to the lack of an agreed contingency plans for the scheduled consultant absences, and asked to speak separately to the review team. CONCERNS TITLE Detail of the risk Rationale Executive lead for cancer Key worker There was limited visibility of, and communication with the Executive Lead for Cancer for MDT members and notably with the peer review programme. A key worker should be identified throughout the entire patient pathway and communicated to the patient and Communication is key to understanding issues and improving services. Health board clinicians feel disengaged on matters concerning the executive lead for cancer. CNSs are often identified as the key worker and actively manage the patient pathway. 15 September

10 CONCERNS TITLE Detail of the risk Rationale Health Needs Assessment (HNAs) Variation in preoperative assessment between sites Variation between teams patient management and data primary care provider. No provision for key workers for metastatic disease and oncology for Ysbyty Glan Clwyd and Ysbyty Gwynedd. Health Needs Assessments (HNAs) are not routinely being completed by the MDTs and communicated to the wider team and/or primary care. YGC limited and selective access to Cardio Pulmonary Exercise Testing (CPEX) and preoperative assessment, noted that access to critical care beds was a constraint leading to cancellation on day of surgery YG high quality dedicated single anaesthetist preassessment but limited access to CPEX WMH has access to CPEX on site The Health Board provides services for residents across North Wales, but there is a wide range of variation in provision of service and quality performance indicators between the various MDTs, notably emergency rates, detection rates, treatment pathway (USC/ nusc), and stage recorded. Whilst of limited risk in terms of clinical practice there is a concern that a single organisation operates services Where the care for a patient is handed over, such as to oncology for metastatic disease, the change should be noted and communicated on correspondence to reflect provision of key worker. Health needs assessments are essential to provide appropriate care for the patients needs. There is no unified Health Board approach to dealing with this gap in the provision of services. Pre-assessment and the use of CPEX testing allows stratification of patient risk and better planning of critical care bed use. Many patients can be managed postoperatively on the ward if identified through pre-operative assessment leading to more appropriate use of scarce ICU resources. Single organisations should endeavour to limit the variation between clinical teams to ensure that residents of the Health Board receive consistent care and that service enhance their flexibility in terms of being able to cover each other. 15 September

11 CONCERNS TITLE Detail of the risk Rationale that demonstrate such significant variation within the same sub-specialty. High levels of emergency presentations Follow up clinic Joint Advisory Group (JAG) on Gastrointestinal Endoscopy Accreditation Although the proportion of cases presenting as emergency admissions has fallen at Glan Clwyd they remain significantly above the national average, and are also high at Wrexham Maelor. Audits have shown that the data is correct, but there is no explanation as to why rates are so high for these MDTS Follow-up services at Ysbyty Gwynedd are consultant led. There is no use of nurse-led follow-up clinics. No valid JAG accreditation for Wrexham Maelor Hospital Audit demonstrates that patients first presenting as emergencies have more advanced disease and significantly poorer outcomes. The health board has undertaken a number of studies to check the validity of the data, and found them to be correct, however they are unable to explain why there is such significantly different practice in these areas in comparison with practice elsewhere in Wales and England. Consultant-led follow-up does not make the best use of scarce senior medical time and resources. Nurse led follow up clinics are recommended in current practice. The service is not accredited through the Joint Advisory Group, who quality assure endoscopy units under the Academy of Medical Royal Colleges. 15 September

12 PEER REVIEW PANEL NAME Position Organisation Hywel Morgan Associate Network Director Wales Cancer Network Jared Torkington Consultant Surgeon Cardiff & Vale University Health Board Tom Crosby Consultant Oncologist Velindre NHS Trust Mandy Tapscott Clinical Nurse Specialist Aneurin Bevan University Health Board Andrea Hague Director of Cancer Services Velindre NHS Trust Jeremy Surcombe Programme Manager, Bowel Screening Public Health Wales Dana Knoyle Improvement Nurse Wales Cancer Network Gareth Popham Peer Review Project Lead Wales Cancer Network Sheila James Cancer Network Administrator Wales Cancer Network HEALTH BOARD STAFF AND MULTIDISCIPLINARY TEAM MEMBERS (YSBYTY GLAN CLWYD) NAME Position Organisation Shirley Wainwright MDT Co-ordinator Betsi Cadwaladr University Health Board David Ramanaden Consultant Gastroenterologist Betsi Cadwaladr University Health Board Ed Favill Consultant Radiologist Betsi Cadwaladr University Health Board 15 September

