London Cancer Head and Neck cancer bid Submission document Proposals for: Level 1 Local unit Level 2 Extended local unit Level 3 MDT hub centre Level 4b Specialist treatment centre: clinical oncology Monday, 17 June 2013
HEAD AND NECK CANCER STATEMENT OF INTENT Barts Health is one of the major providers of head and neck cancer in London with high volume, high quality services. We support the programme of review of head and neck cancer services which has led to the proposal to centralise specialist surgical services. After extensive discussion within the Trust we have decided to concentrate on non-surgical cancer services for head and neck patients. We are therefore bidding to maintain a major head and neck service within the Trust by becoming recognised as a local unit, extended local unit, MDT hub centre and specialist treatment centre for Clinical Oncology. OUR VISION Cancer services are a significant part of the overall service portfolio at Barts Health. Head and neck services are an important part of our overall cancer services given our long track record of providing high quality services. We intend to be nationally recognised for excellent non-surgical head and neck services that will: Meet or exceed all diagnostic and treatment standards Provide excellent patient access, meeting all cancer targets Be responsive to and integrated with primary care partners Provide an excellent patient experience and be responsive to patient needs. All this will be underpinned by our education and research activities as a major academic centre. 2
INTRODUCTION TO HEAD AND NECK CANCER The majority of head and neck cancers arise from the surface layers of the upper aerodigestive tract (UAT): the lip, mouth (oral cavity), the upper part of the throat and respiratory system (pharynx), and the voice- box (larynx). Other UAT areas include the salivary glands, nose, and sinuses, but these cancers are relatively rare. Cancers that originate in the connective tissues of the head and neck are even rarer. Most patients with UAT cancers are middle-aged or older, often with other co-morbidities or health issues. Survival rates differ markedly according to the site and stage of the cancer. The graph below labelled figure 30 is taken from the Cancer Services Case for Change 2010. It appears to show that of the 26 UAT surgery providers in London, 19 (73%) performed 100 or less of the total of 1,321 surgical procedures performed in 2007/08. 3
However, the head and neck cancers IOG was only being implemented during 2009 and peer review visits have shown surgery has been concentrated to the designated centres. The graph shows Barts Health predecessor Trust, BLH, as one of the major providers of head and neck surgery. Since 2011 all major head & neck surgery from Whipps Cross University Hospital (WCUH) & Barking Havering & Redbridge Hospitals (BHR) has been centralised to Barts & The London Hospitals. OUR POPULATION AND REFERRAL BASE Borough and Population Statistics: Inner North East London BOROUGH POPULATION Hackney (incl. City) 273,000 Tower Hamlets 243,000 Waltham Forest 271,000 Newham 333,000 Redbridge 264,000 TOTAL: 1,384,000 Outer North East London BOROUGH POPULATION Barking & Dagenham 182,000 Havering 252,000 TOTAL: 434,000 Sum Total of Inner and Outer North East London 07 Boroughs 1,818,000 (1.8m) Source: The Link. Issue 153. Barts and the London NHS Trust publication. Nov. 2011. Population Ethnicity Profile East London has considerable racial diversity and significant socio-economic deprivation with two of the poorest London boroughs, Tower Hamlets and Hackney, within the Barts Health area. Diversity poses significant challenges for healthcare providers. British Minority Ethnic groups often have problems in accessing healthcare with factors such as language, culture and the attitudes of healthcare professionals compromising their likelihood to receive the care they need. In addition, certain ethnic groups are known to be more pre-disposed to certain illnesses. North East London is steeped in a legacy of historical deprivation and has some of the worst health outcomes and starkest health inequalities in London. Significant deprivation affects much of the local population with 50% of people living in the most deprived quartile nationally. Incidence and mortality from stomach cancer are strongly related to social class 4
and measures of deprivation, with higher rates in socially and economically deprived groups. The incidence of Head & Neck Cancer in certain areas within the current catchment area of the MDT is well above national averages (source: NCAT Cancer Commissioning Toolkit) 5
London Cancer Standards London Cancer was formed within University College London Partners (UCLP) to develop an integrated cancer system across North Central and North East London in response to the need to improve cancer outcomes. It brings together providers from across the health community, academia and the voluntary sector to drive step change improvements and experience for cancer patients and populations. By 2015, London Cancer seeks to deliver: Improved one- year survival Improvements in patients self-reported experience of the care they receive and Increased participation in clinical trials to a third of all patients Barts Health has a major contribution to make to achieve these aspirations. Barts Health Organisational Ethos Leadership and collaboration Barts Health has a strong history of organisational leadership. The Royal London Hospital undertook the largest hospital relocation in Europe when we moved in to our new building in January 2012. In March 2012, Barts Health was created as a merger of Barts and the London Trust, Whipps Cross University Hospital and Newham University Hospital. It is the largest hospital Trust in England and provides secondary healthcare for a population of 1.4 million people. Barts Health is in the lowest category for NHS Litigation and has the ninth lowest standardised hospital mortality in the UK. Dr Foster Mortality Measures 2011 6
