Urological Cancers Peer Review 2014 MEETING ATTENDANCE Peer Review Team Name Job Title Organisation Dr Tom Crosby Network Medical Director South Wales Cancer Network Mr V Srinivasan Mr J Featherstone Consultant Urology Surgeon Consultant Urology Surgeon Betsi Cadwaladr UHB Abertawe Bro Morgannwg UHB Dr Mau-Don Phan Consultant Oncologist Singleton Cancer Centre Abertawe Bro Morgannwg UHB Janet Marty Urology Clinical Nurse Specialist Aneurin Bevan UHB Melanie Simmons Performance Manager Abertawe Bro Morgannwg UHB Mansel Thomas Lay Reviewer Healthcare Inspectorate Wales Dinene Rixon Observer Healthcare Inspectorate Wales Sue Davies Review Co-ordinator South Wales Cancer Network Network Title Organisation Title Team title South Wales Cancer Network Urology Multidisciplinary Team Review Date Title 30 January 2014 Name Job Title Organisation Mr K Asaad Medical Director Dr J Barber Consultant Oncologist Velindre NHS Trust Georgina Boon Uro-oncology Nurse Practitioner Mr G Brown Consultant Surgeon Paula Cooper Lead Nurse Palliative Care 1 of 8
Marie Evans Deputy Head of Strategy Miss J French Consultant Urologist Mr D Jones Consultant Urologist Keryn Jones Lead Urology Nurse Practitioner Dr S Kumar Consultant Oncologist Velindre NHS Trust Gaynor Laver Urology Secretary Dr B Palaniappan Consultant Radiologist Anthony Shanahan Urology Surgical Care Practitioner Mr R Singh Consultant Surgeon Craige Wilson Dr R Winter Assistant Director of Operations Cancer Lead Clinician Consultant Radiologist 2 of 8
REVIEWERS REPORT Key Themes 1 Structure and Function of the Service The peer review team met with representatives of the Urology multidisciplinary team (MDT) to review their urological cancer services. The Health Board provides health care to the communities of Merthyr Tydfil, the Cynon Valley, the Rhondda Valley and Taff Ely which contain some of the most socio-economically deprived areas in Wales; as a consequence there is higher incidence of malignant disease and comorbidities. Urological cancer services are provided over two acute sites at Royal Glamorgan Hospital and Prince Charles Hospital; delivering a service to a deprived health community can be very challenging and is compounded by the two hospital sites being 30 miles apart. The team receive high volume of referrals which convert to high levels of disease. Complex cases requiring radical treatment are discussed via video conferencing with the Cardiff and Vale MDT at the Tuesday MDT meeting, following MDT discussion patients are seen in UHW urology clinic. GP referrals are received electronically or via fax to both Royal Glamorgan and Prince Charles Hospitals. There are different pathways on each site and this has led to delays in the management of referrals which has impacted on the clinical pathway. An acknowledged priority for the team is to streamline the referral process and move to a single point of receipt for referrals by implementing an electronic referral system. The Urology MDT is supported by two MDT Co-ordinators, one in Prince Charles Hospital and one in Royal Glamorgan Hospital. Patients to be discussed at the multidisciplinary team meeting (MDM) are entered on to Canisc by either co-ordinator depending on where the referral is received. The MDM is held at Royal Glamorgan Hospital and co-ordinated by the Royal Glamorgan MDT Co-ordinator. It is hoped that streamlining the referral process will also impact on MDM co-ordination. The team are keen to implement the live use of the Canisc MDM module and are in discussion with Cancer Services management team to discuss resources to support this development. Currently, the MDT management plan is completed on a pro forma, a copy of which is entered into the patients notes and a copy is sent to primary care, it was noted that all letters are available electronically on Myrddin (patient administration system). The MDT meeting is well attended by representatives from Radiology, Pathology, Oncology and urology nurse specialists, however a member of the palliative care team has not been present at the MDM on 25 occasions (52%); the peer review team were reassured that there are robust pathways in place to refer patients to the palliative care team. A team of three radiologists provide excellent support and provide cross cover for TRUS biopsy lists and specialist MRI; additional lists are also available to support the current demand on the urology service. It was noted that bone scans are temporary unavailable; the review team were reassured that this was soon to be resolved. Both sites have a one-stop haematuria clinic and following collaboration with NLIAH have set up a one-stop prostate biopsy clinic. Current demand exceeds capacity and waiting list initiatives have been put in place to secure extra capacity. Due to lack of junior grades these 3 of 8
