Meeting of the London Cancer Breast Pathway Board meeting Date: Wednesday 7 th March 2018, 09:30-11:30. Venue: Chair: Rebecca Roylance

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1 Meeting of the London Cancer Breast Pathway Board meeting Date: Wednesday 7 th March 2018, 09:30-11:30 Venue: 6 th floor West, 250 Euston Road, London, NW1 2PG Chair: Rebecca Roylance 1. Welcome and minutes from the last meeting and matters arising The minutes were accepted as accurate. Action Feb 17-07: The radiology guidelines have been circulated for comment with a deadline of the end of March. Action Dec17 12: Board membership there are still gaps for pathology and GP representation and it would be helpful to have an additional member for radiology. It was requested that if representatives are not able to attend that they have a named deputy who has the authority to make decisions Breast event update: JG gave an update and confirmed the date as the 2 nd July. A sign up link will be circulated shortly. BS agreed to share survivorship contact with ESp. Action Dec17-13: HER-2 FISH testing timelines RR gave an update that there had been an issue with a defective probe which was being resolved. However it was agreed that this would be kept under review as the issue was not fully closed. 1. BS to share survivorship contact with ESp. 2. Circulate study day save the date, and registration details 2. Enhanced supportive care Caroline Williams, Lead Clinical Nurse Specialist/Project Manager and Dr Jane Neerkin, Consultant Physician in Palliative Medicine gave an update on this project at UCLH. It is funded through a CQUIN which is in place at 21 cancer centres nationally The presentation was circulated for information in advance (available on request) Key points of discussion were: o The understanding and branding of palliative care can mean that patients are not referred early enough o The model has been clinic based with the rest of the breast team and this integration has been beneficial o Communication with GPs, community services and patients has been a key part of the project o The funding has been extended until March 2019 and the team are writing a business case to take to commissioners to expand the service to other patient groups. DG suggested taking a patient representative to this discussion o There were questions regarding how the CQUIN will be evaluated and the complex social issues trigger o Caroline agreed to contact details being circulated for further questions o There may be opportunities to communicate learning from this work through the Cancer Vanguard as the Christie and Royal Marsden are also participating sites to help other sites develop this service

2 3. HS to circulate CW s details 4. HS/CW to consider communication of learning from Enhanced Supportive Care CQUIN 5. Genetics guidelines MA presented the guidelines which had been circulated in advance. The updated guidelines have broadened criteria. The aim is to achieve consistency across London although there are resourcing challenges associated with this, especially given the RMH mainstreaming work. There has been a change to the Ashkenazi Jewish criteria. JF suggested that this should be changed to just Jewish as the risk is no different from the Sephardi Jewish community The service needs to prioritise patients who have cancer. Patients without cancer should be seen in family history clinics. The board discussed the fact that some of these patients are being referred for suspected cancer and being seen in one stop slots which is not appropriate The family history clinic at BHRUT is now working well and making very few inappropriate referrals and two way communication has helped this. MA suggested that the team are happy to take queries as this is more efficient than rejecting inappropriate referrals. These queries should include postcode and NHS number. MA also offered to help support family history clinics set up if required, and there may be some PA time to set up a genetics clinics at other sites if required. There was a discussion about testing all women under 40. This would be desirable but the current laboratory and human resource constraints would mean that this change would lead to an increase in waiting times for results The current waiting times for results was discussed. Urgent cases are 4 weeks, others 8 weeks. MA emphasised that it is very helpful for the team to know when the planned date for surgery is to help with prioritisation. MA is happy to deliver education on genetics but suggests larger forums to give the greatest value. Primary care is a key target also. HS to link with GP cancer leads to discuss this. 5. ALL to consider appropriate education opportunities for genetics guidelines 6. HS to link MA with GP cancer leads to discuss education 6. Data review and timed pathway sign off Performance data will be circulated for information. The timed pathway was reviewed. There was a discussion about timings after the first subsequent treatment, in particular chemotherapy following surgery which has a target of 31 days. This is currently very challenging to achieve. The board approved the updated timed pathway. 7. Denosumab self-administration

