Upper GI Peer Review Aneurin Bevan, Cardiff & Vale, Cwm Taf University Health Boards & Velindre NHS Trust South East Wales Regional Level MDT MEETING ATTENDANCE Peer Review Team Name Job Title Organisation Damian Heron Andrew Baker Yvonne Lush Thirilonganathan Mathialahan Associate Chief of Staff, Cancer CPG Consultant Upper GI & Laparoscopic Surgeon Senior Macmillan Development Manager-Wales Consultant Gastroenterologist Betsi Cadwaladr UHB Betsi Cadwaladr UHB Macmillan Cancer Support Betsi Cadwaladr UHB Mansel Thomas Lay Reviewer Healthcare Inspectorate Wales Duncan Wilkins Consultant Medical Oncologist Betsi Cadwaladr UHB Gareth Brydon Peer Review Lead Healthcare Inspectorate Wales Hywel Morgan Network Director South Wales Cancer Network Network Title Organisation Title Team title South Wales Cancer Network Aneurin Bevan, Cardiff & Vale, Cwm Taf University Health Boards & Velindre NHS Trust South East Wales Regional MDT Review Date Title Name Job Title Organisation Adam Christian Consultant Histopathologist Cardiff & Vale UHB Sunil Dolwani Consultant Gastroenterologist Cardiff & Vale UHB Carys Morgan Consultant Clinical Oncologist / MDT Chair Velindre NHS Trust Wyn Lewis Consultant Surgeon Cardiff & Vale UHB Tim Havard Consultant Surgeon Cwm Taf UHB Xavier Escofet Consultant Surgeon Cwm Taf UHB Guy Blackshaw Consultant Surgeon Cardiff & Vale UHB
Ceri Jones Service Improvement Manager, Cancer Services Cardiff & Vale UHB Gary Howell Surgical Lead Dietitian Cardiff & Vale UHB Alex Karran Clinical Research Fellow Upper GI Surgery Cardiff & Vale UHB Annie Jones Oncology CNS (Upper GI) Velindre NHS Trust Rhiannon Bowen Anita Willicombe Upper GI Advanced Nurse Practitioner Upper GI Surgical Care Practitioner Cwm Taf UHB Cardiff & Vale UHB / Aneurin Bevan UHB Annie Proctor Lead Cancer Clinician Cardiff & Vale UHB Maggie Lucas Lead Cancer Manager Cardiff & Vale UHB Caroline Methuen Oncology CNS (Upper GI) Velindre NHS Trust Eva Glass Macmillan Dietician Velindre NHS Trust
REVIEWERS REPORT Key Themes 1 Structure and Function of the Service The South East Wales Regional Upper GI service was established in September 2010 as part of the reconfiguration of Upper GI Surgical Services in South East Wales. It serves the population of Aneurin Bevan, Cardiff & Vale and Cwm Taf University Health Boards, approximately 1.25 million. In 2011/12 the MDT reviewed 134 new patients, The MDT works at a tertiary level, receiving referrals from the local MDTs in the three Health Boards. Patients will have been diagnosed and usually staged prior to referral. There is a weekly MDT meeting which is held at Velindre Cancer Centre. Patients are booked into the Regional MDT meeting by the local MDT cancer co-ordinators, in collaboration with the Regional MDT co-ordinator. Following discussion at the Regional MDT meeting, those patients requiring radical treatment (surgery or definitive chemo-radiotherapy)) will be managed by the Regional MDT, whilst those deemed unsuitable for radical treatment will be referred back to their local MDT for ongoing care. All radical surgery is centralised at the University Hospital of Wales (UHW). Surgery is undertaken by three Upper GI surgeons based at UHW and two based in Cwm Taf Health Board. There are 3 all-day Upper GI operating lists. The Cwm Taf surgeons have access to a full day list every fortnight. Each surgeon operates on between 16-22 cases per year, but in addition double-handed surgery is routine for all high risk cases. There isn t a formal process for pooling patients; wherever possible, patients are operated on by the surgeon they have seen during the diagnostic process, but in some cases they are operated on by another of the service s five surgeons, when lack of capacity would otherwise lead to a delay. Patients are pre-admitted by the Surgical Care Practitioner or the CNS two weeks before surgery, and are informed who the surgeon will be. In some cases patients may not meet the surgeon until the day of admission. It is possible that the surgeon who has carried out the staging laparoscopy may not do the resection, however the MDT did not feel this is a significant issue. Common guidelines and protocols are in use across South East Wales, and the MDT feels its team working and communications are one of its major strengths. There is also a shared electronic patient record (Canisc) used across the region which supports communication across all aspects of the service. The operating surgeon, irrespective of bases hospital, takes primary responsibility for post operative emergencies up to 72 hours. After that time responsibility rests with the UHW surgical team, but the operating surgeon would still be called and the MDT stated they invariably attend. There is a single follow-up protocol used in all hospitals. Most patients choose to go back to their local MDT for follow-up, but they can choose to be followed-up by the operating team. Non-surgical oncology services are provided by Velindre Cancer Centre, and patients who require chemo-radiotherapy receive it at Velindre. Any medical problems resulting from chemotherapy or radiotherapy will usually be managed by the Acute Oncology Service based at Velindre which holds daily meetings at which cases are discussed, together with a formal weekly AOS MDT meeting.
