Improving services for upper GI (OG) cancer Application template

Transcription

1 Trust Improving services for upper GI (OG) cancer Application template Clinical lead Managerial lead Barking Havering and Redbridge University Hospitals NHS Trust Mr Dipankar Mukherjee Eileen Moore Date completed 12 th June 2012 Applying to provide: Local OG Cancer unit Specialist OG Cancer surgical centre This bid is to become one of the two proposed OG specialist cancer centres for the Integrated Cancer System covering North and North East London Proposed sites Local OG Cancer unit Complete Part I Specialist OG Cancer centre Complete Part II Queens Hospital (Barking,Havering and Redbridge University hospitals NHS Trust) Queens Hospital (Barking,Havering and Redbridge University hospitals NHS Trust)

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5 Vision for future upper GI (OG) cancer services Introduction Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) wholeheartedly welcomes the exciting opportunity of radical cancer reform brought about by London Cancer and UCLPartners (UCLP). BHRUT is one of the largest partners in UCLP and since joining the Trust has been working with UCLP in the areas of developing a value based service, training provision, Academic Health Service Network (AHSN) for cancer. The Trust envisages collaborative work to extend between two proposed oesophago-gastric (OG) cancer centres in the integrated cancer system (ICS). We strongly believe this is crucial to deliver the vision of London cancer for the OG cancer patients in the capital. The OG cancer centre at Queens Hospital (QH) aspires to be a world leader in care provision, innovation, education, training and research. In particular the OG cancer centre at BHRUT welcomes the opportunity to work with the partners in London Cancer in delivering and developing care pathways. The vision for the future is to work in collaboration with the other OG cancer centre (s) in London Cancer. This collaboration is envisaged to extend to innovation, research, governance as well as having a joint multi-disciplinary team (MDT) meeting. Collaborative working will extend into all disciplines working as a single team across the ICS. The MDT recognises that innovations for early diagnosis are more likely to evolve from joined up working between academics and clinicians. This is the reason that OG cancer centre at BHRUT is keen to work collaboratively to deliver the best possible outcomes for our patients. The OG cancer centre at BHRUT has worked with the Hutchison/Medical Research Council (MRC) Cancer Cell Unit of Cambridge University in pioneering developments for screening of OG cancer and is keen to take this further across London Cancer. BHRUT BHRUT serves a population of around 750,000 from a wide range of social and ethnic groups, making it one of the largest acute hospital trusts in England. It delivers health care services for 4 main boroughs of Barking and Dagenham, Havering, Redbridge and Waltham Forest. It also provides services for the population of South West Essex. Across the main boroughs, the population is growing faster than the London and national average, at a rate of 9% over the last two years. The local boroughs of Barking and Dagenham, Havering and Redbridge anticipate a further population increase of over 35,000 over the next 5 years. This is a significant demographic challenge and this reality must be a major consideration in planning future services for the ageing population. With close proximity to the M25 and extensive transport links, the physical location of BHRUT in the centre of these future populations makes it ideal to be one of the OG Cancer centres under the auspices of London Cancer. The Trust envisages that it will be providing services to an extensive catchment population. Patients from Harlow and Waltham Forrest will naturally migrate to the specialist centre at QH where transport links are extensive and travel times are short. Essex commissioners fully support patients exercising their right to choose to have their surgical treatment at BHRUT. Whilst acknowledging that the North London boroughs such as Barnet, Enfield and Haringey are not as well connected, BHRUT is ideally situated and has the capacity and clinical expertise to also provide services to the population of East London such as Tower Hamlets, Hackney and Newham as part of the configuration of two new OG centres. The long term vision for the BHRUT OG Specialist Cancer Centre and Specialist MDT is to provide a high quality, patient centred specialist service for a population of 2 million. This service will be readily accessible and supports the delivery of the care pathway, where appropriate, closer to the patient s home. The Trust will ensure that where patients can access these services it will facilitate the provision or transfer of care through a managed and seamless process. Patient choice will be central to the care pathway. Cancer in BHRUT BHRUT has 14 cancer MDTs and treats 10% of all cancers in London and 50% of all cancers in the previous North East London Cancer Network. BHRUT sees 1000 suspected cancer referrals a month. It has delivered all cancer waiting time targets (CWT) for the last 4 years. BHRUT has participated in all local and national cancer projects, 5