This benchmarking indicates that all three legacy Trusts had lower than expected standardised hospital mortality indices and Barts and the London and Newham also has lower than expected hospital standardised mortality rates. In addition, Newham had a lower than expected deaths from low risk conditions. The Trust showed exemplary organisational leadership in the development of the London Trauma and Stroke Network. The stroke unit was commended as the best organised stroke unit in England by the Royal College of Physicians. 7
Trust Cancer Strategy and Vision With a turnover of 1.1 billion and a workforce of 15,000, Barts Health is the largest NHS trust in the country, and one of Britain s leading healthcare providers. The trust s five hospitals St Bartholomew s (Barts) in the City, The Royal London in Whitechapel, The London Chest in Bethnal Green, Newham University in Plaistow and Whipps Cross University in Leytonstone deliver high quality, compassionate care to the 2.5 million people of east London and beyond. Barts Health is committed to providing excellent healthcare and to ending the historic health inequalities of east London. Working with our patients, health and community partners, we will transform the way we deliver healthcare and support our local communities to live healthier lives. We will create a world-class health organisation, delivering compassionate care to the highest international standards to every patient, every time. Our care will be clinically leading-edge and, through the involvement of our patients, truly focused on the patient experience. We will build an international reputation for excellence in patient care, research and education, and through our key role in UCLPartners, the largest Academic Health Science System in the world, we will ensure that our patients are among the first to benefit from the latest drugs and treatments. We are a health organisation, and we will use every contact with our patients, not just to treat illness and injury, but also to promote health. As a result, Barts Health will focus on the delivery of a comprehensive patient pathway that delivers rapid diagnostics and timely treatment with surgery, chemotherapy or radiotherapy. In addition, Barts Health will work with primary and community services to improve prevention and early diagnosis and provide optimal end of life care, in particular ensuring that where possible patients die at home should they so wish. Barts Health is committed to high quality and high volume cancer services as a fundamental part of its overall service and academic aspirations. Barts Health will be an active participant and leader at all levels in the developing London Cancer Integrated Cancer System to ensure patients are provided with the best services possible at the appropriate time in the pathway and in most appropriate location, determined by available expertise and patient choice. Barts Health will improve patient experience as demonstrated in the National Cancer Patient Survey. (appendix) Barts Health will review and report all mortality from cancer and compare with our peers by tumour type. National audit/tcr 8
Description of Barts Health current local and specialist head and neck service We currently provide a comprehensive integrated pathway for patients diagnosed with head and neck cancer. There has been considerable service development over the last few years with the evolution of a comprehensive treatment centre at St Bartholmews and The Royal London Hospital with established local units working in partnership. The evolution of an integrated comprehensive cancer centre at Barts and the London has been ongoing for many years. The North East London Head and Neck Tumour Advisory Board which was under the chairmanship of Dr Amen Sibtain and latterly Mr Simon Whitley agreed that concentration of surgical services on one specialist site would be advantageous in improving patient experience and outcomes. This resulted in a single surgical site been established in 2010. Radiotherapy is delivered at two sites, St Bartholomew's Hospital, and Barking Havering and Redbridge Hospitals. There is currently a single multidisciplinary team meeting serving north-east London which is hosted at St Bartholomew's Hospital on a Wednesday. The hospitals which are involved are: St Bartholomew's Hospital (Barts Health NHS Trust) The Royal London Hospital (Bart Health NHS Trust) Whipps Cross University Hospital (Barts Health NHS Trust) Homerton University Hospital Princess Alexandra Hospital (OMFS) Barking Havering & Redbridge Hospitals NHS Trust Elements of the service include. Surgery Surgical treatment is undertaken at the Royal London Hospital. There are Currently 13 sessions of theatre time devoted to head neck oncology surgery with eight head and neck surgeons operating. There are two dedicated head and neck operating theatres and a head and neck ward shared with neurosurgery. A wide range of surgical techniques are employed including microvascular reconstruction, photodynamic therapy and topic laser surgery. Clinical oncology Clinical oncology is based at St Bartholomew's Hospital. Cutting edge techniques such as rapid arc IMRT Cyber and Gamma knife are available. Inpatient clinical oncology beds are located within the new build. Multidisciplinary team meeting. There is a weekly three-hour meeting which takes place on Wednesday lunchtime. The meeting room is equipped with projection of PAC's images and pathology microscopy. Videoconferencing is via an N3 connection. Currently the average number of cases discussed per week is 32 Multidisciplinary clinics. 9
