Health Board/Region: Cwm Taf University Health Board Main Hospital Base: Royal Glamorgan Hospital, Llantrisant. Date of review: 20 September 2017

Transcription

1 Peer Review: Cancer Sub-site: Head & Neck Cancers Health Board/Region: Cwm Taf University Health Board Main Hospital Base: Royal Glamorgan Hospital, Llantrisant Cycle: Second Date of review: 20 September 2017

2 REVIEWEES SERVICE DESCRIPTION KEY THEMES STRUCTURE AND FUNCTION OF THE SERVICE brief overview, including objective of the service To collectively manage all Head and Neck cancers in a multi-disciplinary setting to ensure patients are managed according to latest evidence and clinical guidance, and that they are treated appropriately, with dignity and taking into account patient choice. The role of the Head and Neck MDT is to ensure that all patients diagnosed with head and neck cancers are managed within an appropriate multidisciplinary care pathway. The MDT serves the population of Cwm Taf University Health Board and ENT patients from the Princess of Wales Hospital Bridgend. The MDT provides a coordinated approach to diagnosis, information giving, treatment options and overall care and is a central point of reference for individuals and organisations outside the MDT. The aim is to provide the best quality, evidence-based, timely care to patients with a diagnosis of Head and Neck cancer. PATHWAY describe links between primary care, diagnostics, MDT and treatment The patient will be referred to the ENT/OMF specialist at their local hospital by their GP or GDP. Some patients may be referred via A&E or another consultant from a different speciality. If from the history and examination a cancer is suspected the patient will require further diagnostic tests. The ENT/OMF clinician responsible for the patients care will request these tests via the USC pathway. The following diagnostic tests may be carried out at the outpatient clinic appointment: - nasendoscopy - blood tests Other diagnostic tests may be required and requested via the clinician responsible for the patients care. These tests would wherever possible be carried out near the patients home and could include investigations such as: - USS and FNA - CT scan - MRI scan - PET scan - Chest XRay 20 September

3 - Panendoscopy/EUA - Biopsies All Cwm Taf patients who have undergone further diagnostic tests/biopsies which confirm malignancy will be seen in one of two clinics ENT (Friday am RGH designated diagnosis clinic) or OMF Clinic (Tuesday am RGH and Thursday am PCH) so that a clinician who is a member of the Head and Neck Cancer MDT and head and neck CNS can discuss the results, explain the next steps in their pathway and provide any necessary support required at that time. All POW patients with a confirmed malignancy will be seen in ENT clinic, POW on a Tuesday PM dedicated Head and Neck Clinic. The patients will be seen by a clinician who is a member of the Head and Neck Cancer MDT and Head and Neck CNS can discuss the results, explain the next steps in their pathway and provide any necessary support required at that time. AHP support is available at this point if required. The patient will be advised that they will be referred to the Cwm Taf Head and Neck cancer MDM and clinic which is held at the Royal Glamorgan Hospital every Wednesday morning where a plan of care will be determined. At the point of informing the patient of the cancer diagnosis a letter is sent to the referrer (GP or GDP) with a copy faxed to the GP within 24 hours of patient being seen. A letter detailing the management plan will be sent by the Head and Neck Cancer Services MDT coordinator to the GP following the initial MDM and clinic on Wednesday morning. A decision is made by the MDT regarding treatment intent as either curative or palliative. The following are treatment options which may be offered to a patient with head and neck cancer by the MDT: Surgery Radiotherapy Chemo-radiotherapy Chemotherapy Best Supportive/Palliative care Prior to any treatment commencing the treatment modalities of choice would be discussed with the patient and their relatives / carers by the clinician, normally the consultant, who would be responsible for providing that treatment. The Clinical Nurse Specialist and other relevant members of the MDT will also attend and support patients in their decision making. All patients who require head and neck cancer surgery without reconstruction will be admitted to the Royal Glamorgan Hospital. Patients who require reconstructive surgery using free tissue transfer will be admitted to the University Hospital of Wales. For patients attending the MDM from Princess of Wales Hospital this service can be provided at Morriston Hospital or they may be provided at the University Hospital of Wales in Cardiff. Patients from Cwm Taf and Princess of Wales Hospital requiring input from upper GI, craniofacial, cardiothoracic or neurosurgery colleagues will be admitted to the University Hospital of Wales. Patients will stay on the designated ward until they are fit to be discharged/transferred. During the post-operative period the patient will be cared for by the ward nursing and medical staff. In addition to this they will be reviewed and treated by other allied health professionals and others as required. 08 June