6 including National Awareness and Early Diagnosis Initiative (NAEDI). BHRUT has worked very closely with primary care and patient groups and enhanced these links by implementing a clinically led management structure within the Trust. BHRUT has 1300 beds in two sites. Queens Hospital (QH) and King George Hospital (KGH). The Trust has consolidated surgical and medical oncology and radiotherapy services at QH with the provision of modern diagnostic, laparoscopic theatre and radiotherapy facilities. QH is a new modern building that opened in 2006 with 813 adult beds. As a Private Finance Initiative (PFI) hospital the equipment at QH is provided via a Managed Equipment Service (MES) and as such the equipment is replaced and updated as part of a regular refresh cycle. Annual funding for this is part of the PFI contract. This ensures premises and equipment are regularly renewed and modernised. There are excellent purpose built oncology, theatre and academic facilities. There are more than 900 parking spaces for patients and visitors. There is an Acute Oncology Service (AOS) that includes a newly refurbished cancer day centre and a dedicated oncology ward with ring-fenced assessment beds for cancer patients. As a result of a successful bid the Trust was awarded 750,000 from the Radiotherapy Innovation Fund and 750,000 was awarded. This money was used to upgrade the department to deliver IMRT, VMAT and RapidArc. There are two JAG approved endoscopy suites with full diagnostic and therapeutic capability including endoscopic ultrasound. The thriving palliative care team has strong leadership and is extending its service to provide on-site care 7 days a week. The travel links, including train and bus routes, with outer North and North East London and Essex are well established. Rural communities in these areas are particularly well served. For those who drive, QH is within easy reach of the M25 and there is a dedicated car park for cancer patients and carers available free of charge. This is an important part of the service for patients. There are 94 free spaces dedicated to oncology and a further 65 free for disabled parking. BHRUT has consistently achieved excellent peer reviews in many tumour groups including for OG cancer. There are regular cancer away days, both Trust wide and tumour group specific, to modernise and develop cancer services. Excellent links with primary care and newly formed Clinical Commissioning Groups (CCGs) to provide integrated care. The Trust has a track record of working with patient groups to shape services. The OG cancer patient group has been meeting monthly for more than 10 years. OG cancer centre BHRUT has provided specialist OG cancer service for over 15 years and has a specialist MDT which evolves and modernises itself in line with national and international developments. Prospective data collection has been carried out from the date of inception of the first national database ASCOT (Assessment of Stomach and Oesophageal Cancer Outcomes from Treatment) that was rolled out in Subsequently the Trust has entered data into National Oesophago-gastric Cancer Audit (NOGCA). Comprehensive annual audits of process and outcomes have been taking place for more than 10 years. The specialist OG MDT at BHRUT is mature and highly successful with excellent clinical leadership and engagement. The Trust s MDT has a successful history of working with other specialist OG MDTs. These include Barts Health, Imperial and Guys and St Thomas. The Trust s vision is to continue to build on its capability to collaborate and expects a single model of care to be developed across the specialist surgical centres. To support this vision the MDT has an ultra modern video conferencing facility and the capability to video conference with all hospitals in North and North East London and Essex. The Somerset database was introduced two years ago and the MDT has participated in the national MDT-fit project. The OG specialist MDT has achieved 100% completeness of staging data in all four quarters of BHRUT is the only Trust to achieve this in OG cancer out of 38 Trusts in London, Sussex, Kent and Medway, Surrey and Hampshire. 6

7 The MDT believes care closer to the patient s home is paramount and discussions with the stakeholder Trusts has supported this. Travel to the centre is considered acceptable only when there is a valid clinical reason e.g. during survivorship. Our vision is for the specialist clinicians to travel to the patient and to attend, develop and work with local MDTs. This will ensure continuity, improve patient satisfaction to patients and crucially will support the local/diagnostic MDT and Nurse Specialists. BHRUT OG MDT has delivered this type of service to Basildon University Hospital for a number of years and the model proved highly popular. The Trust has recently delivered surgical services to OG cancer patients from Harlow. The additional benefit of this model is that for clinicians it helps to retain and update local expertise and prevent erosion of clinical interest and skills for those participating in the diagnostic MDT. Being strategically located, BHRUT has successfully treated patients from the Thames corridor and West Essex. This is a direct result of the excellent reputation of the OG cancer centre and with patients exercising choice. Commissioners have welcomed and sanctioned this. Surgical service The surgical caseload for OG resection was the highest among the three existing centres during the last recorded year in the ICS. During 2012/2013 the Trust undertook the largest number of oesophagectomies (32) and the largest number of palliative operations (9) in London cancer. 12 gastrectomies were also performed. Surgical outcome data has demonstrated outstanding results. The 30 and 90 day mortality for resections has been zero for the last four years. This has been a consequence of many years of close team working amongst all professions delivering upper GI services at BHRUT and the clinical networks that they have developed with other referring centres. The OG cancer centre sub specialised 10 years ago. Three specialist surgeons, working as a cohesive team, currently provide the OG surgical services. Patients have benefited from the skills and expertise of all three surgeons where postoperative care is provided entirely by this team. Funds have recently been made available to recruit a fourth surgeon to join this team. The surgeons also perform all complex benign OG surgery and provide cover for specialist OG emergencies, such as strangulated hiatus hernia, oesophageal perforation for the local and neighbouring hospitals. OG resections are currently supported by specialist Upper GI anaesthetists who are all dually trained as Intensivists. OG cancer patients receive goal directed fluid therapy, using the LIDCO devise. BHRUT has an Enhanced Recovery Programme (ERP) supported by a nurse specialist. A dedicated team which includes an acute pain service, three laparoscopic resectional surgeons, nutrition team and dedicated therapy support is well established in providing enhanced recovery for OG cancer patients. This results in rapid recovery and patient experience as well as reduced length of stay. The Trust s Executive Committee has approved funding for the reconfiguration of services in order to release theatre capacity at QH. This will enable the service to meet the demands of the proposed increased surgical capacity for OG cancer. This theatre capacity will be made available to both existing surgeons as well as OG surgeons from other hospitals. Funding for a new surgeon will facilitate the employment of OG surgeons currently practicing in the region, either as a full time or part time basis if required. They will be welcomed as a key member of the team. A planned reorganisation of critical care services in line with the Trust s clinical strategy will increase the critical care bed base from 32 at QH to 40 supporting those who need intensive care following surgery. Clinical Governance Joint working and learning between specialist centres and local providers in ICS is central to the Trust s vision. This is crucial to further develop the cancer services at BHRUT. It will ensure the patient pathway is constantly reviewed against best practice. Adherence to guidelines and standards will ensure that the patient is kept central to service provision. The Trust s vision is that there will be one joint audit, governance and research programme 7

