Consultation Response Form

Consultation Response Form Your name: Organisation (if applicable): Email: Dr Martin Rolles Standing Welsh Committee of the Royal College of Radiologists Martin.rolles@wales.nhs.uk Telephone number: 01792 285292 Your address: Dept Oncology, Singleton Hospital, Sketty Lane, Swansea, SA2 8QA The comments contained within this response are those of the Standing Welsh Committee of the Royal College of Radiologists. The Royal College of Radiologists is the professional body responsible for the specialties of Clinical Oncology and Clinical Radiology throughout the United Kingdom. The Standing Welsh Committee represents Clinical Oncologists working in the 3 Welsh Cancer Centres, and Clinical Radiologists working in all the NHS Local Health Boards in Wales. The majority of Oncologists and Radiologists working in Wales are Members or Fellows of the Royal College of Radiologists. Please respond by answering the questions at the back of this document and sending it to: HQDMailbox@wales.gsi.gov.uk Or by post to: Matthew Tester Healthcare Quality Division Department of Health and Social Services Welsh Government Cathays Park Cardiff

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Chapter 1: The changing shape of health care Promoting health and well-being 1. Should further changes to the law be made to strengthen local collaboration in planning and meeting people s health and wellbeing needs closer to home? Wherever possible it is desirable to meet healthcare needs close to home, but this should not be at the expense of quality. Some services require centralisation. This is all prudent healthcare and changes to legislation may be unnecessary. It does however need significant commitment and active management to achieve the realistic ideals. Recruitment of suitably qualified staff in Wales, particularly outside the South East, remains a significant barrier to satisfactory achievement. 2. If so, what changes should be given priority? For cancer care this includes: chemotherapy delivered at home, in mobile units, or in local DGHs, community or cottage hospitals. This can be facilitated by regionally-commissioned electronic prescribing and dispensing systems as demonstrated in South West Wales by the collaboration between ABMU and Hywel Dda. Currently patient follow-up involves a lot of patient travel time to hospital clinics, and it takes up a significant hospital resource. Rationalisation of follow-up, using telemedicine, should be promoted wherever possible. Radiotherapy is expensive to provide in satellite centres with risks to quality, and will always remain based in a few cancer centres. Decentralisation of Clinical Radiology is less of an issue, apart from serious current and anticipated staffing problems in Wales. It is imperative that radiology IT barriers across Wales are resolved to facilitate remote reporting. Patients requiring specialist interventional radiology and some specialist imaging techniques (e.g. PET-CT) will have to travel to a relevant centre. The primary-secondary care interface is inefficient. There are frequently barriers to communication and referral between community and secondary providers, which wastes resources and impacts on the quality of healthcare. This particularly applies to referrals for suspected cancers in subsites such as urology and colorectal cancer, which have high-volume Urgent Suspected Cancer screening requirements and low conversion rates. Far too many lung cancers present late or as unplanned emergencies. None of these problems are new, but the solutions are elusive. Discharge back to the community is neglected. There is a perennial disconnect between the needs of hospital/gp, and social services, which greatly reduces the efficiency of discharge, particularly for patients requiring care or nursing home placement. This leads to delayed discharge, with the associated hazards of prolonged hospital admission, and it can cause bed-blocking. There are additional issues for tertiary providers when attempting complex discharges to distant authorities. GP handling of discharges would be facilitated by better communication from hospitals. Investment in community palliative medicine services would seem prudent. 3. Is there anything else we should do to strengthen legislation to ensure

