Peer Review: Cancer Sub-site: Head & Neck Cancers Health Board/Region: Cardiff & Vale University Health Board Main Hospital Base: University Hospital of Wales, Cardiff Cycle: Second Date of review: 20 September 2017
REVIEWEES SERVICE DESCRIPTION KEY THEMES STRUCTURE AND FUNCTION OF THE SERVICE brief overview, including objective of the service The aim of the MDT is to ensure a coordinated approach to diagnosis, treatment and care services for all patients diagnosed with Head and Neck cancer. The function is to facilitate involvement in decision making by all individuals involved in the care of the patients. The functions of the MDT: A rapid diagnostic and assessment service Treatment and care considered by professionals with specialist knowledge and skills in Head and Neck Cancer. MDT assessment of patients prior to treatment plan discussion MDT discussion of scans, histology and treatment options of all suspected/diagnosed patients Effectively communicate the treatment options with patients and carers, and engage patients in shared decision making Individual Consultants to identify and manage their patients with Head and Neck cancers (including tertiary referrals) Assess patients and carers information needs and offer the level of information and support for all aspects of their treatment and care throughout the course of their illness. Provide treatment and follow-up for these patients and ensure that every patient with Head and Neck cancer receives multidisciplinary management with appropriate oncological input Provide a rapid referral service for patients who require specialist management Provide clinical information prior to and during the MDT meeting, for live update to Canisc, ensuring that data is validated at source. Communicate effectively with patients, carers, other MDT s, and outside agencies including primary and secondary care. Ensure that GPs and community workers are given prompt and full information about any changes in their patients illness or treatment. Data collection of the service for audit locally/nationally for improvement of the service delivery, care and local guidelines. Implement service improvement working with the site specific oncology, radiology and pathology teams and cancer services collaborative to adopt modernisation to benefit the patient journey. Provide a forum for training juniors and informing medical students of the process and function of an MDT Develop a portfolio of clinical trials and ensure that patients are considered for trials in line with guidance. Ensure that protocols/guidelines/standard operating procedures are developed /updated for all aspects of management /diagnosis/treatment of patients with Head and Neck cancer. Clinical Audit Incorporate advances in management and treatment into the patient pathway. Business Meetings (every other month) 20 September 2017 1
PATHWAY describe links between primary care, diagnostics, MDT and treatment 08 June 2017 2
IMPROVEMENTS/CHANGES SINCE LAST REVIEW refer to last Action Plan The format of the MDT has not significantly changed since the last review. Further to the previous peer review we have benefited from the appointment of 2 consultant radiologists and a dental therapist and dietetic assistant (funded by Faceup Cymru). The clinic model remains the same whereby the head and neck clinic runs every Tuesday morning. The MDT places a significant emphasis on the importance of treatment planning and values the importance of all members of the team seeing all new patients before treatment planning and having plenty of time to do so. As part of this treatment planning the AHPs and CNSs have introduced a Pre-Treatment Clinic which is held on a fortnightly basis to meet the needs of those patients seen the previous week at New Patient Clinic. Each patient has an allocated appointment of 1.5hrs and will have the opportunity to see a Speech and Language Therapist (SLT), Dietitian and CNS. Please see the embedded documents under Theme 3 for full details. As such the new and followup patient clinics are separated and alternate each week. This means we operate fortnightly clinics for new and followup patients. We do not feel that this model causes a significant problem with the cancer pathway and on the rare occasion we need to see new or followup patients outside of this model then they have been accommodated. Ultimately we would prefer to have a weekly clinic for our new patients but this change in service would have a significant cost implication and affect on other aspects of the overall service. In response to recommendations made at the last peer review, the AHPs and CNSs have collaborated to set up a Post-Treatment Clinic which provides continuity of care for patients who have completed their treatment and follow up at Velindre Cancer Centre, but are still awaiting an appointment at the UHW MDT Clinic. Each patient has an allocated appointment of 1.5hrs and has the opportunity to see a Speech and Language Therapist, Dietitian and CNS. The clinic is held on a fortnightly basis. Please see the embedded documents under Theme 3 for full details. We are also exploring other models which include weekly all day clinics (for all members of the MDT) which could then include both new and followup patients. Our last peer review highlighted a low access to theatre problem. This has remained unchanged however the introduction of a Post operative Anaesthetic Unit (PACU) has meant that the number of patients cancelled due to the lack of an ITU bed is very low. This has been a significant benefit to the service we provide as during the review period 51 patients required a free flap and therefore the requirement for PACU or the high dependency equivalent is high. 08 June 2017 3
MDT SERVICE Specifics Local / Regional VC Used with whom? Membership / attendance Adequate time for discussion MDM Module used Details The Cardiff and Vale UHB Head and Neck Cancer Multidisciplinary Team (MDT) is a multi-professional group of clinicians from the University Hospital of Wales (UHW) and Velindre Cancer Centre (VCC), and is based at the University Hospital of Wales. The team serves a population of 472,400, with referrals from Cardiff and the Vale of Glamorgan, and from other health boards within South Wales. It is also the tertiary centre for ophthalmology in south Wales. Not required Membership of all the required specialists for this peer review and well attended. There is one consultant oncologist with no cover. 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 Details Named key worker from a point of diagnosis that continues through the patient pathway. However, the MDT do not regularly communicate this beyond the MDT and into primary care. The MDT have identified the handover to oncology as requiring improvement. Holistic needs assessments completed pre-op and not reassessed. Piloting the use of electronic HNAs to be uploaded to internal health record systems. HNAs are not regularly communicated to primary care. Follow up post treatment by referral and hand-over within the MDT includes dietetics, occupational therapy, psychological support and physiotherapy. Treatment summaries not regularly communicated to primary care. 20 September 2017 4