8 across ICS. The Trust has a yearly audit programme for all OG cancer patients (including operated patients) auditing and examining both process and outcome. There are ongoing targeted audits in diverse areas of the patient pathway e.g. anaesthetic care, ITU stay, pain control, palliative care, endoscopic palliation, patient experience, provision of patient information, and quality of life. The centre has participated in NOGCA from its inception. During the annual meetings of the MDT, operational policies are revised to reflect changes in national guidelines, new evidence, service elements and change in staffing. An annual work programme is developed to reflect this. The team is developing a comprehensive governance framework which will be adopted in July The expectation is that this will provide clinical and managerial governance to ensure ongoing clinical and financial assurance for safety, quality and patient experience. The aim is to provide a listening service constantly updating and learning from patient and staff feedback. Joint policies will be developed and agreed between the two proposed centres, both for operational management as well as governance and quality assurance. The Trust will also work with all referring organisations to ensure there is a seamless transfer of data and patient information between organisations. In summary BHRUT s vision is to provide a world class OG Specialist Surgical Cancer Centre at QH for the population of East and North East London and West Essex and offer choice to those resident in South Essex. These services will be delivered by a mature, well governed and forward thinking MDT, incorporating a specialist surgical team with a proven track record of safety and quality. The service looks forward to the addition of new OG specialists, both medical and allied health professionals, into this team. OG cancer has the capacity and capability to extend its service to cover a much wider population. The Trust s long term clinical model of service reconfiguration will fully support the model of care required to deliver timely services to a greater number of OG cancer patients. Additional capacity and funding has already been identified to support the surgical cancer pathway. The OG MDT, supported by a modern university hospital, the Acute Oncology Service, interventional radiology services and on-site chemotherapy and a state-of-the art radiotherapy department, will ensure that patients will access services closer to home wherever possible and that it will facilitate the provision of care through a managed and seamless process. High quality care, timely access, patient choice and patient satisfaction will be central to the care pathway. Have you secured trust board-level approval for your application? (please give details) Yes. Presentation of the bid was made to the Trust Board on the 5 th June The Board fully support the bid and the requirement of investment. Have you discussed your proposals with other trusts and/or local GPs? (If so please give details) Yes. The local CCG chair persons have been involved and support the bid. Their letters of support are available on request. Formal meetings have taken place between cancer clinicians, managers and executives between BHRUT and Princess Alexander Harlow (PAH). Patients from Harlow have now received treatment at BHRUT. Agreement has been reached for cancer resections for PAH to take place at BHRUT if two centres are approved. There have been several meetings between clinicians at University College London Hospitals (UCLH) and Barts Health who all agree to work in a collaborative manner. Have you discussed your proposals with any other relevant stakeholders? (If so please give details) 8

9 Yes: Local Cancer Services Advisory Team (CAST). Local patient support group linked to the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS) that has a membership of 400 patients from local boroughs and Essex. These local support groups will provide letters of support. The Trust s stakeholders including; Nursing Directorate, diagnostic services (radiology, pathology and endoscopy), theatre, anaesthetic and critical care, Allied Health Professionals, the Acute Oncology Service and Palliative Care services. The Local Commissioning Support Units. 9