agencies work together to plan to meet people s health and wellbeing needs? Much greater emphasis on personal and community responsibility in prevention (obesity, smoking, alcohol) and emphasis on the timely use of health services. Harmonisation of the standards, requirements and expectations for social services and LHBs to improve collaboration in respect of patient care in the community, hospital discharge. Continuously engaging with citizens 4. Are there ways in which the law could be reformed to shape service change? Public Health legislation such as minimum pricing for alcoholic drinks, and measures to reduce consumption of refined sugars would likely have significant knock-on benefits in shaping service change. 5. Should we consider establishing, on a statutory basis, the requirement for health boards and NHS trusts to constitute permanent engagement mechanisms, such as patient panels or participation groups? Formal Patient panels / participation groups in oncology often have a skewed distribution and promote highly motivated individuals from predictable patient groups to champion certain issues and cancers at the expense of those cancers that are disproportionately derived from lower socioeconomic groups, and rarer cancers. Whilst patient involvement is key and the case for statutory involvement in decision making is strong, novel ways of engaging a wider more representative patient voice that would not necessarily sit on a panel or participation group is needed. CHCs can be useful in this respect. The Wales Cancer Alliance, comprising senior members of the major cancer charities, is also a reasonable surrogate, though it has to be acknowledged that the charities also have their own agenda. 6. Do you support the idea of a national expert panel to which referrals might be made rather than referral to Ministers? If so, how might the law be reformed to constitute such a panel? What rules should govern the process of referral in such an arrangement? This idea merits a much more detailed analysis. Chapter 2: Enabling Quality Quality and co-operation 7. Are legislative measures the most effective tool to address the issues raised in this section? Legislative measures may be helpful if properly directed. We are not certain whether the following points require legislation or whether they can be addressed through other means, but they are pivotal: Quality / Meeting common standards in oncology the Peer Review system backed by HIW and publically published is already providing this in a developing format. A requirement to

participate in the process is reasonable, but to have greater value the process should have greater independence. Within Wales it is hard to divorce drivers for change on quality and political grounds. As such the definition of Peers should be widened to outside of Wales or at least has an oversight by a non-governmental independent body. Quality metrics are not always easily available (e.g. patient-specific mortality data) or may, arguably, produce perverse, sometimes non-prudent incentives (e.g. cancer SaFF targets) at the expense of more clinically relevant priorities. High quality, prospective data relevant to the entire patient pathway is fundamental: much of this exists but in isolated IT silos, inaccessible and underexploited. Benchmarking of electronic clinical datasets across Wales and with England is important, but sometimes difficult. Integration of public health and primary care datasets with those of secondary care is a basic requirement. There is a clear need to foster regional inter-lhb cooperation for cancer services, radiology and other issues. Current financial arrangements (LTAs, WHSSC) between LHBs, NHS trusts are frustratingly opaque, and are a barrier to this. There needs to be consideration to given to how the needs of equity, quality and cooperation can be ensured, given the 2 different commissioning models currently being developed in Wales for cancer services: South East Wales, compared to South West and North Wales. Wales compared to the UK and EU. Parochial measures of quality and equity within Wales are useful up to a point, but there has to be explicit recognition that Wales exists as part of the rest of the UK/EU/World in terms of staff training and recruitment, specialist service commissioning, and health outcome measures. The continued divergence of NHS Wales and NHS England presents immediate and growing practical issues. 8. If so, how can we use our legislative powers to build on the existing duty of quality to better fit with our integrated system? See 7. 9. What legislative measures could we introduce to ensure quality is put at the forefront of all decisions and joint decisions of health organisations? 10. What would be the advantages and disadvantages of setting out in legislation the role of responsible individual for health bodies in Wales? 11. What would be the advantages and disadvantages of legislating for a fit and proper persons test, and to whom should it apply? Integrated planning

12. Do we need to strengthen our existing legislation further to promote quality through the NHS planning framework? See 7. Chapter 3: Quality in Practice Meeting common standards 13. Is there a case for changing the basis under which the healthcare standards for use in the NHS are set? Yes. Agree with point 52. 14. Could a common standards framework, which covers both the NHS and the independent sector, better deliver a focus on improving outcomes and experience for citizens? Yes. 15. How could we further require the use of mechanisms such as accreditation and peer review to promote better service quality? The HIW cancer peer review programme has matured and proved to be useful. It promotes data transparency and a reciprocal, critical multidisciplinary review of local services by a wider Welsh expert panel. The process could be extended to other services. Accreditation beyond Wales is already required for participation in certain areas of clinical research, and this is a clear driver for service improvement. It is important that Wales should be actively involved in generating the UKwide peer review and accreditation agenda, rather than assuming the role of a passive follower. Clinical supervision 16. How can we ensure health professional registrants have the opportunity to have clinical peer supervision? Should we be considering the use of legislation in this regard and if so, how? All doctors are subject to annual appraisal and 5-yearly revalidation under GMC regulations. Clinical peer supervision and support is more than this however, and professional isolation of medical specialists, often in small departments in District General Hospitals is a very real problem. Isolation makes vacant posts unattractive, and compounds recruitment problems especially in the periphery. Professional guidance and needs will vary between specialties. For Clinical Oncology and Clinical Radiology, the RCR can provide guidance. Whether this needs specific legislation or an obligation to follow RCR (or equivalent) guidance is moot: the work required for medical appraisal and revalidation is already a significant burden for doctors, and we would advise caution if considering adding extra to the current appraisal process. 17. What arrangements should be put in place for self-employed health professional registrants? Self-employed health professional registrants should have the same standards applied as NHS