2 Patient Centred Care and Experience The MDT stated that the strong links between the Clinical Nurse Specialists (CNS) across the region were critical to its success. Each of the local MDTs has a CNS, with a second recently appointed within the Aneurin Bevan service (at Nevill Hall Hospital). The CNSs are members of the Regional MDT and attend their weekly meetings. In addition there is a Surgical Care Practitioner based in the Surgical Centre, who provides support to patients during their surgical pathway, and two Oncology CNSs based at Velindre providing support whilst patients are receiving treatment at the centre. These nurses liaise with their local MDT colleagues to ensure continuity of care. The CNSs have developed a range of patient information leaflets which are used in all hospitals in the region. The MDT has developed a Nurse Led Telephone Follow-Up Clinic, and had undertaken a review and Patient Satisfaction Survey. Whilst there were some disadvantages, such as the lack of family perspective and loss of visual clues, there were significant benefits in terms of patient and carer travel time saved. a. Evidence of Key worker This was examined in the Peer Review visits to each of the local MDTs. 3 Service Quality and Delivery a. MDT Service Support The regional MDT had met on 45/52 weeks (86%). This was below the National Cancer Standard of 90%. The Regional MDT is well attended with representation from the local MDTs and from the surgical and oncology centres, with named cover for most of the core members, however there was no gastroenterologist present at 20/45 meetings (44%), and there was also no named cover. The MDT explained that gastroenterology support for the MDT had improved significantly lately. The MDT had also experienced some problems with interventional radiology attendance (not represented at 20/45 meetings 27%). This was due to the cover radiologist being on maternity leave. Although there was no anaesthetist at any of the MDT meetings, the MDT did not consider this to be a major issue as there were very close links with anaesthetics outside of the meeting. The MDT was unable to access Radio Frequency Ablation (RFA) other than via the Individual Patient Funding Request (IPFR) procedure, which was not felt to be an appropriate mechanism. The inability to access RFA had affected management plans. b. Service Outcome Data
Regional MDT National Target Number / proportion of patients undergoing curative resection Gastric 21/123 (17%) Oesophageal 33/181 (18%) GIST 15/28 (53%) Number of USC referrals treated within 62 days Number of non USC referrals treated within 32 days Stomach 18% -30% Oesophagus 12% - 24% See Local Reports 95% See Local Reports 98% Number of patients with Pretreatment stage recorded 273 of 304 patients (89%) 70% Number with pre treatment performance status recorded Number of patients entered into clinical trials Number/proportion of patients receiving adjuvant therapy Number / proportion of patients receiving radical chemo/radiotherapy. Poorly Recorded 70% 47 10% 21/54 20 Oesophageal c. Key audits projects and outcomes The MDT participates in the National Oesophago-Gastric Cancer Audit. The Team also has an active local audit programme looking at all aspects of the pathway, and regularly has papers published. They had recently undertaken a major audit of the regional service looking at the effects of re-configuration on a number of measures including outcomes, length of stay etc. This was due to be published in a major peer-reviewed journal. The Surgical Care Practitioner undertakes an annual survey of all surgical patients across the region, which has a high response rate. There are high levels of patient satisfaction with the service but issues raised include delays in specialist diagnostic tests e.g. EUS and PET, the time taken in getting a confirmed diagnosis, and perceived delays in primary care prior to referral to secondary care. The South Wales Cancer Network organise an annual workshop at which audits can presented and discussed. d. General Observations The Review Team noted that 61% of patients went straight to surgery. The MDT agreed that seemed low, and they would review their data to check its accuracy, as they believed that it