10 Part I: Outline of proposed Local OG cancer unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service at each pathway stage. Please consult the service document for a more detailed description of the provision we would expect services Part of pathway High-level summary of Diagnosis of cancer Fast-track referrals for patients with suspected upper GI (OG) cancer Clinical nurse specialist present at all cancer diagnoses Fast Track referrals BHRUT has a proven track record for treating patients within the cancer waiting time standards. The Trust has systems in place to accept Choose and Book (C&B), written or faxed referrals and those received via through NHS.net. The Trust is currently working with the Clinical Commissioning Groups (CCGs) to increase the use of C&B as the most efficient way to receive cancer two week wait (2ww ) referrals. GPs use NICE 2-week GI referral criteria and London Cancer agreed forms and use the NICE dyspepsia guidance for referrals. Diagnostic facilities on-site (CT and MRI) Robust coordination with other centres in situations in which facilities or resources are not available in-house (e.g. rapid access, PET-CT) BHRUT has extensive experience in the use of C&B and will employ its expertise to ensure that the system is integrated within the patient administration system (PAS) to ensure maximum clinic utilisation. Patients who are booked via the C&B system will have access to clinics at different locations to support their choice of being seen locally. BHRUT, through regular service reviews, will work with GP s to ensure the C&B services are meeting their needs. BHRUT has an established Inter Provider Transfer (IPT) team which tracks referrals to and from other providers to affect efficient patient care and ensure that the Minimum Data Set (MDS) is correct. This enables smooth transition of the patient data to manage a continuous pathway. Clinical workforce trained in advanced communication skills Referral from Primary Care is already supported by the provision of specialist advice from BHRUT to local GP colleagues. To support early diagnosis GPs are given direct access to a pre-determined set of diagnostic services for patients in accordance with agreed pathways GPs can also access pathology results on Cyberlab. All patients referred with suspected cancer will be seen by a consultant within two weeks. The Trust s performance for the 2ww target in was 97.23% and this performance is expected to increase going forward. Treatment within 31 days for all cancers was 99.21%. The Directory of Services for C&B directs GPs to the most appropriate clinician. The BHRUT website further supports this with a section on Upper GI services. GPs can also call through directly to the 2ww office with any queries. If the administration staff cannot assist, they will speak to the consultants to directly advise GPs accordingly. Advice and guidance is available to GPs. Three consultants review patients in clinic that have been referred through the 2ww cancer route. There is clinic capacity to ensure cover for any leave or absence without causing delay to the patient. Patients referred into the specialist clinics are seen within 10 working days. Patients notes and diagnostic tests are available at the time of attendance.

11 Part I: Outline of proposed Local OG cancer unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service at each pathway stage. Please consult the service document for a more detailed description of the provision we would expect services Part of pathway High-level summary of There is a robust administrative infrastructure in place to ensure the waiting times are minimised between tests. All patients suspected of cancer are fast tracked through the appointment systems. All referrals are entered onto the cancer Somerset database so that the specialty team can track each patient through their diagnostic and treatment pathway. Patient tracking meetings and escalation processes are in place twice a week to ensure there are no delays in the pathway. The pathology department makes the result available to the referring surgeon or imaging consultant. All pathology specimens and diagnostic requests are highlighted as urgent with a 2ww sticker in order to fast track for diagnosis. Patients are added to the MDT for discussion as soon as cancer is highly suspected or diagnosed. For patients diagnosed in outpatient clinics, confirmation will be faxed by the CNS to the GP within 24 hours. The hard copy of the fax/clinic letter is sent via the post within 3 to 5 working days. For patients diagnosed with Upper GI cancer during a hospital admission, a discharge summary will be received by the GP within 1 to 3 working days post discharge. Benign clinical diagnosis is communicated to patients on the same day. The OG specialist MDT uses the agreed North East London Cancer Network (NELCN) 2ww referral proforma and has been involved with updating this proforma for use across London Cancer. All patients are entered onto the Somerset cancer database which enables the specialty team to review all stages of the cancer pathway up until the point of treatment or decision to discharge. In order to improve early diagnosis of cancer BHRUT has a very large Barrett s surveillance programme and has worked collaboratively with GPs and with UCL for trials helping to recruit patients with Barrett s and high grade dysplasia The OG department has collaborated with Dr Rebecca Fitzgerald, Cancer Research UK and Cambridge University MRC cancer cell unit. This group is developing a cytosponge test for Barrett s screening for early detection of oesophageal cancer. The Trust is also collaborating with the lead borough, Havering, with public awareness events and the Trust currently participates in cervical screening, bowel cancer screening and breast screening programmes. Clinical Nurse Specialist (CNS): There are two full time CNS posts within the Trust for OG cancer. All new patients are allocated a CNS at the time of diagnosis and at subsequent appointments or admissions. The CNS will ensure that they work with their colleagues 11