employees. Chapter 4: Openness and honesty in all that we do Being open about performance and when things go wrong 18. Do you agree that we should introduce a statutory duty of candour within the NHS in Wales? Yes. 19. How could we use legislation to further improve transparency on performance in the Welsh NHS?. Making it easier to raise concerns in an integrated system 20. What legislative steps can we take to improve the joint investigation of complaints across the NHS and social services in Wales? Agree with points 68, 69, and 70. Chapter 5: Better Information, Safely Shared Sharing information to provide a better service 21. What are the issues preventing healthcare bodies from sharing patient information? This is key for Oncology treatment management and research. The unnecessarily restrictive sharing of data is one of the key barriers to future improvements in outcomes. Whilst necessary protection to individuals is important there should be an assumption of free sharing of medical information between health and social care professionals particularly across primary / secondary care and health board boundaries for the benefit of individuals. 1. Technical. Data silos within LHBs (often between departments) and between LHBs (Radiological images and reports are a prime example.) Basic technical sharing issues can be overcome. It is ironic that there remain severe longstanding problems sharing radiological information between units along the South Wales corridor, which have been solved by a private provider of outsourced radiology reporting based in Australia. 2. Future commissioning of IT systems requires an all-wales set of standards. Wales has to overcome the legacy of multiple non-integrated systems, some of which are obsolete. 3. More advanced integration of data to permit sophisticated population analysis requires a feed from Public Health Wales, Public Health England, and from primary care, amongst others. At present this is in development through the SAIL project, but this remains purely academic, without a clinical interface. This represents a profound opportunity for intelligent, information-driven service development. Cross-border data sharing issues are a problem e.g. death data administered by the Office of National Statistics. 4. Data security and confidentiality. Whilst this is obviously central, it is frequently misapplied,

increasing clinical risk. For example the insistence on using anonymised Fax to transfer radiology reporting between health boards, when nhswales email is probably safer, and less prone to patient identification error. We question whether Fax is appropriate in the modern NHS at all. 5. Lack of appreciation of the clinical risks and inefficiencies associated with unavailability of information at the point of clinical decision making. For example Regional MDT review of images from neighbouring LHBs, which often arrive without an attached report. Admission of acutely ill cancer patients to a DGH who are receiving treatment at a specialist unit elsewhere: lack of access for the acute admitting team to details of diagnosis and treatments for a complex condition, current treatment and possible morbidities, ceilings of care. 22. How can we consider breaking down any barriers? See 21. 23. What are your views on the collection and sharing of patient identifiable information for non direct patient care, such as research? What are the issues to be considered? Crucial, within accepted, well-defined research guidelines. For the purposes of research, data should be pseudo-anonymised, but then made freely available to appropriately approved researchers. In a similar way to the Welsh leading the way on presumed consent to organ donation, Wales should lead the way on presumed consent for healthcare data sharing on both the individual patient management level and the pseudo-anonymised research level. These arguments have been well articulated by the European Data in Health Research Alliance (http://www.datasaveslives.eu/) Chapter 6: Checks and Balances A seamless regime for inspection and regulation 24. Are there gaps in the current legislative framework to enable HIW to operate effectively? If so, what are they? No Comment 25. Are there persuasive arguments against providing HIW with full statutory independence? If not, how should the law be reformed to best effect? What would be the implications of doing so for CSSIW? No Comment 26. How can we improve joint working between HIW and CSSIW short of creating

