Meeting Title Mid and South Essex Acute Trusts Joint Working Board (meeting in public) Meeting Date 18 th October 2017 Agenda No 10 Report Title Oncology Service Report Lead Executive Director Report Author Yvonne Blucher, Managing Director Southend University Hospital Michael Catling, Cancer Programme Director MSB Action Required Decision Discussion Monitoring Background / Context The oncology service at Mid Essex is experiencing an acute shortage of consultant staff with only 1 wte in post and 5 wte vacancies. The service has been unable to recruit despite recently advertising. As a stand-alone service outside of a cancer centre it is exceptionally difficult to attract candidates. The service has short term measures in place (including locums and support from Southend and Colchester) but faces genuine risks to the service and to patients the longer this continues. There has been an agreement at JEG to move to integrated clinical and managerial leadership for oncology across the group. This will create a hub and spoke model for oncology with the service hosted at Southend as the cancer centre. There are some details to be finalised between the Trusts concerning accountability prior to formalising this change. The strategic plans for cancer care across the group continue to develop in conjunction with the STP leadership and wider health economy. There is a particular focus strategically on innovations to support early diagnosis, stratified follow up and the survivorship agenda. This risk has been escalated recently and added to the Board Assurance Framework as joint risk 1.0C. To supplement the BAF update this paper has been brought forward to describe and contextualise the workforce challenges and the steps underway to mitigate and ultimately resolve these. The Joint Working Board comprises a committee (known as the Success Regime Committee) of Basildon & Thurrock University Hospitals NHS Foundation Trust, the Success Regime Committee of Mid Essex Hospital Services NHS Trust and the Success Regime committee of Southend University Hospitals NHS Foundation Trust which meet in common.
Assessment of Implications Financial Does this proposal have revenue (recurrent or non-recurrent) implications for the Trusts? Yes / No Does this proposal have capital (recurrent or non-recurrent) implications for the Trusts? Yes / No Risk Equality and Diversity Freedom of Information Other Implications Identified (including patient safety and quality, legal and regulatory compliance) Recommendation MSB Joint Risk 1.0C Failure to recruit to achieve sustainable establishment in Medical workforce at MEHT leading to inability to deliver needs of service and support clinical trials programme. Failure to embed robust governance arrangements to support the delivery of safe, high quality care to patients. Failure of group model to progress at pace. This proposal has been subject to an equality analysis and there are no implications for groups with protected characteristics No exemptions apply (i.e., information is in the public domain) Impact on the safety of patients/quality/adverse publicity Regulation 9 Person-centred care Regulation 10 - Dignity and respect Regulation 12 - Safe care and treatment Regulation 18 Staffing Regulation 17 Good governance The Success Regime Committees which comprise the Joint Working Board are invited to: Note the oncology workforce challenge and actions planned to improve Appendices N/A The Joint Working Board comprises a committee (known as the Success Regime Committee) of Basildon & Thurrock University Hospitals NHS Foundation Trust, the Success Regime Committee of Mid Essex Hospital Services NHS Trust and the Success Regime committee of Southend University Hospitals NHS Foundation Trust which meet in common.