12 Part I: Outline of proposed Local OG cancer unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service at each pathway stage. Please consult the service document for a more detailed description of the provision we would expect services Part of pathway High-level summary of to support onward referral to other departments or providers and ensure that patients are aware of their diagnosis at all times. The CNS has received training in holistic assessment to the required standards. CNSs undertake a significant part in the cancer pathway and are already present at the time of cancer diagnosis to provide support to the patient and to the clinician when treatment options are being discussed with the patient. Furthermore the CNS ensures that the appropriate written information is provided to the patient, including the use of Information Prescriptions. Patients are informed immediately by the clinician, accompanied by the on-site CNS, if they have suspected cancer. Benign clinical diagnosis is communicated to patients on the same day at endoscopy. There is an agreed communications protocol in place between the clinician and CNS to ensure timely follow-up. The CNS functions as the patient s key worker who also shares key information freely with specialist centre or other providers delivering stages within the care pathway. Diagnostic facilities There is choice of diagnostic facilities and patients will have access to a full suite of diagnostic services provided by BHRUT. This includes state of the art radiology facilities providing MRI and CT scanning and two modern JAG accredited endoscopy suites each available at QH and KGH. The Trust recently completed the build of a new endoscopy suite at KGH. Following their 2ww consultation with a consultant, patients will leave their appointment with any additional diagnostic tests booked, such as access to endoscopy, CT or other scanning facilities with dedicated appointment slots to ensure timely access. There are drop in services for both ECG and blood tests at QH and KGH. The Trust provides direct access to gastroscopy for all GPs that are graded according to urgency by a speciality registrar or consultant. Access will be within 2-3 weeks. Results will be provided to the patients at this one stop service. The Trust provides direct referral to endoscopy within one week from any specialty for suspicion of OG cancer. There is capacity for the patient to be seen sooner if there is clinical need. Patients will be discussed at the next MDT. With support from the CNS, the endoscopist informs the patient on the day if there is a suspicious cancer. The patient is always offered a copy of the endoscopy report to take away with them, if appropriate. Results of the endoscopy are faxed to the GP within 24 hours. The GP is informed of the diagnosis once the patient 12

13 Part I: Outline of proposed Local OG cancer unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service at each pathway stage. Please consult the service document for a more detailed description of the provision we would expect services Part of pathway High-level summary of has been informed. The Trust has an excellent, long established, EUS service. This is a led by a highly skilled Gastroenterologist with 2 other consultants in support. The unit provides services to Basildon and Harlow Hospitals. The service runs 4 days per week and can accommodate a patient within the next working day.24 hours of referral. Over 300 radial and linear scopes are undertaken per annum with the capability of undertaking biopsies, FNAs and dopplers. An urgent CT scan is requested as soon as cancer is suspected. Access to CT scans and dedicated slots for patients when they leave their endoscopy appointment with a high suspicion of cancer can be provided by Radiology. There is capacity for the CT scan to take place within one week following the endoscopy. However should there be clinical need for the patient to be seen sooner this can be accommodated. The key features of the Trust s diagnostic services are: Patient centred, patient sensitive Responding to the patients needs and where these can be delivered Hot reporting on images with fast turnaround Reporting done by specialist radiologists Routine pathology tests within 4 hours Urgent pathology results with 60 minutes Order Comms in place for pathology and being implemented for radiology (October 2013) Compliance with Royal College of Radiologists and Royal College of Pathologists Guidelines MDT assessed competencies. Endoscopy services are JAG accredited. Radiology operate in accordance to IR(ME)R regulations All required reporting is undertaken by qualified and experienced Consultants, Clinical Scientists or Radiographers as appropriate who are registered with nationally recognised professional bodies. The pathology department is compliant with Clinical Pathology Accreditation (CPA), Medicines and Healthcare Products Regulatory Agency (MHRA), the Human Tissue Authority (HTA) and the Royal College of Pathology. The competency of reporters and staff is assessed and reviewed: Radiology: Competencies are assessed and reviewed via a number of Peer meetings including: Clinical Governance Quality and Safety 13

14 Part I: Outline of proposed Local OG cancer unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service at each pathway stage. Please consult the service document for a more detailed description of the provision we would expect services Part of pathway High-level summary of Morbidity and Mortality Clinical Leads Section Heads Radiation Supervisors Radiation Protection Committee Clinical Audit Clinical Discrepancies Pathology: All undertake formal Continuing Professional Development and participate in: National External Quality Assurance Schemes (NEQAS) Internal Quality Assurance Peer Reviews Clinical Audit Quality and Safety Clinical Governance The Trust will ensure that patient choice is maximised throughout the patient pathway, with patients being able to access sites and departments across a wide geographic area at a date and time of their choice. There is a lead consultant radiologist in place who has overall responsibility for the imaging service provided to OG cancer patients. There is protected time in job plans for preparation and attendance at MDT. Specialist Interventional Radiologists are available for the upper GI service. The Trust delivers timely imaging investigations and reports in order to meet the nationally set target for the commencement of definitive treatment within 31 days of the decision to treat, or, if the patient is on the 2ww pathway, within 62 -days of urgent referral. All patients suspected of cancer or diagnosed have timely access to plain X-ray, US and FNA procedures, CT, MRI and scintigraphy locally. Those requiring PET/CT scans currently access services at Bart s Health. Where it is not possible for the imaging department to provide a report within 5 working days the radiologist will attend the next MDT meeting and provide a verbal report. There are 13 histopathologists employed by the Trust. 4 support the Upper GI services and attend the MDT. There are band 7 dietitians specialising in oncology currently supporting the treatment plans for the OG patients. All patients are screened using the Malnutrition Universal Screening Tool (MUST) during their clinic appointment and any patients with a MUST score of 2 will be referred to a specialist dietitian who is available during the one 14