13 HEALTH BOARD STAFF AND MULTIDISCIPLINARY TEAM MEMBERS (YSBYTY GLAN CLWYD) NAME Position Organisation Caroline Williams Performance Lead, Cancer Betsi Cadwaladr University Health Board Ramesh Rajagopal Consultant Surgeon Betsi Cadwaladr University Health Board Geraint Roberts General Manager Cancer Betsi Cadwaladr University Health Board Julie Mylchreest Colorectal Nurse Betsi Cadwaladr University Health Board Nia Archampong Colorectal Nurse Betsi Cadwaladr University Health Board Dylan Williams Directorate General Manager, Surgery Betsi Cadwaladr University Health Board Andrew Maw Consultant Surgeon, MDT Lead Betsi Cadwaladr University Health Board Beryl Roberts Lead Cancer Nurse Betsi Cadwaladr University Health Board Mradul Gupta Consultant Radiologist Betsi Cadwaladr University Health Board Caroline Usborne Palliative Medicine Consultant, Clinical Director for Cancer Betsi Cadwaladr University Health Board Ellen Greer Hospital Director, YGC Betsi Cadwaladr University Health Board John Collins Radiology Performance Lead Betsi Cadwaladr University Health Board Mahir Al-Rawi Consultant Surgeon Betsi Cadwaladr University Health Board Simon Gollins Consultant Oncologist Betsi Cadwaladr University Health Board Hasan Hadi Consultant Surgeon Betsi Cadwaladr University Health Board 15 September

14 HEALTH BOARD STAFF AND MULTIDISCIPLINARY TEAM MEMBERS (YSBYTY GWYNEDD) NAME Position Organisation Lowri Jones Colorectal/Stoma CNS Betsi Cadwaladr University Health Board Ffion Hughes MDT Co-ordinator Betsi Cadwaladr University Health Board Rachel Everett Site Specialty Manager Betsi Cadwaladr University Health Board Anil Lala Consultant Surgeon Betsi Cadwaladr University Health Board Claire Fuller Locum Consultant Oncologist Betsi Cadwaladr University Health Board Beryl Roberts Lead Cancer Nurse Betsi Cadwaladr University Health Board Caroline Williams Performance Lead, Cancer Betsi Cadwaladr University Health Board Caroline Usborne Palliative Medicine Consultant, Clinical Director for Cancer Betsi Cadwaladr University Health Board Geraint Roberts General Manager Cancer Betsi Cadwaladr University Health Board Nik Abdullah Consultant Surgeon Betsi Cadwaladr University Health Board Andrew Owen (VC) Cancer Services Manager Betsi Cadwaladr University Health Board HEALTH BOARD STAFF AND MULTIDISCIPLINARY TEAM MEMBERS (YSBYTY WREXHAM MAELOR) NAME Position Organisation Yvonne Whittaker Colorectal Nurse Practitioner Betsi Cadwaladr University Health Board 15 September

15 HEALTH BOARD STAFF AND MULTIDISCIPLINARY TEAM MEMBERS (YSBYTY WREXHAM MAELOR) NAME Position Organisation Fiona Davies MDT Co-ordinator Betsi Cadwaladr University Health Board Alison Roberts Macmillan Colorectal CNS Betsi Cadwaladr University Health Board Abozed Ben-Sassi Consultant Surgeon Betsi Cadwaladr University Health Board Michael Thornton Consultant Surgeon Betsi Cadwaladr University Health Board Peter Marsh Consultant Surgeon Betsi Cadwaladr University Health Board Simon Gollins Consultant Oncologist Betsi Cadwaladr University Health Board Helen Lawrence (VC) Cancer Information Manager Betsi Cadwaladr University Health Board Rachel Heywood (VC) Speciality Manager Betsi Cadwaladr University Health Board Hamid Khan (VC) Consultant Gastroenterologist Betsi Cadwaladr University Health Board Helen Cottle (VC) Colorectal Nurse Practitioner Betsi Cadwaladr University Health Board Karen Prevc (VC) Site Speciality Manager Betsi Cadwaladr University Health Board Paulose George (VC) Consultant Gastroenterologist Betsi Cadwaladr University Health Board Conor Corr (VC) Consultant Radiologist Betsi Cadwaladr University Health Board Charlotte Williams (VC) Colorectal Nurse Practitioner Betsi Cadwaladr University Health Board Jaime Windsor (VC) Colorectal Nurse Specialist Betsi Cadwaladr University Health Board 15 September