There is a weekly multidisciplinary clinic on a Wednesday afternoon. Both new and follow up patients are seen. The clinic is attended by clinicians from clinical oncology, ENT & OMFS. Clinical Nurse Specialists, Speech and Language Therapists and Dieticians are also in attendance. Rapid access diagnostic clinic. There is a weekly rapid access diagnostic clinic which takes place on Wednesday afternoon. Patients are seen by the surgical teams and, if necessary, ultrasound is performed by dedicated Head and Neck Radiologists who are in attendance. There is a cytologist present to report on any specimens taken. Dental Assessment. A consultant restorative dentist attends the multidisciplinary team meeting and patients are referred for preoperative assessment. The patients are seen for the dental treatment at The Dental Institute based at the Royal London Hospital. Gastrostomy insertion Dietetic assessment is undertaken for patients prior to commencing treatment and if necessary just trust me insertion is undertaken both percutaneous endoscopic and radiologically inserted techniques are used. Delivering an Integrated Pathway for Head and Neck Cancer The following sections describe our commitment to the principles set out in the service specification. We already fulfil most of the requirements for London Cancer s specification for the levels we aspire to. Where these standards are not met, these are addressed in the relevant part of the template. The London Cancer templates follow. Leadership: Members of the Head and Neck Team who have significant roles in leadership include: Simon Whitley Consultant Oral & Maxillofacial Surgeon He is the Named Clinical Lead for The Head & Neck MDT. He is responsible for the clinical management of the team at Barts Health and to liaise with members of the MDT working at other trusts. He is responsible for ensuring that best clinical practices are maintained & cancer wait time targets are achieved. He chairs the weekly MDT meeting. He is also Pathway Director for Head & Neck Cancer for London Cancer ICS and was previous Tumour Advisory Board Chair for Head & Neck for North East London Cancer 10
network. He was previously Lead Clinician for Head & Neck Services at Princess Alexandra Hospitals. Dr Amen Sibtain Consultant Clinical Oncologist He is the Named Clinical Lead for Radiotherapy at Barts Health and is the Lead Clinical Oncologist for the MDT. He is the Deputy Chair and lead for research of the Head & Neck Pathway Board for London Cancer and has previously been Chair of The Tumour Advisory Board for Head & Neck for North East London Cancer Network. In addition, Dr Sibtain is the North & East Training Programme Director for Clinical Oncology for the London Deanery. He is Lead for Year 3 Clinical Oncology FRCR course, an MSc supervisor for The Institute of Cancer Research and an advisor in Clinical Oncology to Macmillan. Dr Polly Richards Consultant Radiologist. Dr Richards is the Clinical Lead for Head & Neck imaging at Barts Health. She is the radiology representative for the Head & Neck Pathway Board for London Cancer. She is Chairwoman of the British Society of Head & Neck Imaging, is a National Examiner for Dental & Maxillofacial Radiology and is on the Thyroid Cancer working group for the National Cancer Intelligence Network. Professor Kim Piper Consultant Oral Pathologist Professor Piper is the Lead Pathologist for the MDT. She is lead for Education for the Head & Neck Pathway Board of London Cancer. In addition, she is National Lead for Oral Pathology CPD & Teaching for FRCPath, Chair of Additional Dental Specialities London Committee and representative for East London & The City on the National Ethics Committee. She is Head of Undergraduate Medical & Dental Admissions for QMUL Professor Iain Hutchison Consultant Oral & Maxillofacial Surgeon Professor Hutchison is Lead OMF Surgeon for the MDT. He is the lead for early detection for the Head & Neck Pathway Board of London Cancer. He is Immediate Past President of The British Association of Oral & Maxillofacial Surgeons and is the founder and Chief Executive of Saving Faces, The Facial Surgery Research Foundation Charity and is Director of The National Facial & Oral Research Centre. Ms Claire Morgan Consultant Restorative Dentist Claire is the Lead for Dentistry for the MDT and is also the Dental representative for the Head & Neck Pathway Board of London Cancer. Mr Mike Dilkes Consultant ENT Surgeon He is the MDT lead for Audit and runs the regular Morbidity & Mortality meetings. Commitment to partnership working We are committed to working together as part of an integrated team, and demonstrate this commitment to partnership from the outset by working collaboratively to develop plans 11
against the service specification that are focused on delivering the best outcomes and experiences for patients Examples of the commitment shown to date include: Partnership working with several trusts across North and East London to establish a single surgical centre and single unified MDT - Homerton University Hospital Foundation Trust - Barking Havering & Redbridge Hospitals NHS Trust - Princess Alexandra Hospitals NHS Trust - Whipps Cross University Hospital NHS Trust (now part of Barts Health NHS Trust) Joint Consultant appointments in place between Barts Health and: Princess Alexandra Hospital NHS Trust Homerton University Hospital NHS Foundation Trust Barking Havering & Redbridge Hospitals NHS Trust Creation of Honorary Consultant appointments at Barts Health for MDT members from: Barking Havering Redbridge Hospitals NHS Trust Commitment to audit, data collection and sharing We are committed to collecting data on clinical outcomes and patient experience (and other relevant metrics), and comply with requirements for submission to national audits (DAHNO, COSD) and other local/regional requests for performance and outcomes data. Real time recording of staging,mdt discussions and outcomes is undertaken during the MDT meeting using the Somerset Cancer Register Regular Morbidity & Mortality data is collected and audited with fixed sessions for MDT discussion and pathway development Commitment to gathering and responding to patient feedback We are committed to eliciting feedback from patients on a regular basis and to use this intelligence systematically and routinely to inform service improvement. The feedback from the national patient experience survey for cancer patients are taken very seriously by Barts Health and we aim to continuously improve the experience for our patients. Our Clinical Nurse Specialists undertake annual surveys of the patients under the care of the head & neck team. This information is invaluable in driving forwards our commitment to improve what we do. Commitment to research and innovation As a major teaching hospital we participate fully in the clinical trial and research portfolio, and carry out prospective audits of services and publish transparent outcomes data. We participate in tissue banking and support the use of research nurses, as well as promote research into improving patients functional outcomes and rehabilitation therapies. 12