Oncology Service Report 1. Introduction The oncology service at Mid Essex is experiencing an acute shortage of consultant staff with only 1 wte in post and 5 wte vacancies. The service has been unable to recruit despite recently advertising. As a stand-alone service outside of a cancer centre it is exceptionally difficult to attract candidates. The service has short term measures in place (including locums and support from Southend and Colchester) but faces genuine risks to the service and to patients the longer this continues. This risk has been escalated recently and added to the Board Assurance Framework as joint risk 1.0C. To supplement the BAF update this paper has been brought forward to describe and contextualise the workforce challenges and the steps underway to mitigate and ultimately resolve these. 2. Background 2.1 Oncology Oncology is the field of medicine that is devoted to cancer and consists of three primary disciplines: Clinical Oncology (the treatment of cancer with therapeutic radiation and chemotherapy) Medical Oncology (the treatment of cancer with medicine, including chemotherapy) Surgical Oncology (the surgical aspects of cancer including biopsy, staging, and surgical resection of tumours) The oncology service in a DGH setting incorporates Clinical and Medical Oncologists. Their practice operates as a tertiary service with referrals made from other Consultant Surgeons or Physicians. Surgical Oncology as aligned with surgical disciplines across the organisational structure. This paper is concerned exclusively with Clinical and Medical Oncology which shall hereafter be referred to as Oncology. 2.2 National consultant shortage In 2015 the faculty of Clinical Oncology undertook a UK workforce census across all cancer centres. Whilst the report noted an increase in wte Consultants of around 4% pa this was deemed to be insufficient to keep up with demands made on Oncology services. Key factors driving this demand increase were identified as: Increasing rate of cancer incidence Rapid growth in people diagnosed and living with cancer due to an aging population Complexity of technological developments such as IGRT and SABR Page 1
The report surmised that further and continued expansion of the clinical oncology workforce is required, not only to meet the demands of a growing population of cancer patients, but also to fully realise the opportunities made available by new cancer treatment technologies for improved patient outcomes. In 2014 the faculty published a report on Clinical oncology workforce the case for expansion which considered in detail the changing demands on oncology. This report forecast a growing deficit in workforce against the clinical workload as demonstrated below: UK clinical oncology consultant workforce and workload forecast One of the key factors driving the oncology workload is the development of advanced radiotherapy techniques. These developments (such as IMRT, IGRT and SABR) improve tumour control and reduce toxicity associated with radiotherapy. The faculty forecast that consultants will need additional 0.75 PA time per week for the additional workload associated with these advanced techniques. This drives an even greater gap between the forecast workforce and workload across the UK: UK clinical oncology consultant workforce and workload forecast (with additional 0.75 PA time per week for advanced radiotherapy planning) Page 2
2.3 Increasing specialisation The Royal College of Radiologists faculty of Clinical Oncology recommends that a consultant should normally undertake no more than two broad areas of tumour site specialist practice as it is unlikely that a clinician can remain up to date across too wide an area of practice (RCR Guide to job planning in clinical oncology, 2015). The rapidly emerging evidence base in clinical practice, together with operational commitments such as MDT meetings and cross-site working, make it increasingly difficult for consultants with three or more site specialities to maintain adequate CPD in all areas. The national census identified that 36% of UK consultants had 3 or more site specialities. In 2016 the number of site specialties per consultant working across Mid & South Essex was well above the national average as demonstrated below. Tumour sites per Consultant National benchmark 2015 Mid & South Essex 60% 50% 40% 30% 20% 10% 0% 1 2 3 4 or more 2.4 Cancer treatment services in Essex There are Radiotherapy departments located at Southend Hospital, Queen s Hospital Romford and Colchester Hospital. Each of these three Trusts is a cancer centre under the 1995 Calman-Hine definitions and are still recognised as such. Solid tumour chemotherapy is provided from units at each of the cancer centres listed above and from Broomfield Hospital. 2.5 Oncology service arrangements in South Essex For many years (15+) the oncology service in South Essex has been delivered by a single team of consultants employed by Southend Hospital as the cancer centre. These consultants provide a full range of outpatient clinics at both Basildon and Southend hospital sites (and some satellite clinics). With few exceptions, South Essex patients attend Southend Hospital for Radiotherapy and Chemotherapy treatments. The oncology service for South Essex is governed entirely through Page 3
