PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM) Network Organisation (Trust) Team MVCN LUTON AND DUNSTABLE Luton & Dunstable Colorectal MDT (11-2D-1) - 2011/12 Peer Review Visit Date 11th November 2011 Compliance COLORECTAL MDT COLORECTAL LOCALITY MEASURES Zonal Statement Completed By Job Title Self Assessment 100.0% (41/41) Self Assessment 100.0% (2/2) Donna McKenzie Quality Manager Peer Review 84.2% (32/38) Peer Review 50.0% (1/2) Date Completed 26th January 2012 Agreed By (Clinical Lead/Quality Director) Sally Edwards Date Agreed 25th January 2012 Key Themes Structure and function of the service The Multidisciplinary Team (MDT) is fully constituted with a full core membership and large extended membership although not all disciplines were covered appropriately. The Clinical Oncologist reported she had no cover and the Clinical Nurse Specialist (CNS) was covered by a support nurse, who was not currently fully trained to CNS level. The support nurse, who is not currently trained to CNS level, is employed on a temporary basis to provide cover for a second CNS who had taken up a secondment opportunity. On discussion with the team, it was evident that this arrangement had now become permanent and the vacant post is to be made substantive. The current postholder, who is part time, is expected to undertake further training to enable her to meet the requirements of a CNS. The issue of CNS PEER REVIEW VISIT REPORT for Luton & Dunstable - Colorectal MDT (published: 26th January 2012) Page: 1/8
cover and appropriate training were not reflected in the MDT's workplan. The Clinical Oncologist was clearly balancing a significant number of commitments including supporting a reported ten MDT's and working across more than one site. On discussion with the MDT team it was apparent that they had been under significant pressure in terms of managing workload with insufficient theatre capacity than required for the demand and despite several initiatives that have taken place within the trust this has not been fully resolved. The team have been relying on a Locum Consultant to support them who is not currently listed as a core member of the MDT despite treating colorectal cancer. The endoscopy service was managing current demand. However, there is no reserve capacity in the system and with the forthcoming awareness campaign and age extension to the bowel screening programme this is likely to increase demand on the service in the near future. Although the team reported holding weekly meetings on a Thursday lunchtime, there have only been 45 meetings out of a potential 52 (23% of meetings didn't take place). On discussion with the team this was reported as being due to the lack of oncology and radiology availability for the meetings that were cancelled. The MDT support team are responsible for recording and monitoring attendance. Arrangements for all new patients to be reviewed by the MDT are clearly described in the operational policy. The MDT have approximately 150 new patients per annum. Both named core surgeons undertake the minimum number of operative procedures for colorectal cancer per year. However the workload of the locum consultant was not recorded. The histopathology service is adequate. However, if the service is to subspecialise a further consultant histopatholgist will be required and this might be necessary to fulfil Clinical Pathology Accreditation (CPA) in the future. Demand is expected to rise as for all support services as a result of the age extension for bowel screening and the National Awareness and Early Diagnosis Initiative (NAEDI) campaign. Both the colorectal nurse and the support nurse have completed psychological assessment skills training enabling them to provide psychological support to patients with colorectal cancer. The CNS receives one hour clinical supervision per month from the consultant clinical psychologist. An annual meeting to discuss operational policies took place on 12th May 2010. Coordination of care/patient pathways The operational policy states that it is the responsibility of the Consultant or Colorectal CNS to record decisions regarding the individual patient's treatment plans following discussion at the MDT. There is an MDT proforma and evidence of this being filed within the patient notes. However, the notes provided as evidence on the day of the review related to patients' who had only very recently been discussed and therefore it was difficult to follow through the patient pathway and confirm MDT decisions had been actioned. The Colorectal CNS is responsible for informing the General Practitioner (GP) of a patient's diagnosis within 24 hours of the patient being told. An audit had been undertaken with eleven PEER REVIEW VISIT REPORT for Luton & Dunstable - Colorectal MDT (published: 26th January 2012) Page: 2/8