4 The consultant who undertakes the patient s operation will write a clear operation summary in the patient s medical notes and this summary will include a clear plan of care for the post operative period. The patient will be reviewed on a daily basis by a Consultant led ward round. A MDT ward round happens once a week in RGH and once a week in UHW. Following their surgery patients will be discharged home/transferred to local hospital for further aftercare and support with rehabilitation by the members of the local support team. Referrals to community nursing service and palliative care are made when required. The patient will have a clear discharge or transfer plan which identifies what care is required for the patient following discharge/transfer and who should be providing this care. All patients who require radiotherapy will attend Velindre Cancer Centre (VCC) for the planning and delivery of the radiotherapy treatment. Information (Velindre patient information booklets) will have been given to patients by the clinical oncologist and CNS when they are first seen in the Royal Glamorgan Hospital prior to attendance at Velindre. Patients are also given verbal information about radiotherapy treatment, side effects and functional impact at their local AHP pre treatment clinic appointment at the Royal Glamorgan Hospital/Princess of Wales Hospital/Tenovus Bus Bridgend. The patient will attend the chemotherapy clinic in Velindre for assessment and consent prior to initiation of treatment. Information (Velindre patient information booklets) will have been given to patients when they are first seen in the Royal Glamorgan Hospital prior to coming to Velindre. These include relevant contact details, details of the chemotherapy to be given and potential side effects. Where the disease or condition of the patient precludes curative treatment, the patient will be considered for (non-curative) palliative therapy with chemo- radio- biological or any other measures likely to provide symptomatic relief, prolongation of survival or maintenance of the best possible quality of life. IMPROVEMENTS/CHANGES SINCE LAST REVIEW refer to last Action Plan There has been considerable investment in the Princess of Wales service with the appointment of a new consultant and a full SALT/Dietetic/CNS service now in place. The service is now fully integrated within the Cwm Taf MDT pathway. The surgical pathway has been realigned to meet the recommendations of the 2009 external review of Head and Neck Cancer Services in South East Wales. This recommended that all inpatient work for maxillo facial and ENT be centralised on the RGH site for all patients including Bridgend patients. This has now been implemented. Timely access to plastic surgeon has been improved due to second H&N plastic surgeon appointment in Swansea. Cross cover arrangements now in place for CNS. Patients now receive holistic needs assessments and care plans. 08 June

5 MDT SERVICE Specifics Local / Regional VC Used with whom? Membership / attendance Adequate time for discussion MDM Module used Details The local MDT serves the population of Cwm Taf University Health Board and ENT patients from the Princess of Wales Hospital Bridgend. Videoconferencing used to link into the regional MDT meeting, but not required in the local MDT meeting. The MDT is well attended by the current makeup of team members. The MDT is not attended by Consultant Restorative Dentist or Dental Hygienist. Not raised by the MDT. Canisc MDM module used live in the MDT PATIENT CENTRED CARE AND EXPERIENCE Specifics Named Key Worker / contact details Care plans / holistic needs assessment Follow up process Patient involvement and quality measures Details Named key worker from a point of diagnosis that continues through the patient pathway. The MDT recognised that there is no formalised handover. HNAs are completed and electronically accessible. Good communication with primary care. Follow up post treatment by referral and hand-over within the MDT, further details within the MDT Operational Policy. The MDT actively seek patients views and reviewed the results of the national questionnaire survey. Details contained within the MDT Operational Policy. 20 September

6 SUPPORTIVE CARE Specifics Patient Questionnaire Dental assessments Details MDT reviewed the results of the national patient questionnaire survey. Consultant Restorative Dentist and Dental Hygienist arrangements through Cardiff & Vale dependant on Health Board funding. Patients do not have appropriate dental support through the pathway for pre-op dental assessments and post-op reconstructions. STRATEGIC INTERFACE Specifics Business meeting Policy Links to organisational strategy / planning Details The MDT detail business meetings within their operational policy. Operational Policy Health Board Lead Clinician is also Consultant ENT Surgeon within the MDT. GENERAL OBSERVATIONS The MDT actively review their practice and pathways by way of: Business meetings Successful neck lump pathway, acknowledging excellent referral time to diagnosis Audit The MDT consider: 20 September

7 GENERAL OBSERVATIONS How to deliver a Sentinel Lymph Node Biopsy service The potential for robotic surgery and use of similar Da Vinci model within Cardiff & Vale University Health Board, which is currently used for prostate surgery and has reported increased outcomes and quality of life for patients within other areas such as head and neck surgery The value of the regional MDT The MDT acknowledge the number of cases being discussed multiple times The lack of dental assessments for their patients GOOD PRACTICE GOOD PRACTICE AND SIGNIFICANT ACHIEVEMENTS identify any areas of good practice Health Board / MDT have addressed their action plan from the review of 2014 Proactive team with a good team ethos Radiologist one stop clinic and staging HNAs electronic accessible Patient experience, own patient survey Time to diagnosis 20 September