The Head & Neck MDT Clinicians are actively recruiting into NCRN trials such as SMA, SEND and ART-DECO St Bartholomews Hospital is the base for The National Facial & Oral Research Centre (NFORC) Close links are established with QMUL with cancer biology research ongoing at both Charterhouse Square and Blizard sites. A large tissue bank has been established at QMUL allowing for ongoing and future research projects. 13
Commitment to education and training We facilitate access to high quality training and development opportunities for staff and services. Specifically: Training is available for junior medical staff, nursing staff and allied health professionals (AHPs). Recognition is given to the importance of education for CNSs, and protected time is offered to CNSs to enable them to access development opportunities. Level 2 psychological training is available for every member of the MDT with monthly supervision in line with the requirements of Peer Review. All relevant staff are supported to undertake Advanced Communication Skills Training (ACST). This is mandatory for all MDT core members who have significant patient contact. The vast majority of the team have completed this training and it is considered in annual appraisal for clinicians Training for rehabilitation therapists in the community is be competency-based and offered to those working in community settings. Education and training activity is subjected to ongoing monitoring and audit to establish what works and identify opportunities for improvement. A six weekly formalised morbidity and mortality audit session is in place to ensure ongoing improvements in the service Summary Barts Health has a well-established comprehensive head and neck cancer centre established at St Bartholomew's Hospital and the Royal London Hospital. We have a dedicated team of highly skilled clinicians with a proven track record in head and neck Cancer care. Many of our clinicians are involved with the head and neck pathway board of London cancer and have actively engaged in the technical subgroup and specification writing. Although the trust has not applied to become a specialist surgical centre we are keen to continue with the care of patients with head and neck cancer in all other respects. We feel we can provide an excellent service as both a local centre and as MDT Hub Centre. We have established strong working relationships with partner trusts and feel that a collaborative approach yields a successful working environment and a better patient 14
experience. St Bartholomew's Hospital is an established centre for excellence for head and neck clinical oncology with cutting edge technologies and world-class clinicians. We are keen to be at the forefront of working in partnership with other trusts to develop London cancer as a UK leading centre for head and neck cancer. Risks The transfer of surgical services from Barts Health to UCLH must be very carefully actioned and considerable effort will be required to ensure that patient care is maintained. This is equally important in the interim phase. It is hoped that close working relationships will be established with colleagues at UCLH to carefully plan these changes. It is important that skilled surgeons at Barts Health have the opportunity to work within the new specialist cancer centre should they desire. Should Barts Health fail in a bid to be a specialist MDT Hub Centre or centre for clinical oncology this is very likely to have a destabilising effect on many of the other services within the trust and within the workforce. The time period likely with a proposed move of surgical services being at least two years will allow the trust to mitigate against the loss of staff and surgical activity but again it must be stressed that this process will require joint working with the UCLH if a successful outcome is to be achieved 15
Improving services for head and neck cancer Application template Trust Clinical lead Barts Health NHS Trust Mr Simon Whitley Managerial lead Date completed Applying to provide: Level 1: Local unit X Level 2: Extended local unit X Level 3: MDT hub centre X Level 4a: Specialist treatment centre: surgery Level 4b: Specialist treatment centre: clinical oncology X Proposed sites Level 1: Local unit Complete Part I Level 2: Extended local unit Complete Part II Level 3: MDT hub centre Complete Part III Level 4a: Specialist treatment centre: Surgery Complete Part IV Level 4b: Specialist treatment centre: Clinical oncology Complete Part V Royal London Hospital, St Bartholomew s Hospital, Whipps Cross University Hospital. Royal London Hospital, St Bartholomew s Hospital, Whipps Cross University Hospital. St Bartholomew s Hospital N/A St Bartholomew s Hospital 16
