Network Trust NICaN Western Health and Social Care Trust Lung MDT Visit Date 13 September 2017 Structure and function of the service The Western Health and Social Care Trust (WHSCT) was established on 1 April 2007 under the Review of Public Administration. The Trust brought together the delivery of health and social care which previously had been provided by three separate Trusts, and now provides services across the super council areas: Strabane and Derry City, Fermanagh and Omagh District and a portion of the Causeway Coast and Glens Borough Council area. Services are provided to approximately 300,000 people. The vast majority of services are provided in community based settings with access to specialist inpatient services available from a number of hospitals such as Altnagelvin, Grangewood, Lakeview, South West Acute Hospital, Omagh Hospital and Primary Care Complex. Altnagelvin Area Hospital is the main acute hospital site offering a range of services and has been recently designated as the second cancer centre in Northern Ireland following the opening in 2016 of the North West Cancer Centre (NWCC). This contains a new 27 bedded inpatient haematology and oncology ward of which 14 beds are currently operational and the Trust can flex up to 18 beds to meet service demands. There is also a chemotherapy suite with 25 chairs and 5 single treatment rooms and a dedicated radiotherapy unit with three Linear Accelerators and associated state of the art equipment. Radiotherapy is currently being delivered for breast, prostate and colorectal cancer. The South West Acute Hospital (SWAH) was opened on 21st June 2012 and serves a population of 60,570 which is predominately rural in nature with limited public transport infrastructure. The Omagh Hospital has also undergone a substantial redevelopment programme transforming into a local enhanced hospital and primary care complex which opened in June 2017. There was a good representation from members of the MDT team across disciplines but no representation from SWAH. The MDT demonstrated as a cohesive and well-functioning group with good communication and working relationships across departments. All core MDT members are in place and there is adequate cover for each core member. There are currently three substantive consultant respiratory physicians in Altnagelvin equating to 2.9 Whole Time Equivalent (WTE) with a further post that has been vacant for the last 12 months despite advertising and with no locum cover. This work is being absorbed by the other three physicians and creating pressures as only one of the consultants currently provides the Endobronchial Ultrasound (EBUS) service. There are two substantive posts in SWAH and there has been a long time period where there was a single handed physician supported by variable locums, although the last appointee has been in post for over 12 months, as the Trust has been unable to recruit to the second substantive consultant post. At the time of the peer review visit, it was reported that there are now no consultant respiratory physicians on the South West Acute Hospital (SWAH) site. The substantive consultant is Quality Surveillance Team, MDT Peer Review Visit Report 1
on long term sick leave with no return date envisaged, and the locum consultant covering the second post was reported as having taken unplanned leave the day before the visit and as not being available for at least two weeks. This puts patients, staff and the service at major risk. It also puts additional pressure on the Altnagelvin site. This will create significant delays for patients diagnosis and treatment and could affect patient outcomes. There was no cohesive plan represented to mitigate these circumstances at the visit and so currently red flag referrals are not being triaged and processed. This is an immediate patient and staff safety concern. This risk has been escalated to the senior management team. Immediately following the visit an action plan was formulated to add these referrals into the Altnagelvin consultant s workload whilst a longer term plan is agreed. Whilst this ensures patient referrals are processed appropriately, this further adds to the pressure described above on the Altnagelvin consultants and is not sustainable in the medium term. With the ongoing development of the NWCC, the MDT now has three resident rather than visiting oncologists for the lung service, one medical and two clinical, and with further recent oncology appointments appropriate cover arrangements have also improved substantially. Attendance and commitment for the MDT meetings has also improved substantially with no meetings in the reported year not covered. There are four CNSs currently in post of whom three are part time. They work on the three different main hospital sites and cover for absence remains difficult to arrange. One full time CNS is based at Altnagelvin with a second 0.4 Whole Time Equivalent (WTE) CNS who is also the Gynaecology CNS for the other 0.6WTE part of her contract. This joint role was reported as working well. The other two CNSs each work 0.5 WTE in cancer at SWAH and the Omagh Hospital and Primary Care Complex and the other half of their roles as respiratory nurses. None of the CNSs travel to the other hospital sites and so any cover is by telephone only. Lack of CNS support for patients, especially at the peripheral sites, was raised at the two previous peer review visits in 2010 and 2014 and the cover at peripheral hospitals still needs to be more robust. The CNSs at Altnagelvin covered all of the MDT meetings in 2016 but there were seven meetings where neither of the two CNSs from the south sector of the Trust were present. There are two thoracic surgeons based at Belfast HSCT who link with the MDT. Only four meetings in 2016 had no surgeon present. There is an experienced histopathologist who has recently become a core member of the MDT with good cover arrangements in place and the discipline achieved 100% attendance at the MDT. There is also a clinical scientist who regularly attends the meeting which helps smooth the diagnostic pathways. There are two radiologists based at Altnagelvin who are core members of and attend the MDT and one based at SWAH who attends by video link. There was 100% coverage of the MDT meetings during 2016. There is now a substantive MDT co-ordinator who is obviously an integral part of the MDT and she meets regularly with the CNS and clinical lead. Cover provided by the co-ordinator team. Quality Surveillance Team, MDT Peer Review Visit Report 2