services are vulnerable due to low staffing levels. Nurse led raised PSA clinics have been set up on both sites, patients referred with a raised PSA are seen initially by the urology nurse specialists and the diagnostic procedure is explained. Patients receive a follow up telephone call with the results of their biopsy, patient booklet and key work information is sent to the patient by post. The nursing team have undertaken an audit of this service the findings of which have been very positive. Achieving urology cancer waiting times is a challenge for the health board, despite the introduction of the one-stop clinics there are still delays in the pathway. Patients referred to Cardiff and Vale UHB for radical surgery have long waits to receive their surgery. It was recognised that the health board needs to strengthen its mechanisms for performance monitoring of patients referred to tertiary centres for treatment. Cancer Services facilitate a weekly tracker meeting to discuss cancer performance and waiting times; areas of concern are highlighted to the appropriate directorates. The peer review team expressed their concern that there was no clinical involvement at the tracker meeting, noting that clinical engagement at the performance meeting is vital and ensures the pro-active management of patients by the MDT. It was highlighted that the National Institute for Clinical Excellence has updated their guidance on Improving Outcomes in Urological Cancers; the Health Board has pro-actively worked through the recommendations of the guidance and currently provide multiparametric MRI and are moving from targeted biopsy to template biopsy. The Health Board recently held a stakeholder event, at which the development of an acute oncology service was identified as a priority. The Health Board is currently exploring different models, and is due to visit Aneurin Bevan UHB to understand how they have implemented their acute oncology service. Recruitment to clinical trials is available for patients referred to the tertiary centres for their treatment; health board recruitment of specimens for Cancer Bank is poor due to lack of resources. 2 Patient Centred Care and Experience The team of Clinical Nurse Specialists (CNS s) work on both sites providing nursing and key worker support for patients. The CNS s run a raised PSA clinic, patients referred with a raised PSA are seen initially by the urology nurse specialists and the diagnostic procedure is explained. Patients receive a follow up telephone call with the results of their biopsy, patient booklet and key work information is sent to the patient by post. The nursing team have undertaken a number of patient-centred audits to gain the patients view of the information they provide and the appropriateness of patient areas. It was noted that the results from a recent Macmillan patient survey have been circulated to all health board; however the findings from the survey had not been shared with the urology team. a. Evidence of Key worker The clinical nurse specialists confirmed that they provide the key worker role for patients; all patients are given a key worker card with the telephone numbers for the team. Evidence of key worker was recorded in four of the five sample cases notes provided by the health board. 4 of 8
3 Service Quality and Delivery a. MDT Service Support The MDM is held at Royal Glamorgan Hospital and co-ordinated by the Royal Glamorgan MDT Co-ordinator; referrals are entered onto Canisc depending on where they are received either by the MDT Co-ordinator in Royal Glamorgan Hospital or the MDT Co-ordinator in Prince Charles Hospital. The team is currently streamlining their referral process this should also improve the co-ordination of the MDM. The MDT is keen to implement the MDM module within the multidisciplinary team meeting to aid co-ordination of the meeting and support live data collection and validation. The MDT meeting is well attended by representatives from Radiology, Pathology, Oncology and urology nurse specialists, however a member of the palliative care team has not been present at the MDM on 25 occasions (52%); however robust referral pathways are in place to refer patient to the palliative care team. The radiology team provide an excellent service, allowing the team to access to high resolution radiology imaging, including CT, MRI and interventional radiology which supports the patients diagnostic pathway. b. Service Outcome Data Number/% of USC referrals treated within 62 days Number/% of non USC referrals treated within 32 days Number/% of patients with Pre-treatment stage recorded Prostate 74% Bladder 68% Renal 64% Prostate 94% Bladder 100% Renal 96% Prostate 218/270 (80%) Bladder Not staged until TURBT Renal 38/56 (68%) Target 95% 98% 70% Number of patients entered into clinical trials 9 patients via tertiary oncology centre 10% Number of patients donating to Wales Cancer Bank Number/% of patients discussed at MDT Median time for patients with muscle invasive TCC Bladder start of definitive curative treatment Median time to TURBT 8.1% - health board level data Prostate - 270/270 (100%) Bladder No data provided Renal 37/56 (66%) Not available Not available 100% 93 Days 5 of 8