out of fifteen GP's receiving the notification by the end of the following day. The GP notification proforma includes the location of the patient when the diagnosis was given, for example outpatients or as an inpatient. It was again difficult to confirm within the patient notes that this had been completed systematically because of the notes presented as evidence on the day. The operational policy describes the arrangements to be followed when patients are admitted as an emergency and are in line with the Network agreed guidelines. There is a comprehensive set of Network agreed guidelines which have been adopted and are being implemented by the MDT. There is a list of named personnel judged competent for colorectal stenting within the Network Guidelines which includes personnel both within the Network and outside of it. The practitioner identified as undertaking this procedure for Luton and Dunstable patients is at University College London Hospital (UCLH). The use of a service outside their own network was discussed with the MDT team and was reported to be the most efficient pathway with patients being transferred via ambulance and returning within 24hours. There is reference in the operational policy to laparoscopic resection being offered to patients by a surgeon who has completed training in this technique. The Network guidelines state that all cases suitable for laparoscopic surgery are allocated to one of the three laparoscopic colorectal surgeons, although there are seven listed for the whole Network, as being authorised. In practice, at Luton and Dunstable Hospital, those patients who are under the care of the surgeon, who does not perform laparoscopic surgery are not offered the choice. One of the named core surgeons is named as being trained in laparoscopic surgery and is on the list of authorised personnel within the Network guidelines. However, no evidence was provided of either a letter from the national training programme of confirmation of competence or verification that the named surgeon is exempt agreed by the lead clinician of the MDT. In addition the locum consultant is reportedly undertaking laparoscopic surgery and no evidence of his training was provided either. The Network have recently agreed that the Colorectal MDT based at the Lister Hospital will incorporate the anal service for the Network. On discussion with the MDT it was clear that, although this was now operational, no patients had yet been identified for referral. The MDT agree to the Mount Vernon Cancer Network (MVCN) clinical guidelines for the resection of liver metastases and refer patients to the supra network team at the Royal Free Hospital. Patient experience There is a network wide key worker policy which is comprehensive and clearly written. The policy is supported by a competency framework and workbook which practitioners who have been identified as working as a key worker are expected to complete. A summary of the policy and the responsibilities of the key worker are also provided within the operational policy. The trust participated in the National Cancer Patient Experience Survey of 2010with 42 patients responding who had colorectal cancer. The results are reported in the work programme together with actions, time scales and nominated leads. Whilst 34 of the 67 indicators show the team to PEER REVIEW VISIT REPORT for Luton & Dunstable - Colorectal MDT (published: 26th January 2012) Page: 3/8
be performing at or above the national average, there are a number of areas where the trust performed less well, particularly around the amount of information given to patients. A further survey was undertaken locally with 42 questionnaires returned out of 53 sent out. Key outcomes included 29% of patients reporting they waited more than two weeks for an out patient appointment, 22% of patients reporting they did not have a specialist nurse present when told they had cancer and 22% of patients not offered a permanent record of their consultation despite wanting one. The issue regarding a permanent record being offered to patients has been ongoing since 2009. The Macmillan Unit undertakes the annual local surveys with good rates of return and analysis of responses. However, follow up actions from these have not been comprehensively implemented which is demonstrated by the same issues being raised repeatedly. There is a comprehensive range of patient literature including trust, network and national booklets. The exception to this is information on patient involvement opportunities. The trust is in the process of introducing patient information prescriptions. The national patient experience survey would suggest that patients are not always given enough information to meet their needs. There are issues around information for patients who do not have English as their first language. The MDT reported, in particular, the Polish population. Whilst translation services including "Language Line" are in place they were not necessarily available in a timely way. The team made good use of the Macmillan Information Unit on site which enables patients to access a good range of information. There is a trust-wide service user group specific to cancer patients, which the team use to pilot any new patient literature. All members of the MDT who have direct clinical contact with patients have attended the national advanced communications skills training course. The team has also identified the core member for imaging who would benefit from attending the training in the future and have included it in the MDT work plan. Clinical outcomes/indicators The MDT's annual report states there is no agreed Network Site Specific Group (NSSG) minimum dataset. The MDT does