Vision for future head and neck cancer services Cancer services are a significant part of the overall service portfolio at Barts Health. Head and neck services are an important part of our overall cancer services given our long track record of providing high quality services. We intend to be nationally recognised for excellent non-surgical head and neck services that will: Meet or exceed all diagnostic and treatment standards Provide excellent patient access, meeting all cancer targets Be responsive to and integrated with primary care partners Provide an excellent patient experience and be responsive to patient needs. All this will be underpinned by our education and research activities as a major academic centre. Have you secured trust board-level approval for your application? (please give details) The Trust Board confirmed its support for this submission at its meeting on 5 June 2013 Have you discussed your proposals with other trusts and/or local GPs? (If so please give details) There has been full discussion with other Trusts and the local CCGs Other Trusts are supportive of our submission to be a local and 4b centre We have had discussions with CCGs as follows: - Tower Hamlets CCG Lead Dr Sam Everington - CCG Cancer Leads: Liliana Risis, - Newham CCG Leads: Dr Zuhair Zarifa Have you discussed your proposals with any other relevant stakeholders? (If so please give details) - Other partners in London cancer are aware of our submission. 17
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Part I: Outline of proposed Level 1local unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway Diagnosis of cancer Additional notes in Appendix Fast-track referrals for patients with suspected head and neck cancer Once we receive these referrals we will aim to book their 1 st OPA within 5 working days of receipt of the referral. The patent is then seen by the appropriate clinician for assessment and where necessary further diagnostic tests will be arranged The majority of patients will have access to a Rapid diagnostic clinic where patients can have an USS FNA with same day cytology results. Where this is not possible an appointment for the next available rapid diagnostic clinic will be available within a week. To meet the specification- we will need to re profile our clinic structure so we have enough capacity to see new target patients within five working days in a consultant-led clinic. We will also need to facilitate the clinicians with a tool that they can populate with the sufficient data set needed for MDT discussions which will help MDT decision-making. See Level 2 extended local unit specifications Clinical nurse specialist present at all cancer diagnoses There are 3 CNS available to be present at all cancer diagnoses. Exceptions are at PAHH for OMFS and the Homerton Hospital for both ENT / OMFS CNS / Key worker role at the Homerton and Princess Alexandra Hospital Harlow will need to be developed with coordination with CNS at Barts Health. Diagnostic facilities on-site (CT and MRI) We aim for a 5 working day turnaround for request to report for radiological procedures(ct, MRI, USS, PET-CT) Workforce planning is required to ensure that there are adequate numbers of sessions for specialist head & neck radiologists to undertake and report work in the specified time frame The creation of dedicated ringfenced slots for scans will be considered to ensure targets are 19
Part I: Outline of proposed Level 1local unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway met. Robust coordination with other centres in situations in which facilities or resources are not available in-house (e.g. rapid access, PET- CT) Continued use of IEP transfer of images See Level 3 MDT hub specifications Clinical workforce trained in advanced communication skills The Majority of the H&N MDT Core members have attended the advanced communication course. Continued work will be put in to ensure the remaining core members of the MDT have attended this training course. Attendance is deemed a mandatory requirement and will form part of the annual consultant appraisal. Non compliance will result in suspension from the MDT MDT MDT conferencing capability with MDT hub Our MDT meets face to face on a weekly basis at St Bartholmews Hospital and via videolink with colleagues at Whipps Cross Hospital with extended & core members from other trusts dialling in via video link. See Level 3 MDT hub specifications Access provided to a key worker for all patients (usually a clinical nurse specialist) 3 CNS are available to act as Key worker for all patients with a cancer diagnosis. 20
Part I: Outline of proposed Level 1local unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway Carries out holistic assessment, including palliative care and travel needs 3 CNS carry out Holistic assessments and provide support and ongoing referral to Palliative care teams both in hospital and to Community. Also referral to appropriate agencies for support & advice on travel needs and cost reimbursement. Development of possible additional members of MDT to carry out Holistic assessment as well as CNS i.e clinicians and AHP s By the use of tools such as a patient concerns inventory Development of additional clinics run by CNS / AHP s to provide an holistic approach to patient needs and concerns A dietitian is present in MDT meeting to consider the need for gastrostomy tube feeding throughout treatment and to enable a more holistic approach to the patients circumstances. The dietitian is able to initiate optimising nutritional status prior to primary treatment. There is dedicated time in dietitian job plan to attend MDT meetings. Widespread uptake for all patients of a nutritional assessment screening tool with incorporation into MDT discussion 21
Part I: Outline of proposed Level 1local unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway Treatment decision Patients are offered all appropriate treatment options and all appropriate types of reconstruction whether or not these are available at that particular provider site Decision-making process involves rehabilitation and supportive care and palliative care professionals All patients are discussed at the weekly MDT meeting and all treatment options are considered. Patients are given all the information in a level that is understandable to them and are given opportunities to discuss any aspect of their care with the clinical team Advice is given on the best possible treatment options and the possible side effects and complications of treatment is given The rehabilitation team (SLT, Dietitians, CNS, Dental ) are all core members of the MDT and are actively involved in decision making. See Level 3 MDT Hub specification 3 CNS support decision making with written and verbal information and act as the role as central point of contact. SLT and dietetics local teams are also involved in the decision making process. Patients are seen by SLT therapy prior to 22