15 Part I: Outline of proposed Local OG cancer unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service at each pathway stage. Please consult the service document for a more detailed description of the provision we would expect services Part of pathway High-level summary of stop clinic to offer advice on nutrition. There is access to a senior specialist dietitian (level 3) as per the National Cancer Action Team (NCAT) definition or patients during their inpatient treatment stage and as follow-up in the community. The dietetic service is provided by North East London Community Services (NEL CS) at all stages so there is continuity across the pathway regardless of setting. All patients who present with an unintended weight loss weight loss over last 6 months are referred to the CNS and dietitian for health needs assessment. Coordination with other centres In order to deliver an integrated care pathway the Trust will use its already established links with the following organisations to coordinate and access services/support as required: Community health providers Social services Acute Trusts Acute Trust laboratories as required Local voluntary and third sector organisations Other local treatment centres Clinical Commissioning Groups NHS or independent Diagnostic Providers The skills of collaboration and integration play an important role in patient care and the Trust will work with the wider health economy to refine and improve current care pathways, encourage and develop innovative approaches to pathway management and ensure that services are delivered at the convenience to the patient (not the provider). A strong interface between primary and secondary care services is vital to eliminate un delays and to secure early diagnosis. The Trust collaborates with other providers as well as local GPs to share information and work jointly to ensure the patient pathway is delivered without delay and the patient is supported throughout. The Trust strives to deliver services that increase efficiency and reduce delays. Adherence to the cancer care pathway is monitored by core members within the Trust. In order to facilitate discussion with other health care trusts BHRUT has dedicated video conferencing facilities for MDT discussions which can link to all London and Essex trusts. BHRUT is currently working with our partners to ensure that all patients receive tests requested externally are done so in a timely manner. Should an inward referral from another centre or local provider be required facilities are in place to support rapid referral via video conferencing, weekly MDT meetings and daily patient tracking supported by the Somerset cancer database as well as the image exchange portal (IEP). This will facilitate both onward and inward referrals from other trusts to ensure a seamless transfer for patients. 15

16 Part I: Outline of proposed Local OG cancer unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service at each pathway stage. Please consult the service document for a more detailed description of the provision we would expect services Part of pathway High-level summary of There is a robust cancer service administrative infrastructure in place to coordinate any onward/inward referrals. All patients are entered onto the Somerset database to support the tracking of patient pathways. The Trust also participates in the London Cancer Inter Trust Referral Service as a means of receiving referrals for patients from other hospitals and will acknowledge receipt of these referrals. Patients have access to key workers who are aware of their diagnosis at all times, the CNS ensure that they work with their CNS colleagues in the patient s local provider to coordinate tests and support onward referral. BHRUT also proposes that a CNS network is established across North East London to ensure robust communication and hand over of care. The Trust also has in place a Palliative Care MDT where there is cross-working and provision of on-call Palliative Care services with St Francis Hospital. In order to ensure further collaboration with other palliative care providers the Trust would develop a network for palliative care teams that enables all providers to be linked into the Trust and to facilitate communication between the specialty teams during each part of the care pathway. Communication Skills In order to ensure that staff are appropriately trained to communicate with patients on the cancer pathway, all current key members of the clinical staff, including therapists, have obtained certificates of attendance on Advanced Communication Skills training and the Trust will maintain access to the Advanced Communication Skills training, supported by St Francis Hospice. In addition, facilities are in place to run in house training sessions to wider members of the cancer team. The Trust is also in the process of implementing level 4 supervision for those who have undergone level 2 psychology training. MDT Local MDT with conferencing capability with specialist MDT Access provided to a key worker for all patients (usually a clinical nurse specialist) MDT and conferencing capability As a Specialist MDT BHRUT is committed to providing the best systems to support patient focused healthcare. The Trust s IM&T systems are selected on the basis of: Resilience/Reliability Integration with existing clinical and administrative systems Integration with national systems ensuring security compliance Compliance now and in the future with NHS Information Standards Data Set notices. BHRUT conduct a considerable number of IT system upgrades each year to ensure that its IT systems are compliant. Carries out holistic assessment, including BHRUT has dedicated video conferencing facilities for MDT discussions which can link to all London and Essex trusts. The current OG MDT is based in a video conferencing room and has connectivity to all local MDT s. This has 16