was very rare for a patient not to see an oncologist. The MDT had not audited stage migration, but discussed every case pathologically, and if there was a difference in pathological staging, the radiology is reviewed as a matter of course. The MDT were concerned about the time it took for patients to go through the pathway from diagnosis to treatment, particularly those presenting as non-urgent suspected cancers, where the waiting times target only covered the time from when the treatment plan was agreed with the patient through to the start of treatment. The MDT accepted that there needed to be more clinical ownership of waiting times and also of the collection of clinical data. 4 Review of Clinical Information in the Clinical Notes and Canisc This was examined in the Peer Review visits to each of the local MDTs 5 Engagement with Management Although all three Health Boards had signed up to the reconfiguration of Upper GI services and the resulting establishment of the Regional MDT and service, there was no clarity as to where overall responsibility for the service lay e.g. the surgical service was hosted by Cardiff & Vale UHB, Velindre NHS Trust hosted the MDT Meeting, and the three health boards had individual responsibility for providing services for their own population. Whilst the local MDTs were an integral part of the overall regional service, they had individual lines of responsibility to their respective Health Boards, and there was no structure covering the regional service as a combined entity. This meant that the MDT were unclear as to who to approach to discuss issues regarding the service, how to take forward planning for the service across the region, or how to ensure equity of access to new treatments across the region, especially as the service was not part of the Welsh Health Specialist Services Committee (WHSSC) portfolio. 6 Culture of the Teams The Review Panel noted that the MDT had developed quickly into a strong, energetic team with extremely close working relationships. There were particularly strong links between the various specialist nurses across the region. There was an active research and trials programme but the MDT felt that it could do even better with trials recruitment. The Panel suggested that MDT consider establishing an Annual Business Meeting at which the totality of the Upper GI service including early detection, and particularly the non-radical management of patients would receive appropriate attention. The MDT agreed that there was no clear lead for the Upper GI service in South East Wales. The Review Panel noted that MDT had a very good Chair, who provided effective leadership of the MDT Meeting and who had taken on responsibility for overseeing the peer review submission for the regional MDT, but they felt that this role was separate from that of an overall Clinical Lead for the regional service. GOOD PRACTICE Identify any areas of good practice
Good Practice/Significant Achievements: A very well attended functional MDT with a strong commitment to its success from all participants The MDT is well led by its Chair, who was supported by all members of the team Good research activity and good trial recruitment Effective out-reach / in-reach with the local MDTs CONCERNS There is a lack of clear ownership of a multi-organisational MDT and lack of clarity over responsibility for issues such as service planning and service development. Health Boards may wish to consider a governance / accountability framework that supports the MDTs function. Consideration could be given as to the role of the regional MDT in the development of the wider Upper GI service across S E Wales. Health Boards may wish to consider similar services in other parts of the UK, such as the East Midlands Upper GI service. There is no clear clinical lead for the whole South East Wales service. This is a different role from the chair of the MDT, though both may be undertaken by the same individual. The data submitted suggested a high percentage of patients going straight to surgery, although it is accepted that the accuracy of this data needs to be verified. The inability to access Radio Frequency Ablation (RFA) for patients, which may affect cancer management plans. SERIOUS CONCERNS None IMMEDIATE RISKS None Z:\SWCN 13\Peer Review\Upper GI\HB Peer Review Reports\Final Reports\S E Wales Upper GI Final Report 19-3-14.docx