collect Cancer Waiting Time and Cancer Registry data. The NSSG annual report makes reference to data collection throughout the Network including a commitment to collect the data fields noted in the National Bowel Cancer Audit Programme (NBOCAP). In addition, it is not clear whether the MDT has started to record the minimum data set (MDS) for each patient on proformas. Data collection is clearly an issue for the MDT with only three patients being submitted to the NBOCAP audit making the audit meaningless for this Trust. Historical clinical Lines of Enquiry (CLE) data from 2003-2006 shows a relatively high 30 day mortality rate. Clearly much has changed in the last six years so it is difficult to ascertain why this is so. A recent network-wide audit of 30-day mortality demonstrated an overall rate of 8.7% which was reported as not being an outlier within the Network. Figures on staging suggested very low usage of Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) in PEER REVIEW VISIT REPORT for Luton & Dunstable - Colorectal MDT (published: 26th January 2012) Page: 4/8
patients with bowel cancer. The MDT did not recognise these figures and feel that almost all patients diagnosed with bowel cancer would undergo these investigations as appropriate. Certainly figures for other trusts are also low which would suggest a national problem with this data. The surgical team perform approximately 100 major resections per annum which is an acceptable workload for three cancer surgeons. The average length of stay is 10.1 days. The surgical team do not, at present, have an enhanced recovery programme (ERP) and are awaiting the appointment of an enhanced recovery specialist nurse prior to implementing this. Some elements of the enhanced recovery programme have been implemented. However the lead clinician admits patients the day before surgery which contributes to the length of stay. The readmission rate is around 9%, which is below the national average. The team have generally met both the two week wait and 31 day cancer waiting times targets but have performed significantly worse in three out of four quarters in 2010/11. The MDT have suggested this is due to capacity and resource issues and feel the appointment of the locum surgeon should help to resolve this. There is a list of approved trials and the MDT is actively recruiting patients via Mount Vernon Cancer Centre (MVCC). Open clinical trials and the number of people recruited was discussed at an NSSG meeting on 28th July 2011. A research network representative was present and after discussion it was agreed that no remedial action was required at the time. The Clinical Oncologist is supported by two research nurses. Good Practice Good Practice/Significant Achievements The competency framework for key workers, with the accompanying workbook for completion, helps to ensure that the operational policy for key workers is well implemented in practice. Both the colorectal nurse and the support nurse have completed psychological assessment skills training enabling them to provide psychological support to patients with colorectal cancer and clinical supervision is provided by two Clinical Psychologists one at level three and the other at level four. All members of the team with direct clinical contact with patients have undertaken the national advanced communications course Concerns Immediate Risks - There is an ongoing issue relating to theatre capacity which is impacting directly on the patient PEER REVIEW VISIT REPORT for Luton & Dunstable - Colorectal MDT (published: 26th January 2012) Page: 5/8
pathway, resulting in breaches and inappropriate delays to patient treatment. Ultimately this could affect patient outcomes. This was raised at last year's Internal Validation (IV) and to date has not been adequately addressed. Theatre capacity is a trust-wide issue - not one related solely or specifically to the Colorectal Service. Physical theatre capacity within the hospital is under considerable pressure and the Trust has explored ways to increase its capacity. It is not possible to increase the number of theatres within the hospital due to site constraints. The Quality Innovation & Improvement Project (QIPP) office has completed a detailed capacity and demand study across the Trust in relation to theatre capacity and specifically within the Colorectal Service. The study has looked at the totality of theatre work across cancer and benign work. - There is a risk that not all Polish patients understand the implications and risks of chemotherapy treatment because information leaflets are not accessible to them. Whilst translation services including "Language Line" are in place they were not necessarily available in a timely way. This lack of information could affect treatment decisions and ultimately impact on morbidity and clinical outcome. The Trust uses Language Line to ensure that translation services are available to patients whose first language is not English. It is the responsibility of the clinical team/cns to ensure that where such support services are required, they are booked in advance for a patient's attendance. The Oncology Department will review availability of information in other languages. The Trust will also be exploring with the network the