Patient involvement and quality measures The MDT do not actively seek patients views through and are not aware of the response to the national patient survey. SUPPORTIVE CARE Specifics Patient Questionnaire Dental assessments Details The MDT do not currently seek the views of their patients through local questionnaires or surveys. Consultant Restorative Dentist and Dental Hygienist ensures patients have appropriate dental support through the pathway for pre-op and post-op reconstructions. STRATEGIC INTERFACE Specifics Business meeting Policy Links to organisational strategy / planning Details The MDT have a business meeting bi-annually. MDT Operational Policy and follow a number of national guidelines Fortnightly executive meeting GENERAL OBSERVATIONS The MDT actively review their practice and pathways by way of: Access to imaging from primary care referral Audit 20 September 2017 5
GENERAL OBSERVATIONS The MDT consider: Whether a weekly MDT is required and how to deliver, with weekly new patient clinic Lack of access to theatre list for reconstruction How to deliver a Sentinel Lymph Node Biopsy service The potential for robotic surgery and use of similar Da Vinci model, 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 GOOD PRACTICE GOOD PRACTICE AND SIGNIFICANT ACHIEVEMENTS identify any areas of good practice A well-functioning team Dental assessment pre-op and access to post op dental rehabilitation Ultrasound access daily for neck lump assessment Improvement since last review as evidenced by the action plan Improved radiology input to the MDT Key worker copied into letters IMMEDIATE RISKS TITLE Detail of the risk Rationale None None None 20 September 2017 6
SERIOUS CONCERNS TITLE Detail of the risk Rationale None None None CONCERNS TITLE Detail of the risk Rationale Staffing level and skill mix on dedicated head and neck ward A5 Pathology service Outpatient service / survivorship The MDT reported loosing 16 members of staff within 18 months on the dedicated ward. Subsequently the reported cases of near miss incidents have increased on the ward. The Health Board and MDT are aware of forthcoming retirements of the specialist oral pathologist who supports the local MDT but also provides a tertiary second opinion for Wales. There is a concern regarding the lack of succession planning for this specialist role as well as a lack of dedicated ENT pathologist within the team. No service provision post-surgery for specialist outpatient physiotherapy available. HNAs and treatment summaries are not communicated with primary care as standard practice. The Health Board should explore the correlation of ward staffing levels and increased risk, where identified through their quality and safety structure. The turnover of staff will affect patient care and staff morale. Succession planning to continue a seamless service of oral pathology would ensure patients have appropriate specialist oral and specialist ENT pathological input during discussion at MDT and as a tertiary service for Wales. The Health Board should explore service gaps and provision of care in relation to implementing interventions from within the recovery package and supporting survivorship. An essential part of rehabilitation of post treatment care for patients to continue with their lives after cancer. 20 September 2017 7
CONCERNS TITLE Detail of the risk Rationale USC pathway Wound care Oncology cover The Health Board / MDT are below target and show a decrease in achievement since the review of 2014. Dedicated expert nursing time for specialist wound care for complex head and neck reconstructive cases was inadequate Single handed oncologist providing oncology input into the MDT with no cover arrangements for absence. Achievement of the target was reported in the last peer review. The Health Board were unable to satisfy the panel that this is being addressed. Specialist wound care is an essential part of the recovery package for patients and needs to be embedded in the specialist service provided. Where absent, no cover for oncology input to the MDT for discussing systemic anti-cancer treatment and radiotherapy options for each patient. 20 September 2017 8
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 Muthu 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 Owens 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 2017 9
HEALTH BOARD STAFF AND MULTIDISCIPLINARY TEAM MEMBERS NAME Position Organisation Sarah Clements Speech and Language Therapist Cardiff & Vale University Health Board John Potts Consultant Histopathologist Cardiff & Vale University Health Board Adam Jones Consultant Pathologist Cardiff & Vale University Health Board Alyn Coles Cancer Services Cardiff & Vale University Health Board Maggie Lucas Cancer Services Manager Cardiff & Vale University Health Board Annette Beasley Cancer Lead Nurse Cardiff & Vale University Health Board Vicki Stew Clinical Nurse Specialist Cardiff & Vale University Health Board Lynda Bond-Govier Clinical Nurse Specialist Cardiff & Vale University Health Board Alison Ewins Head and Neck Dietician Cardiff & Vale University Health Board Mererid Evans Consultant Oncologist Velindre NHS Trust Sandeep Berry Consultant ENT Cwm Taf University Health Board Rebecca Bailey Clinical Nurse Specialist Velindre NHS Trust Cellan Thomas Maxillofacial Consultant Cardiff & Vale University Health Board Mary Hart Radiologist Cardiff & Vale University Health Board David Owens ENT Consultant Cardiff & Vale University Health Board 20 September 2017 10
HEALTH BOARD STAFF AND MULTIDISCIPLINARY TEAM MEMBERS NAME Position Organisation Graham Shortland Executive Lead for Cancer Cardiff & Vale University Health Board Margaret Hourihan Consultant Radiologist Cardiff & Vale University Health Board Stuart Quinne Consultant ENT Surgeon Cardiff & Vale University Health Board 20 September 2017 11