Part I: Outline of proposed Level 1local unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway commencement of treatment for pretreatment assessment and counselling where it is deemed necessary A dietitian reviews referred patients prior to radiotherapy treatment. The dietitian counsels those referred re gastrostomy feeding prior to placement if patient referred pre treatment and decision re feeding tube already made. All patients to be seen by dietitian and nutrition nurse post gastrostomy feeding tube insertion, registered with Home feeding company for feed and ancillaries as required. Surgery Diagnostic and pre-operative assessment (including access to dental assessment) procedures are available Diagnostics co-ordination and guidance provided by 3 CNS. Pre-operative assessment is co-ordinated by CNS to the clinic. This is attended by 2 CNS, SLT and Dietician for pre-operative counselling. All patients are discussed prior to treatment a with the dental team at the MDT. Where appropriate adental assessment is All patients to be reviewed by dietitian prior 23
Part I: Outline of proposed Level 1local unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway undertaken and dental treatment commenced to ensure good dental health and to minimise long term complications to surgery for nutritional counselling and optimisation. Dietitian sees patients in pre assessment clinic prior to surgery for nutritional counselling and optimisation. Acute oncology Full acute oncology service that meets Peer Review standards Barts is a fully functional Cancer centre with all facilities to provide a Peer Review compliant Acute Oncology Service. There is 24 hour medical cover for oncological emergencies, full diagnostic facilities and intensive care provision if required. There are established protocols and pathways for oncological emergencies and on-call senior support. A dietitian sees patients on treatment once per week to monitor weight, oral / enteral intake and advise accordingly. Availability of additional dietitian time in radiotherapy setting to allow fuller dietetics assessment weekly and to see patient on treatment more than once weekly. Post treatment Clear procedures governing the receipt of patients who have been discharged from care Robust multidisiplinary Discharge summary should be prepared and available for colleagues in primary care, community and See Level 3 MDT hub specification 24
Part I: Outline of proposed Level 1local unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway of the specialist treatment centres other local units Follow-up clinics for post-treatment patients (involving surgeon, oncologist, CNS, rehabilitation services) Weekly multidisplinary clinics are in place which are attended by surgeons. Oncologists, CNS SLT, Dietictians Process in place to enable a patient s rapid readmission, if necessary Currently there is an informal process of CNS contact by patient or to the surgical team for readmission via clinic or A&E. Requires formalisation of this process. A clear pathway needs to be established whereby patients, primary care and other colleagues in secondary care know how to access specialist services appropriately This needs to be in coordination with ongoing workstreams of the Head & Neck Pathway Board of London Cancer. Palliative care Clear referral pathways for patients with palliative and specialist palliative care needs When MDT decision of Palliative Care or need for symptom control, CNS / Clinician referral to Hospital and/or Community Palliative Care team. 25
Part I: Outline of proposed Level 1local unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway Research and innovation Access to multidisciplinary oncology service including clinical trial research and research nursing See Level 4b Specialist Treatment Centre for Clinical Oncology Specification Clinical trial research and research nursing Patients will have access to a range of clinical studies with cross recruitment to those based at other sites within London Cancer. An NCRN portfolio is being implemented. One of the clinical oncologists holds two CRC grants and has supervised MD (res) students, equipping the unit with high level research skills. Encourage participation of clinicians in trial recruitment Coordination with ongoing workstreams of the Head & Neck Pathway Board of London Cancer. Patient travel Informs patients of support available for travel to specialist centre and radiotherapy units Written information given, on resources for travel cost reimbursement/ financial support / referral to welfare rights service to support travel arrangements. Booking of Hospital transport where patient meets the Trust Criteria for this. Part II: Outline of proposed Level 2 extended local unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway 26
As with the Level 1 local unit above, but with the addition of the following extended services Diagnosis of cancer Rapid access clinics with ultrasound and sameday cytology services Weekly rapid access diagnostic clinics are already established at St Bartholomews Hospital which is attended by: - Consultant surgeon - Consultant Head & Neck Radiologist Workforce and capacity planning to ensure that enough slots are available for local patients and those referred from other local units for expert assessment - Consultant Cytopathologist - Clinical Nurse Specialist Patients are assessed clinically, flexible nasendoscopy is available, FNA are undertaken where appropriate and are reported by the cytologist Inadequate specimens are repeated If a diagnosis of cancer is made the CNS is present when bad news is broken and is able to offer appropriate support A weekly rapid diagnostic clinic is being established at Whipps Cross Hospital. Currently no cytologist is present Workforce planning to ensure the availability of cytologist or cytology technician to allow for same visit assessment of adequacy of FNA sample 27