a single inspectorate? Do these arrangements require legislative change? No Comment 27. What are the advantages or disadvantages for citizens of a single inspectorate covering the roles and responsibilities of HIW and CSSIW? A potential problem with integration is loss of specialist understanding of areas inspected. Representing patients and the public 28. Should CHCs activities be refocused on representing the patient voice and on providing advocacy services? If so, how could we legislate to strengthen the CHCs role as representatives of the patient voice? 29. Is the current CHC model fit for purpose in a more integrated system? If not, how would you suggest it needs to be changed? Chapter 7: Finance, functions and planning Borrowing powers 30. Should we change the law to give health boards borrowing powers? Yes, with appropriate safeguards. The Scottish NPD model for infrastructure projects is already being adopted in Wales. Summarised accounts General observations: Finance Reporting whatever changes are made should have the effect of increasing transparency and be comparable across health boards and trusts. LTA arrangements and some WHSSC block disbursements lack the necessary activity-related detail and transparency. Financial Planning requirements should be equivalent for boards and trusts. 31. Is the legislative requirement to prepare NHS trust and health board summarised accounts still relevant?

32. Should legislative changes be made to provide greater flexibility regarding summarised accounts for NHS organisations in Wales, reflecting NHS structural and government financial reporting changes? Planning Yes 33. Should there be an equivalent statutory planning duty for NHS trusts as we have for health boards? 34. Should we review NHS (Wales) Act 2006.planning duties to avoid duplication and improve alignment with the Social Services and Well-being (Wales) Act 2014 and the Well-being of Future Generations (Wales) Act 2015? Chapter 8: Leadership, Governance and Partnerships 35. What measures, including legislative, might be taken in order to strengthen leadership, governance, and partnerships? Leadership should be fostered and developed. Any strong leadership of should be demonstrably impartial and without any conflict of interest LHB size and membership 36. Does the current size and configuration of health board membership best promote an effective focus on decisions, priorities and scrutiny? If not, how might health boards be reformed? 37. Within a set number of executive directors, could health boards have discretion about the role of some of its executive directors? 38. What are your views about the suggestions made by the Commission on Public Service Governance and Delivery, such as the election of community representation?

39. Local government reform is underway; should there be a statutory provision for joint appointments (for example directors of public health) between local authorities and the NHS in the new arrangements for public services? 40. Would you like to suggest any other changes you think are required to health board membership to ensure they are fit for the future? NHS Trust size and membership 41. Does the current size and configuration of NHS trust board membership best promote an effective focus on decisions, priorities and service provision? If not, how might NHS trust boards be reformed? 42. Would you like to suggest any other changes you think are required to NHS trust board membership to ensure they are fit for the future? Board secretary role 43. Does the role of the board secretary need greater statutory clarity? 44. If so, what aspects of the role should be additionally set out in law? 45. How could potential conflicts of interest for the board secretary be managed? Advisory structure 46. Given the many ways that Welsh Ministers and NHS leaders can access expert professional and clinical advice, should we seek to change the statutory status of the advisory committees? Please see the embedded RCR response to the WAG Review of the Advisory Structure for Health (submitted September 2014) 2014 reply RCR Wales Advisory Struc

47. If so, how might we use legislation to ensure that policy and service delivery is based on expert professional advice? See 46. NHS Workforce partnerships 48. Are the current partnership working arrangements fit for purpose or do they need amending in law to reflect increased devolution and the prudent healthcare approach in Wales? See previous comments. Recruitment and retention of staff is significantly affected by training schemes in England and by comparison of Welsh Terms & Conditions with those of England. Given the increasing divergence of NHS Wales from England, the requirements of NHS workforce partnerships becomes more complex, and it is necessary develop a mechanism to keep this under review, in order to plan strategically and sensibly. Hosted and Joint services 49. What legislative measures could be put in place to provide better clarity for hosted, joint and shared services? 50. What changes could be made to provide greater flexibility for NHS Wales Shared Services Partnership (NWSSP) to equip it to take a public sector-wide shared services role?