Southend Hospital including clinical leadership, managerial support, clinical governance, employment and revalidation of medical staff, etc. Within the oncology medical team there is no distinction between colleagues working at Southend or Basildon sites (or both) with all consultants joining a single governance structure (including audit meetings, SACT oversight, service management, etc). 2.6 Oncology service arrangements in Mid Essex Traditionally patients in Mid Essex have travelled to Colchester for Radiotherapy treatment whilst most chemotherapy treatment has been provided at Mid Essex. Prior to the early 2000 s the oncologists working in Mid Essex were employed by Colchester Hospital, mirroring the model still operating in South Essex described above. However, the employment of these consultants transferred to Mid Essex sometime in the early 2000 s. From this time until around 2014 Mid Essex had a stand alone service. In this period the oncologists undertook all their inpatient and outpatient activities at Mid Essex. The clinical oncologists also spent some time every week in Colchester for Radiotherapy planning of their patients. It is highly unusual to have a stand-alone clinical oncology service of this kind. There are some standalone services nationally run by medical oncologists. However, the vast majority of clinical oncologists in the UK are employed in cancer centres which offer outreach services. In 2014 the Mid Essex oncology service had 2 vacancies to which it could not recruit. It was recognised that the stand-alone nature of the service was a considerable barrier to recruitment. An agreement was reached with Southend Hospital to create 4 joint posts working across Mid and South Essex. These posts were advertised and all 4 positions filled. The joint posts were structured with Radiotherapy planning provision at Southend Hospital which has resulted in some Mid Essex patients going to Southend for Radiotherapy. The patients have a choice in this regard and are advised by the clinical team, CNSs as well as the oncologists. The current service model for Mid Essex oncology is best described as a mixed economy. Whilst the evolution of the model did successfully attract new consultants, it has created other difficulties. The joint posts were broadly 50:50 in time split between Mid Essex and South Essex. This created additional pressures for the Mid Essex based team in covering regular duties on that site such as ward rounds. The consultants in the joint posts also struggled with working across 2 separate services with distinct governance structures and leadership / managerial arrangements. This resulted in a lot of duplication for these consultants and planning difficulties across the 2 services (for example, planning annual leave and cross cover). Page 4
2.7 Mid & South Essex Oncology service redesign Whilst there has been a desire over 2-3 years from the oncologists at Southend to develop an integrated service, discussions with MEHT really started in December 2016. From the outset the two teams of oncologists have agreed in principle that a single integrated service is the right model for the future. All parties agree that recruiting and retaining consultants is the priority and a larger team based in a cancer centre gives the best chance of success. The steering group for this process has included the oncology clinical leads, senior managers, cancer lead clinicians and lead cancer nurses. There is a broad consensus that the delivery of oncology services will continue in all three hospitals so patient access is maintained. The discussions have focussed more on the workforce and governance models that can best facilitate recruitment and retention of oncologists into a high quality service. The steering group agreed the following service vision which was later supported by the JEG: High quality clinical care that meets the highest standards and is provided close to patients whenever possible is provided in a centre of excellence when necessary gives patients choice and control of decisions about their care is innovative giving patients access to the latest developments is organised to attract, retain and develop excellent clinicians Oncology outpatient services should be offered on each hospital site for all but the rarest cancers. This is to ensure good access for local patients to local services for both new referrals and follow up. Specialist cancer surgery is not being considered as part of this review. Furthermore, there are no plans to reconfigure specialist cancer surgery within the group. There must be clear cross cover arrangements for each tumour site on each hospital site to ensure that access to services is maintained during planned leave across the service. Appropriate senior medical cover must be maintained on each hospital site to ensure overall supervision of Oncology patients (including inpatients, Chemotherapy, Radiotherapy). Individual Consultants should have duties across a maximum of 2 hospital sites. We aim to design job plans for individual consultants in line with college guidance that a consultant should undertake practice in no more than two broad areas of tumour site specialist practice. Aligned SPA such that all Consultants across the group can participate in shared governance on a regular basis Page 5
3. Oncology consultant workforce 3.1 Current position In total 5 consultant oncologists have left the group in the past 12 months. Two of these resignations were from very senior experienced consultants from Mid Essex with significant clinical caseloads and extended job plans with additional PAs. Covering these 2 positions will require 3 new consultants though the overall cost is comparable. So in summary we have 6 vacancies across the group. Consultants who have left the service: Dr Tahir (based at Mid Essex) Dr Crook (worked across Mid Essex, Southend and Basildon) Dr Skaria (based at Mid Essex) Dr Chan (based at Basildon) Dr Holikova (based at Mid Essex) Within the Southend team there are 11 substantive consultants and one consultant vacancy. This vacancy has been held pending a decision on integrating with Mid Essex as this allows some flexibility to design attractive posts with Mid Essex. This position is being covered by a Trustappointed fixed-term locum consultant. The Mid Essex team has one substantive consultant and 5 vacancies. There are still 2 consultants from the Southend team working in joint posts with Mid Essex making up the equivalent of 1 wte at Mid Essex. The Trust did advertise posts earlier this year for the stand alone service but attracted no clinical oncology applicants. There were applicants for a medical oncology post though these applicants were all known to the Trust and whilst an offer was made no appointment has yet followed. 