Part II: Outline of proposed Level 2 extended local unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway MDT MDT conferencing capability with MDT hub See Level 3 MDT hub Specification Post treatment Comprehensive rehabilitation and supportive care services Dietitian Clear and robust handover provided for every patient being discharged with a feeding tube to community Dietitian for ongoing support. Clear and robust handover provided for majority of patients requiring oral nutritional support to community dietitians where this service exists. Dietetic service provision currently inequitable across the inner and outer north east London region. Dietitian available to review patients in follow up clinic if urgent review required or if patient does not have access to community Dietitian. Nutritional screening tools which are completed for every patient on admission 28
Part II: Outline of proposed Level 2 extended local unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway should flag up dysphagia issues. Speech and Language Therapy (SLT)- Attendance at weekly MDT meeting (Highly specialist SLT with relevant clinical expertise) to ensure timely referral on to local SLT s for assessment and support pre-operatively (Preop) or pre treatment A highly specialist or Lead SLT and a specialist level SLT at weekly HNC MDT clinic who are available to assess and advise patients individually or jointly with other members of the MDT. Intervention in the clinic avoids multiple visits. Access to highly specialist SLT pre-op for all appropriate patients diagnosed with HNC. Pre-op assessment allows a baseline assessment to be completed, identifying any problems with swallowing, which may lead to complications post surgery, and to inform patients of the affects post surgery. This appointment is either offered in the SLT OP clinic or by SLT in the MDT pre op assessment Videofluoroscopy and FEES at Whipps Cross site are in the process of being developed. Levels of staffing do not allow all patients to access instrumental assessment of swallowing e.g. Videofluoroscopy and FEES pre operatively or pre-radiotherapy Training and support for community teams offered but not all community teams will accept referrals for Head and Neck Cancer for patients who require home visits home visits. 29
Part II: Outline of proposed Level 2 extended local unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway clinic. SLT and Dietetic input into this clinic has increased the number of patients receiving pre-op information. Instrumental assessment completed by Lead SLT in combination with a highly specialist or specialist SLT. This is currently available pre-, and post intervention for diagnosis, decision making and to inform the MDT as required e.g. Videofluoroscopy (available at RLH/SBH/Newham) and FEES (available at RLH/SBH). Clear pathway with specialist SLT input from hub to local services for laryngectomy patients avoiding need for lengthy travel to access services. Outpatient SVR for laryngectomy patients at WXH/RLH/SBH to reduce need for patient travel. Appropriate competencies maintained. The service is available daily with highly specialist or Lead SLT for complex decision making. Local access to OP SVR in order to minimise patient travel where urgent need identified and reduce need for patient admission. Air insufflation assessment available at RLH (Lead SLT and highly specialist SLT) to identify appropriate patients for secondary puncture and avoiding unnecessary complications. Expert SLT provides on site 30
Part II: Outline of proposed Level 2 extended local unit N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway training to A&E and ENT for HNC particularly out of hours SVR. OP SLT (Highly specialist and specialist SLT) follow up for weekly therapy to assess and provide rehabilitation for swallowing and communication difficulties post treatment to maximise function. Dental See Level 3 MDT Hub Specification 31
Part III: Outline of proposed Level 3 MDT hub centre N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway MDT Hosts and co-ordinates the weekly head and neck specialist MDT Bart Heath hosts and coordinates MDT meetings on a weekly basis. Currently this meeting takes place on a Wednesday Lunchtime. The meeting is scheduled for 3 hours. The intention is to move the time of the meeting and extend the duration Videolink via a secure N3 connection takes place with ; Barking Havering & Redbridge Hospitals Whipps Cross Hospital The MDT meeting is to be moved to a Wednesday morning and to take up a 4 hour session. This will allow: More time for patient case discussion Regular timetabled teaching, audit and morbidity & mortality discussion Coordination with UCLH MDT meeting time to aim for a more integrated future approach This move will require considerable workforce planning and increased capacity of adequate meeting room facilities. Where possible face to face discussion is desirable. To develop cross trust job planning and contracts to allow for core members based at other local units to attend meeting in person and subsequent Multidisiplinary clinic Multiuser dial in is not currently available To develop videoconferencing allowing multiple sites to access the meeting for the whole duration if desired 32
Part III: Outline of proposed Level 3 MDT hub centre N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway Radiological images are available via IEP. To explore the development of multiuser platform for sharing of images and dual reporting via a cloud based data system Currently in development may require coordination with London Cancer Pathway Board Coordinates data collection for the system Accurate and sufficient data is made available by the MDT for data uploads. (Aids DAHNO audit uploads and other national registry data sets) The MDT coordinator has access to the trusts cancer data reporting tool (Somerset) and regularly updates this with MDT outcomes and treatment plans. Greater clinician engagement in improved patient assessment prior to MDT discussion i.e. Nutrition screening tools and comorbidity assessment (ACE-27) Improved coordination with partner trusts to ensure prompt transfer of clinical information And cancer wait times Greater clinician engagement in data collection for DAHNO Coordination with London Cancer Head & Neck Pathway Board Workstream for information and data collection 33