c. Key audits projects and outcomes The team has undertaken a number of patient-centred audits to gain the patients view on the service they deliver; feedback has been very positive with patients confirming they receive an efficient, effective quality service. The MDT engages in network level audit and Cwm Taf patients are involved in these audits. d. General Observations The review team noted that overall provides an excellent consultant led service, with a fully engaged and dedicated clinical lead. It was noted that the service has capacity issues and regular waiting list initiatives have had to be used to secure extra capacity. The lack of junior grades impact on the service which is vulnerable due to staffing levels. The team confirmed that they found the data collection process challenging and were dependant on information from the tertiary centres to support the self assessment process. The dependency on tertiary centres for treatment was also noted as a concern due to its effect on patient waiting times. The MDT has held two business meetings during 2013/14 as an opportunity to plan their service and identify issues that need to be addressed. An outcome following the business meeting has been the development of their MDT Operational Policy which clearly describes their urology service, supported by an Annual Report detailing the service activity and work plan for 2014. The MDT has excellent support from surgery, radiology, pathology and oncology and patients are supported by a team of clinical nurse specialists. The team has developed excellent links with colleagues at the tertiary centre for patients referred for radical surgery which facilitates good channels of communication. The health board management team facilitates a number of meetings to discuss cancer performance and waiting times, information is disseminated to directorates however the clinical input at these meetings was not clear. It was highlighted that clinical engagement at the performance meetings is vital and ensures the pro-active management of patients by the MDT. The peer review team expressed their concern of the lack of awareness of the recently published Macmillan patient survey which had been made available to the health board several weeks earlier but not shared with the urology team. 4 Review of Clinical Information in the Clinical Notes and Canisc The team reviewed a sample of case notes for 5 patients; 3 of the 5 case notes reviewed had evidence that GP s were sent notification of a diagnosis of within 24 hours. There was evidence in all 5 case notes of the MDT discussion and agreed management plan. The key worker evidence has been referenced in section 2a. 5 Engagement with Management Cancer Services have established a number of Strategy/Steering groups that bring together the main stakeholders who deliver of cancer services to the health community of Cwm Taf. The Cancer Services Steering Group is chaired by the Medical Director/Executive lead for Cancer and is the key forum for communication with the Lead Cancer Clinicians and the 6 of 8
MDT s. The Urology MDT has recently engaged in a number of service improvement initiatives however it was unclear of the Executive Board s involvement/support in these initiatives. 6 Culture of the Teams The team deliver a good consultant led patient centred service, enhanced by enthusiast team work. The MDT Lead Clinician provides the team with excellent leadership and it was evident that the team had developed strong working relationships both within the team and with colleagues at the tertiary centre. The team have recognised that their service could be enhanced and have engaged in a number of service improvement initiatives in collaboration with NLIAH to improve the efficiency, effectiveness and quality of their service. The MDT and Health Board demonstrated their willingness to look outside their own service for examples of good practice, for example acute oncology in ABHB. This might also be undertaken looking at how that Health Board have dealt with the challenges of coordinating a service over two acute sites. GOOD PRACTICE Identify any areas of good practice Good Practice/Significant Achievements: Patient focused enthusiastic team, with excellent leadership, providing a strong clinically led and delivered service Very good radiology service and support to MDT Development of one stop prostate biopsy clinic and Nurse Led raised PSA clinics The MDT have established bi-annual business meeting to help develop their services and have engaged in service improvement initiatives IMMEDIATE RISKS NONE SERIOUS CONCERNS NONE 7 of 8
CONCERNS There are different referral pathways in Royal Glamorgan Hospital and Prince Charles Hospital the Health Board may wish to consider further work to streamline the referral pathway MDT co-ordination is split across sites, and the MDT have been unable to introduce the Canisc MDM module live within the MDM setting Pathway capacity is vulnerable due to staffing levels The Health Board does not have a mechanism to performance monitor cases referred to other health boards for radical treatment. Lack of an Acute Oncology Service Lack of evidence of engagement with the Executive Board around areas of performance and service improvement Poor levels of recruitment to the Wales Cancer Bank 8 of 8