17 Part I: Outline of proposed Local OG cancer unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service at each pathway stage. Please consult the service document for a more detailed description of the provision we would expect services Part of pathway High-level summary of palliative care and travel needs recently been upgraded to N3 and uses the BT network. This site is reliably connected to the Image Exchange Portal (IEP), to facilitate the transfer of images. Through the use of IEP BHRUT are able to exchange Radiological images securely with other NHS organisations. The venue has sufficient capacity to accommodate all relevant members attending the meeting. It is equipped with reliable video conferencing equipment to enable communication to take place. There is a microscope available, which is compatible with the video conferencing equipment to enable projection of slides when needed. There is a compatible diagnostic PACS workstation to enable clear projection of images. There are well established referrals routes used for all MDTs from any specialty within the Trust which are documented in the Cancer Access Policy. A strong working relationship between the two surgical centres will enable the development of a single specialist MDT to share knowledge, expertise and patient outcomes. MDTs use proforma-based reporting, and include staging information. The MDT is supported by the Somerset database on which there is capacity to record all patient tests, demographics and a full nutritional status. There is live data collection into the Somerset Cancer Registry database during the MDT. This includes staging, treatment options discussed and outcomes from the MDT. The Trust compliance to staging data for Upper GI in was 100%. Programmed Activities (PAs) are job planned to support these sessions that also include aspects of education. Annual audits of performance takes place based on a clearly-defined and unified audit programme agreed across the whole system. The Trust s MDT is held on a weekly basis video conferencing with KGH. Over 215 new cases per year are discussed. The weekly MDT discusses 30 patients. All tumour staging at the point of treatment planning are entered onto the Somerset database using the TNM7 staging system. The Trust will participate in the completion of the London Cancer MDT proforma to inform MDT discussion. The core membership of the local MDT is comprised of: Lead clinician Specialist OG surgeon Gastroenterologist Clinical Oncologist Radiologist 17

18 Part I: Outline of proposed Local OG cancer unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service at each pathway stage. Please consult the service document for a more detailed description of the provision we would expect services Part of pathway High-level summary of Histopathologist Clinical Nurse Specialist MDT Coordinators Consultant Gastro Lead Specialist Palliative Care Extended members include: Palliative care CNS Representative from anaesthetic/intensive care. Band 7 dietitians specialising in oncology currently advise the OG patients. A minimum data set is completed prior to discussion in the local and with specialist MDT. The reason for non-curative therapy is recorded at the time of MDT and is entered onto the Somerset database. This will include reasons for watchful wait and palliative care. The OG CNS is level 2 psychology trained. There is a programme in place to ensure that the CNS also receives monthly clinical supervision by a level 3 or level 4 practitioners. All patients are reviewed by a member of the MDT regarding fitness. The unit has been collecting data on ASA grade, ECOG status, WHO performance status, possum scores and co-morbidities onto their local database for the past 10 years. This data is also collected on the Somerset database. The CNSs work as part of collective network. The CNS carries out holistic needs assessment, including an assessment of palliative care and travel needs, and refers to cancer rehabilitation specialists as appropriate. All cases for discussion are communicated to the coordinator before the agreed deadline. The MDT meeting includes the following information: A brief clinical history which will include the patient s presenting symptoms Any significant past medical history, including co morbidity assessment and performance status Any family history of cancer The diagnostic tests that have been performed The question to the MDT Demographics and information on the consultant in charge of care. A provisional agenda is circulated to the MDT at least three days before the date of discussion and the final agenda is circulated to the MDT prior to the meeting. All images relevant to the cases on the agenda are made available for the radiologists to review pre MDT. The discussion notes are checked by a clinician or CNS before circulating. The 18

19 Part I: Outline of proposed Local OG cancer unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service at each pathway stage. Please consult the service document for a more detailed description of the provision we would expect services Part of pathway High-level summary of MDT coordinators for all relevant sites are able to communicate the outcomes and delegate accordingly to ensure all outcomes are not over looked. The MDT also facilitates prompt referral to pre-treatment assessments. In order to further support the joint MDT discussions the MDT coordinator is informed of the outcomes of target cases upon their first appointment at the Trust. All OG clinicians fill in a 2ww form when a patient on pathway is present in clinic. These forms are then passed onto the MDT coordinator at the end of the clinic. All cancer treated cases are logged centrally onto the data Somerset database. This provides accurate clinical information to aid sufficient and accurate data for collection. This is mainly for national audits such as: National registries and datasets such Open Exeter and COSD AUGIS/HQUIP Clinical trial recruitment is embedded into the MDT meeting process. A procedure is in place for returning information on patients in the post-treatment follow-up phase. Access provided to a key worker The CNS, level 2 trained in psychology, works as the patient s key worker. All new patients are allocated a CNS at the time of diagnosis and at subsequent appointments or admission to the dedicated ward. This is supported by a key worker policy. The CNS will be present at MDT meetings. CNS undertakes a significant role in the cancer pathway and is present at the time of cancer diagnosis to provide support to the patient and to the clinician when treatment options are being discussed with the patient and the next steps. The CNS will contact the patient to arrange a suitable time and will be present at the consultation. Furthermore the CNS will ensure that the appropriate written information is provided to the patient, including tumour type and treatment options and the use of Information Prescriptions. BHRUT also proposes that a CNS network is established between the specialist centre and the local providers to support onward and inward referral and to ensure that patients have access to Key Workers who are aware of their diagnosis at all times. Holistic Care All patients will be individually assessed to ascertain their individual needs. As needs are identified, appropriate referrals will be made in order to facilitate the patient s care pathway where possible. 19