8 IMMEDIATE RISKS TITLE Detail of the risk Rationale None None None SERIOUS CONCERNS TITLE Detail of the risk Rationale None None None CONCERNS TITLE Detail of the risk Rationale Dental assessments Outpatient service / survivorship No dedicated provision for dental assessments and access to a consultant restorative dentist, raised within the review of Health Board did not consider the community service as a provision. Patients may not have equality of service compared to provisions across Wales. Variation of post-op service across the Health Board and for patients received from Princess of Wales. The provision of Speech and Language Therapy is fragile with insufficient integration of musculoskeletal, physiotherapy and occupational therapy. Pre and post op dental assessments are a requirement within current guidelines, including provision of post op reconstruction. Progress to appointment of Restorative Dental Consultant is being made, but needs to be appointed and given adequate support to function in the team. The Health Board should explore service gaps and provision of care in relation to delivering elements of the recovery package and supporting survivorship. An essential part of rehabilitation of post treatment care for 20 September

9 CONCERNS TITLE Detail of the risk Rationale patients to continue with their lives after cancer. Clinical Nurse Specialists and cross cover Acute Oncology Service Variation of service across the Health Board and for patients received from Princess of Wales, raised within the review of No dedicated acute oncology service at the Princess of Wales Hospital, raised within the review of The Health Board / MDT should consider arrangements of cross cover and equality of service provision for all patients treated. The Health Board / MDT should consider arrangements for the service and equality of service provision for all patients treated. 20 September

10 PEER REVIEW PANEL NAME Position Organisation Cath Bale Associate Medical Director Wales Cancer Network Conor Marnane Consultant ENT Surgeon Abertawe Bro Morgannwg University Health Board Huw Jones Consultant Maxillofacial Surgeon Betsi Cadwaladr University Health Board Senthil Muthi Consultant Radiologist Betsi Cadwaladr University Health Board Carolyn Faulkner Clinical Nurse Specialist Abertawe Bro Morgannwg University Health Board Wendy Wilkinson Allied Health Professional Lead Wales Cancer Network James Owen Consultant Restorative Dentist Abertawe Bro Morgannwg University Health Board Dana Knoyle Improvement Nurse Wales Cancer Network Gareth Popham Peer Review Project Lead Wales Cancer Network Sheila James Network Administrator Wales Cancer Network OBSERVER Sian Wilson Specialist in Special Care Dentistry Betsi Cadwaladr University Health Board 20 September

11 HEALTH BOARD STAFF AND MULTIDISCIPLINARY TEAM MEMBERS NAME Position Organisation Dawn Casey Macmillan Lead Nurse for Cancer Services Cwm Taf University Health Board Wayne Jenkins Lead Cancer Manager Cwm Taf University Health Board Tarek Allouni Directorate Support Manager Cwm Taf University Health Board Susan Jones Department Manager Maxillofacial Unit Cwm Taf University Health Board Phil Brumwell Consultant Pathologist Cwm Taf University Health Board Claire Brodie Cancer Services MDT Coordinator Cwm Taf University Health Board Cellan Thomas Maxillofacial Consultant Cardiff & Vale University Health Board Sotiris Exarchos ENT Consultant Abertawe Bro Morgannwg University Health Board Richard Webster Oncology Consultant Velindre NHS Trust Rebecca Bailey Clinical Nurse Specialist Velindre NHS Trust Ali Jaffery ENT Surgeon Cwm Taf University Health Board Daniel Ashworth Maxillofacial Consultant Cwm Taf University Health Board Jane Wall Clinical Nurse Specialist Cwm Taf University Health Board Emma Jones Clinical Nurse Specialist Abertawe Bro Morgannwg University Health Board 20 September

12 HEALTH BOARD STAFF AND MULTIDISCIPLINARY TEAM MEMBERS NAME Position Organisation David Smith Consultant ENT Cwm Taf University Health Board Rhian Rhys Consultant Radiologist Cwm Taf University Health Board Sandeep Berry Consultant ENT Cwm Taf University Health Board Claire Osborne Speech and Language Therapist Abertawe Bro Morgannwg University Health Board Rhian Thomas Dietician Cwm Taf University Health Board Menna Payne Speech and Language Therapist Cwm Taf University Health Board 20 September