availability of these leaflets in Polish at Mount Vernon Cancer Centre and the other Trusts within the network over the next 12 months. Serious Concerns - The Locum Consultant is not currently listed as a core member of the MDT but is actively treating colorectal cancer patients. In addition his workload is not recorded appropriately and there is no evidence of his training to support his competency in laparoscopic surgery. The Peer Review period for this tumour site is April 2010 to March 2011. The Locum Consultant did not come into post until April 2011, therefore the documentation pre-dates this appointment and is therefore outside the scope and time period of this review. However, documentation is being revised to ensure that the substantive Colorectal Surgeon appointment (commencing January 2012) is a core member of the MDT. - The data collection systems available to the team are clearly inadequate and are impacting on the services ability to monitor and evaluate their service and contribute appropriately to national audits including NBOCAP. They have recognised this and have identified a solution which PEER REVIEW VISIT REPORT for Luton & Dunstable - Colorectal MDT (published: 26th January 2012) Page: 6/8
includes the procurement and implementation of a electronic data system which will support live data collection at the MDM however, support from the Trust has been limited with lack of resources being cited as a barrier to implementation. he MDT team has had a manual system for the collection of NCASP audit data for a number of years. The findings of the peer review team has highlighted that the MDT has failed to collect this data regularly or systematically. Administrative support for the upload of data to the NCASP audits will be included in the review of the MDT Co-ordination and Support Team. The Trust Executive Team accelerated the implementation of Infoflex in July 2011 to ensure that data collection systems for cancer services were improved within the hospital. This replaces the 11 access databases previously used to collate and record the patient pathway. The Infoflex system has been implemented for the collection and submission of CWTs in the first instance. A business case is being developed by the Infoflex Project Board in conjunction with the Trust Information Services Board to develop the clinical modules, which will enable electronic collection of the all the national audit databases (including NBOCAP). It is factually incorrect to state that there has been limited support from the Trust in relation to resolving this issue. - The MDT only met 45 times out of a possible 52 during 2010/11. On more than one occasion there was a gap of up to three weeks between meetings which could potentially delay treatment decisions and subsequent outcomes. On discussion with the MDT this was reported to be due to lack of availability of core members. The MDT meets weekly. Two meetings were cancelled because of lack of core members (radiology and oncology availability). The MDT has a written operational policy which includes a procedure governing how to deal with referrals which need a treatment planning decision before the next scheduled meeting (this may take the form of a telephone conversation between appropriate core members). All treatment planning decisions are ratified at the next available MDT. Radiology support to MDTs will be reviewed by the Trust to ensure there are more robust cover arrangements over the next 12 months. The Oncologist support to MDTs is a visiting service from Mount Vernon Cancer Centre over which the Trust has no control in relation to cover for core MDT members. - It was reported that in 80% of cases, patients arrived at the oncology clinic without the appropriate set of notes being available. As a result of this temporary notes are regularly used (up to three sets) which do not contain the full patient record. As a result of on-site building works, it was necessary to move some case notes off site and PEER REVIEW VISIT REPORT for Luton & Dunstable - Colorectal MDT (published: 26th January 2012) Page: 7/8
reduce the size of the Medical Records Library on-site during August/early Sept. Problems relating to the logistics of such a move meant that for a period of 3-4 weeks the Trust (as a whole) experienced difficulty with availability of paper case notes. Processes were swiftly put in place to ensure that cancer patient's case notes were not removed off-site when an OPA/treatment procedure was scheduled within 3 weeks of the last. This was a one-off problem which has been resolved. It is not an ongoing issue. Concerns A number of issues raised through the local survey appear to recur year on year. The team should review their process for taking action following the analysis and reporting of this survey to ensure actions agreed are implemented and practice is changed. The service is currently supported by a CNS and support nurse and although a decision has now been made to make the support post a second substantive CNS post, the team need to develop clear plans to ensure the future post holder is appropriately trained to undertake the full role of a CNS. PEER REVIEW VISIT REPORT for Luton & Dunstable - Colorectal MDT (published: 26th January 2012) Page: 8/8