20 Part I: Outline of proposed Local OG cancer unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service at each pathway stage. Please consult the service document for a more detailed description of the provision we would expect services Part of pathway High-level summary of Non-English speaking patients, and those with other communication difficulties, will be provided with interpretation and translation support at all points of their clinical care. This service is managed through the PALS office via a central booking system. An external contract is in place for provision of interpreting services for patients. This is available either through a telephone based service or via a face-to-face interpreter. The British Sign Language interpreting is available for deaf patients through the contract with Newham Language Shop. The Trust also has a communication system for patients who are deaf and blind. The Trust has a Chaplaincy team, with access to a range of local faith leaders, so that patients and relatives are able to access the support they require. Patients may be referred to Chaplaincy at any time. Chaplains work by making an initial spiritual assessment of the patient s needs. This assessment will be wide ranging focusing on what is important to the patient. The Chaplain will endeavour to assist the patient or carer. All Chaplains are able to offer informal counselling support and the team includes a qualified Counsellor. The Chaplaincy team offers a 24-hour generic emergency on-call service. The team are supported by 40 trained volunteers across both sites with links to local faith leaders as required. This service will be available to patients and carers and staff are provided with the relevant contact numbers for both in hours and out of hours requests. The Trust is currently part of the Macmillan electronic health needs assessment (EHNA) project. All patients will have access to an EHNA questionnaire. The EHNA can be recorded on the Somerset database. Based in the Trust s Macmillan suite all cancer patients can access complimentary therapies such as aromatherapy, reflexology and massage, all free of charge. All patients will continue to undergo holistic assessment at diagnosis and throughout their pathway, supported by the specialists in cancer rehabilitation such as specialist Physiotherapy (PT), Occupational Therapy (OT), Speech and Language Therapy (SLT) and on-site Palliative Care team. Band 7 dietitians specialising in oncology currently advise the OG patients. All patients are screened using the Malnutrition Universal Screening Tool (MUST) during their clinic appointment and any patients with a MUST score of 2 are referred to a specialist dietitian who is available during the one stop clinic to offer advice on nutrition. There is access to a senior specialist dietitian (level 3) for patients during their inpatient treatment stage and as follow-up in the community. The dietetic service is provided by the North East London Community Services (NEL CS) at all stages so there is continuity across the pathway regardless of setting. NELCS have sufficient resource to provide assessment and treatment during follow up clinics and in the community. The specialist clinical oncologist and palliative care MDT member s will also provide expertise in contributing to a holistic approach to care. Travel 20

21 Part I: Outline of proposed Local OG cancer unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service at each pathway stage. Please consult the service document for a more detailed description of the provision we would expect services Part of pathway High-level summary of QH in Romford and KGH in Goodmayes, Ilford have excellent transport links throughout London and Essex. Main line and underground stations are close to both hospitals and several bus routes lead into both sites. The Trust will meet patient requirements for provision of non-urgent patient transport through BHRUT s contracted Non-Emergency Patient Transport (NEPT) and Emergency Medical Technician (EMT) services. G4S, the leading provider of patient transport services, is working in partnership with BHRUT to meet the needs of the patient and GPs with a 24/7 operational service with a fleet of 29 vehicles operated by 83 professional, qualified, experienced staff. The service is an integrated part of the patient s clinical pathway. G4S and their staff take great pride in the level of customer care they provide to our patients and they play a significant part in the patient experience. The specialist team will inform patients of support available for travel to the departments serving the cancer centre. The Trust will reimburse allowable patient transport costs on the day. There is assistance available for patients on benefits needing applications for travel costs. There is a dedicated person to support this. The Trust s cancer patients are supported by a Citizens Advice Bureau worker with two dedicated information centres that provide all of the patient information, specific to their condition. The Trust also provides free parking for patients undergoing Chemotherapy and Radiotherapy. Free parking will be available for all cancer patients undergoing treatments regardless of their home address. For patients who prefer to use public transport, both hospitals are well served by local transport links. There are also are currently discussions taking place with Transport for London to further enhance bus routes and with the local council to further increase car parking facilities particularly at the QH site. The Trust will arrange overnight accommodation for patients requiring accommodation close to the hospital. Treatment decision Patients are offered all appropriate treatment options and all appropriate types of reconstruction whether or not these are available at that particular provider site Decision-making process The Trust has the capacity to assess and treat patients with minimum delay within 62 days of urgent referral and 31 days of diagnosis. Both surgical and oncology clinics are in place at which treatment decisions are discussed in the presence of a key worker. The CNS is present when significant results are given. The CNS will be available at every one of the subsequent meetings and this will continue and will be further supported by a written outcome of these discussions being provided to the patient. When being given results the patient has the option to bring someone with them. The CNS will call the patient and arrange a time suitable for them to attend an appointment. The findings will be discussed with the patient in as 21