Part III: Outline of proposed Level 3 MDT hub centre N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway Hosts multidisciplinary clinics attended by surgeons and oncologists undertaking treatment for patient Weekly multidisplinary clinic already take place on a Wednesday afternoon after the MDT meeting It is envisaged that core members from other local units will be able to attend and see patients who have been initially seen locally and are attending to discuss proposed treatment. this will ensure continuity and improve patient experience Cross organisational job planning and contracting will be required Communication with patients, and partner organisations Following completion of treatment initial follow up may be required at MDT hub centre prior to local follow up, again it is envisaged that core members from other trusts may attend Detailed communication of clinic visits and post treatment discharge summaries should be available to patients, primary & community care and local units including rehabiliation services in a timely manner This will require coordination with The Head & Neck Pathway Board of London Cancer and UCLH as the other MDT Hub Centre Greater clinician engagement will be required and adequate resources made available in terms of time within job plans, junior staff resources and administrative and secretarial 34
Part III: Outline of proposed Level 3 MDT hub centre N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway support Transitional Arrangements Although Barts Health is not bidding to be a Specialist Surgical Centre it is clear that centralisation will not occur for at least two years. It is important that there is business as usual in the interim to ensure patients are not disadvantaged Partnership working between Barts Health and UCLH is required to ensure that standards are at the very least maintained if not improved in terms of surgical care during the transition period 35
Part IV: Outline of proposed Level 4a specialist treatment centre for surgery N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway Part of pathway Summary of specification Proposal Developments necessary MDT Treatment decision Surgery Post treatment Participates in weekly MDT hosted by MDT hub centre Patients are offered all appropriate treatment options and all appropriate types of reconstruction whether or not these are available at that particular provider site Decision-making process involves rehabilitation and supportive care professionals and palliative care professionals Close working relationship between both specialist surgical centres (prior to consolidation into a single surgical centre), with unified treatment protocols and sharing of skills, data, etc. Rigorous approach to surgical clinical trial participation Systematic data collection, including capture of outcomes Integration with local services and oncology services to provide a seamless experience for patients Provision for timely discharge and liaison with local units, primary care and local rehabilitation services 36
Part IV: Outline of proposed Level 4a specialist treatment centre for surgery N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway Part of pathway Summary of specification Proposal Developments necessary Acute oncology Palliative care Research and innovation Patient travel Prompt provision of comprehensive discharge information following completion of treatment in line with national standards Process in place to enable a patient s rapid readmission, if necessary Full acute oncology service that meets Peer Review standards Clear referral pathways for patients with palliative and specialist palliative care needs Access to multidisciplinary oncology service including: tissue banking, clinical trial research, and research nursing Informs patients of support available for travel to specialist centre and radiotherapy units 37
Part V: Outline of proposed Level 4b specialist treatment centre for clinical oncology N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each pathway MDT Participates in weekly MDT hosted by MDT hub centre Bart Heath hosts and coordinates MDT meetings on a weekly basis with extended members from other trusts dialling in via video link. All the required core members attend this meeting regularly. We are able to conclude on good clinical decisions for diagnosed cancer patients. Accurate and sufficient data is made available by the MDT for data uploads. (Aids DAHNO audit uploads and other national registry data sets) Consultant Oncologists / surgeons are always present during the decision making for all new H&N cancers and are always available in the joint H&N clinical the same afternoon where the same patients are often seen. We have made plans to improve the reliability of our videoconferencing equipment. We have planned workshops with the MDT coordinators which will train them held them deal with any conferencing hick ups that may disrupt the meetings. Treatment decision Patients are offered IMRT wherever possible. The decision-making process involves rehabilitation and supportive care professionals to enable a richer, more holistic understanding of the patient s broader circumstances Every patient who requires IMRT already receives this treatment technique. RapidArc Volumetric modulated arc radiotherapy will be introduced within the next 3 months. Clinical Nurse specialist support, with a holistic perspective, for patients during the decision making process and throughout the pathway. 38