3.2 Current cover at Mid Essex Mid Essex are currently employing 2 agency locum consultants and are actively seeking a 3 rd agency locum. It has been very difficult to identify locum clinical oncologists in the agency market as demand is so high nationally. This has also led to very high rates being charged. Additional support for Mid Essex has been provided by an oncologist from Colchester and 3 oncologists from Southend attending site to run clinics in various tumour sites. There has also been agreement from the team at Southend to take referrals from Mid Essex if they cannot be accommodated without delaying patient treatment (for example during annual leave of Mid Essex consultants). Page 6
These arrangements have provided a reasonable level of cover for planned activities at Mid Essex. However, the lack of cover for oncologists in key tumour sites (such as Lung and Melanoma) creates real problems for these services during periods of leave or absence. There are requirements under the quality surveillance programme (formerly known as cancer peer review) to have named leads identified for specialist cancer services. This is a key element of the leadership of specialist teams to ensure a safe and high quality service. At present Mid Essex does not have nominated leads for acute oncology (AOS) or teenagers and young adults cancer (TYA). Management of inpatients created a significant burden of work for the oncologists at Mid Essex previously and with the reduced workforce this has been unsustainable. The Trust has transferred the primary responsibility for these beds to another medical firm to relieve the pressure on the oncologists. Possibly the most acute issue outstanding is of on call cover. There is only one consultant providing on call cover currently at Mid Essex. This is clear highly stressful for the individual and not sustainable over anything but the very short term. The future model is likely to be a single on call rota for the group but in the meantime colleagues from Southend have offered to join the rota at Mid Essex. This would bring the rota up to around 1:4 which is reasonable in the medium term. The offer was made in June and Mid Essex are finalising the governance and remuneration arrangements to hopefully start this soon. Although the two oncology teams have worked incredibly hard and shown great flexibility to ensure that the service is covered, the overall position is very fragile. There is clearly an urgent need to achieve a stable and sustainable service model and medical workforce for Oncology in Mid Essex. Taking no action at this stage would result in greater clinical risk in the MEHT Oncology service and greater pressure on the remaining team. It is probable that service provision in Mid Essex would diminish if the service is not stabilised. This would require mid Essex patients to travel further to other centres for Oncology care and treatment. Initially the rarer tumour types would be affected but at some point provision of chemotherapy on site would likely have to cease. 3.3 Workforce plan Following the unsuccessful attempt to recruit into the stand-alone service at Mid Essex, the Oncology steering group agreed over the summer that the posts should be recruited from Southend. The nature of the current jobs market in Oncology and the breadth of specialisation available demand that advertised posts are tailored to be attractive to potential candidates. It was agreed that we should seek to recruit 3 positions initially as a first phase and the make-up of these posts has been agreed through the steering group. The 3 positions are for clinical oncologists employed by Southend, with most of their time based at Mid Essex and undertaking Radiotherapy at Southend. Page 7
Job descriptions were drafted by Southend with input from Mid Essex colleagues and 2 of these were recently approved by the college with minor amendments required on the 3 rd post. Adverts for these positions will be going out in Mid-October. Whilst there is a UK-wide shortage our senior consultants have been working to identify potential candidates and feel we have a reasonable chance of making good appointments. The next round of recruitment to the remaining positions will be planned in 2-3 months when we know the outcome of the current recruitment. 4. Oncology shared governance 4.1 Integrated medical team The JEG have agreed in principle a proposal to integrate the two oncology teams operating within the group. This will see single clinical and managerial leadership of the service across the group, hosted in Southend as the cancer centre. This will be a more sustainable service model in the longer term and will support more responsive decision making in the short term to face the inevitable challenges that the current fragilities at Mid Essex will create. This proposal also included the 1 st phase of recruitment described above. The oncology steering group felt strongly that this recruitment plan must be linked to service integration. Any uncertainty could dissuade potential candidates. This decision has not yet been communicated or actioned pending some discussions between the 3 Trusts to clarify accountability arrangements for this change. This is the first significant movement of clinical service provision within the group and as such it does raise a number of questions for the first time. Whilst we must not be reckless in making this change there is certainly a need to avoid undue delay and move forward at pace with consultant recruitment with certainty on the future structure of the service. Page 8