3 RR tabled the draft standard operating policy and patient information sheet for consideration by board members, being developed for use by trusts in NCEL. 7. ALL to review denosumab self-administration SOP and Patient Information Sheet for comments 6. Audit AP presented RRM audit progress. Patient data is pending from Barts (55), Barnet / CFH (30), RFH (23), UCLH (5), Homerton (5), Whipps Cross (1) o Trust representatives were asked to follow up outstanding returns RR presented Vinorelbine audit data on behalf of MN. o Barts and UCLH have moved to give oral Vinorelbine o NMUH give IV only o BHRUT data was not requested but ESt outlined the BHRUT model which has reduced hospital visits. BHRUT data and information to be added and their model shared 8. Trust representatives to follow up outstanding returns for RRM audit data. 9. Vinorelbine audit to be carried out at BHRUT to allow learning from this model. HS to share proforma with ESt 7. Screening Project update and update on performance data Steven Davies was unable to attend but sent a written update as follows: High Risk patients After genetic testing each patient is assigned a protocol and this will determine the imaging plan and frequency. One of the reasons for introducing high risk into the screening programme was so that there is a seamless transition from high risk monitoring into screening. Post 70 normal protocol would normally end and patients are expected to self-refer. If a patient is deemed to be high risk at an early age and hasn t been diagnosed with cancer up to the age of 70, in terms of protocol within the programme their risk returns to that of a normal client at that age and normal process for screening clients is followed. However there is a current NHSBSP review of the high risk programme and the protocols associated with it and they are subject to change. All screening services are awaiting feedback from National Office. London screening performance: specific information and data isn t owned by NLBSS and the Hub but only reported on and produced. It will be requested that this information is authorised for wide distribution but currently an overview is provided below: NLBSS (North London), CELBSS (Central and East London), WOLBSS (West of London), SWLBSS (South West London), SELBSS (South East London), ONEL (Outer North East London)

4 Round length (No. clients screened within 36 months) NLBSS, SELBSS, ONEL and WOLBSS are meeting this target. SWLBSS isn t currently adhering to this target year to date. CELBSS is also failing to meet this target. In terms of CELBSS, as outlined in the project update below, a major challenge to the service is radiographic staffing. Screen to Normal (No. of women with routine recall letter within 2 weeks) All London services meeting this national target Screen to Date of First Offered Assessment (No. of women offered assessment appointment within 3 weeks of screening) All London services meeting this national target Screen to Assessment (No. of women attended assessment appointment within 3 weeks) NLBSS is meeting this target, all other services in London are failing to meet this target. Technical Recall London services are adhering to this target Project progress: Post April 1 st Service transfer of CELBSS from Barts Health to the Royal Free remains April 1 st. Project steering groups have increased frequency to weekly and all relevant sub groups feedback into this (HR/ IM&T/ Clinical/ Programme management and Admin/ Contracts). Clinical Pathway The clinical pathway (screening/ high risk) will remain as it currently is to ensure there is minimal disruption to the population and clients/ patients currently within the pathway. A review of all practice will be on going in both the NLBSS and CELBSS services to ensure that both adhere to best practice and align to the required National guidelines and protocols. This includes a continuation of current MDM processes and pathology. As noted in the previous meeting, all patients diagnosed with breast cancer will be given patient choice as to the treating organisation, as per NHS BSP guidance. Recruitment and staffing Both services are dealing with major challenges in terms of staffing establishment, most notably in the area of radiographers as noted above. Pre-transfer both services have been actively recruiting with rolling job advertisements on the relevant platforms. Both organisations are looking at methods of alternative and creative recruitment and looking at possible joint recruitment opportunities to attempt to appeal to the widest audience. Agency staff are used in both NLBSS and CELBSS to help ensure the required services are maintained however the availability of agency staff is also now becoming more limited across London. The biggest challenge facing the CELBSS service post April is the recruitment of radiographers to meet the 36 month round planning requirements of the service. A comprehensive round planning exercise is underway to establish the impact on round length in the first 12 months of service delivery and how the best use of available resource and staff can be maintained. Medical equipment Medical equipment is available at each of the planned sites and under the required maintenance agreements. Estates Post April the service will continue to be hosted at St. Barts (Barbican site) for screening, assessment, MDM, film reading and as an administration base. Screening will also to be located as per the needs of the local population. Static screening sites to include: Whipps Cross, Mile End, Olympic Park, Homerton, Kentish Town.

5 A comprehensive feasibility study is underway to ensure that the most optimal sites are utilised for the respective populations and GPs when inviting as per the round plan. HR All workforce changes across the services are under final review by the respective organisation s HR teams and await final sign off in preparation for service transfer on 1 st April. Efficiency Initially as noted above, all plans and processes are in place to reduce unnecessary disruption to the patient pathway. Areas where there are duplication of tasks across both services, for instance pathology, courier services, specific administrative tasks etc... These will be reviewed to ensure that the services operate as efficiently as possible, delivering the best patient service and offering the best use of NHS funding and resources. 8. Nursing update CM gave an update. There is currently a shortage of breast care nurses in the network. UCLH have been very short staffed which is on the Trust risk register but have successfully recruited an ANP (April start date) and two band 7s. NMUH have recently advertised but were not able to appoint The Whittington are interviewing in April but there will be a c.4 month gap The need to look at succession planning and support for nurses was discussed o JF suggested that it would be helpful to have colleagues from the nursing group to come out to Trusts to support with ideas CG stated that at PAH a band 6 has been recruited to help with succession planning There were plans to support UCLH with nurses from across the network but HR processes delayed this. HS gave an update that there is a workforce sharing agreement awaiting sign off across the UCLH Cancer Collaborative which should support such initiatives. CM is feeding into national work on CNS roles with a timeline of September 2018 for a draft guideline. DG felt that this should be practical guidance which is of most use to nurses. 10. Nursing forum to consider how to support the workforce across the network 9. AOB A working group to discuss MDT improvement is meeting on the 15 th March. An MDT study day was held at the Royal Free/Barnet/Chase farm MDTs on the 6 th March. RR advised there had been NCEL locality discussions around introduction of Herceptin biosimilars and it is unlikely to be mandated because of the impact of switching sc back to iv therapy for patient experience and capacity on daycare. 10. Next Meetings Monday 4 th June 2018, 3-5pm; 6 th floor West meeting room, 250 Euston Road, London NW1 2PG Thursday 13 th September 2018, 3-5pm; 6 th floor East meeting room, 250 Euston Road, London NW1 2PG Friday 14 th December 2018, am; 6 th floor East meeting room, 250 Euston Road, London NW1 2PG

6 ACTION LOG Action reference Action Owner Date Due Status Sept Mastectomy audit results to be presented at the MA June 10 Sept Feb next Network Education Day Trust representatives to discuss the consent audit with their teams and ask a named oncologist to carry out the audit to feed back names at the next meeting Update Dec: Deferred as Trusts at various stages of implementing new national consent process RC to update radiology guidelines within surgical guidance An update will be added to the end of the metastatic breast cancer report and will be sent around to check the information is correct. RRM audit data to be presented at the next board meeting. 2ww, 62 day and 31 day data will be presented at the next board along with newly published one year survival data for review and discussion by board members Trust reps Dec 2016 RC Update To be signed off by Sept 17 board 04/06/18 HS 07/03/18 In progress AP 07/03/18 Deferred to June 18 RR 07/03/18 Circulated with March board minutes Nominations to be made for new members to join the board ALL 07/03/18 Ongoing RR to liaise with UCLH regarding PAH and BHRUT RR 07/03/18 Ongoing review HER2 FISH tests BS to share survivorship contact with ESp. BS 04/06/18 Circulate study day save the date, and registration details HS 04/06/18 Complete HS to circulate CW s details HS 04/06/18 Circulated with March board minutes HS/CW to consider communication of learning HS/CW 04/06/18 from Enhanced Supportive Care CQUIN ALL to consider appropriate education ALL 04/06/18 opportunities for genetics guidelines HS to link MA with GP cancer leads to discuss education ALL to review denosumab self-administration SOP and Patient Information Sheet for comments Trust representatives to follow up outstanding returns for RRM audit data. Barts (55), Barnet / CFH (30), RFH (23), UCLH (5), Homerton (5), Whipps Cross (1) HS/MA 04/06/18 Complete ALL 04/06/18 Trust reps 04/06/18

7 09 10 Vinorelbine audit to be carried out at BHRUT to allow learning from this model. HS to share proforma with ESt Nursing forum to consider how to support the workforce across the network MN/HS 04/06/18 Proforma shared CM 04/06/18 Attendees Name Initials Trust/Organisation Rebecca Roylance RR UCLH Claire Grainger CG PAH Joanna Franks JF UCLH Munaza Ahmed MA GOSH Emma Spurrell ESp Whittington Jasdeep Gahir JG NMUH Muhamed Al-Dubaisi MA-D RFL Emma Staples ES BHRUT Lesley Cousins LC Patient Representative Helen Saunders HS London Cancer Joanna Franks JF UCLH Antony Pittathankal AP BHRUT Deborah Glover DG Patient Representative Faye Gishen FG Royal Free Caroline Williams (in attendance) CW Enhanced Supportive Care - UCLH Jane Neerkin (in attendance) JN UCLH Palliative Medicine Claire Mabena CM RFL Bhawna Sirohi BS Barts Health Apologies Name Initials Trust/Organisation Virginia Wolstenholme VW Barts Health Steve Davies SD RFL Ros Crooks RC RFL Patricia Dean PD Patient Representative Mark Nathan MN GSTT Esther Hanson EH Royal Free Mary Burgess MB UCLH Prisca Duah PD Barts Health Tina Dahs TD GP Kate Kavanagh KK NEL CSU