The palliative care service has been re-organised and recruitment completed so that there is now full coverage of the MDT with only one meeting not attended in the reported year. There has been overall a significant improvement in the individual MDT attendance across all disciplines. As a result the quoracy of the MDT meetings has risen from 57% in 2014 to 89% in 2016. This demonstrates good commitment to improving the functioning of the MDT meetings and streamlining pathways and reducing waiting times for patients. The MDT meeting takes place on a Monday from 1pm and is scheduled for 1.5 hours but frequently over runs. The meeting is well structured with video links to SWAH and Omagh Hospital and Primary Care Complex. Time constraints and increasing patient numbers have resulted in a re-analysis of which patients are discussed in which order to improve the effectiveness of the MDT. Due to the meeting being scheduled for a Monday, five meetings were missed due to bank holidays. There is an x-ray lung meeting on a Friday which allows the MDT to be flexible over the bank holidays to ensure timely discussion of patients. There is also a Tuesday follow up meeting between the two CNSs and the MDT coordinator to ensure all actions are followed through and this can facilitate further discussion. Coordination of care/patient pathways The Trust is part of the Northern Ireland Cancer Network (NICaN) and the MDT has been represented at all of the clinical reference group meetings by the lead clinician. All the NICaN guidelines have been agreed and adopted by the MDT. Referral to appointment time for Red Flag referrals is on average 5-6 days. In the light of the SWAH staffing issues there are now only three new patient clinics per week and there will be considerable pressure on appointments. Prior to the staffing crisis, maintaining the 5-6 day time to appointment was only being achieved by undertaking ad-hoc clinics. The recent staffing developments already outlined will add to the pressure and there are concerns that this is not sustainable with increasing referral rates and relies on the good will of the staff involved. This pressure has been raised as a serious concern as it requires urgent and sustainable resolution. Radiology now fast-track abnormal GP requested imaging back to the GP service for advised red flag referral into the Trust. GPs arrange for blood to be taken and book an urgent Computerised Tomography (CT) scan in anticipation of a Chest Clinic appointment. The review team has concerns regarding potential delays to the pathway in the light of the additional pressures on the system raised above. Radiology provide prompt and responsive cover but concerns were raised re potential Positron Emission Tomography (PET) scan delays as patients all have to go to the Belfast HSCT for this investigation and there is currently a three week turnaround time for scans and reports. Some patients are now travelling to Dublin for the PET instead and this adds additional delays. Bronchoscopy was delivered on both sites and EBUS is now provided by only one clinician in Altnagelvin. The impact on bronchoscopy at SWAH has not been addressed in the urgent action plan Quality Surveillance Team, MDT Peer Review Visit Report 3
and this will create additional pressures on the Altnagelvin site. Cover for inpatients at SWAH will also need to be resolved as patients may be too unwell to travel the 118 mile round trip to Altnagelvin. The SWAH site did have an excellent EBUS service but this is currently on hold due to sick leave and therefore creates additional pressure at Altnagelvin where there is only one EBUS endoscope. This limits the number of these procedures that can be undertaken and was highlighted at the last peer review. Along with the staffing challenges this leaves the EBUS service vulnerable. The thoracic surgeons undertake follow-up clinics on the Altnagelvin site to see patients once following their surgery. After this they return to the care of the referring physician or are under the care of the oncologists. There is a protocol driven nurse-led follow-up clinic and patients using the service have given formal survey feedback which demonstrated that this is well run and patients appreciate the slower pace and time given during this session. With the development of the NWCC there are now nine full time oncologists at the Trust with three having direct input to the lung cancer service. Chemotherapy is provided in the NWCC with good evidence of multidisciplinary working and learning. The Acute Oncology Service (AOS) has been in place since May 2017 to support patients on treatment. Radiotherapy treatment for lung cancer is currently undergoing careful planning and will be phased in to NWCC from October 2017. This will negate the 150 mile round trip to Belfast HSCT for the majority of these patients. Patient experience Good evidence was provided of obtaining patient feedback. The patient surveys were produced outside of the MDT and so the favourable responses were not influenced by the CNSs. There is an effective action plan in place which is being monitored for progress. There is a Hospice based Breathlessness palliative care programme in place which lung cancer patients can attend and this acts as a support group to some extent with access to therapists. The new Macmillan information hub in the foyer of the NWCC is a welcome, well situated addition for patients. The hub is managed by an information manager and the patient information and documentation is of good quality and is up to date. There is a leaflet describing the MDT, its function and membership with contact details. Key workers are allocated at first appointment or diagnosis if an inpatient. This is well documented within the patient records and the information given to all patients has the details of all four CNSs included so that someone is always available for advice. There is excellent use of the ability to document patient interventions on CaPPs by the CNS and copies are printed off and filed in the patient records. Quality Surveillance Team, MDT Peer Review Visit Report 4
A Permanent Patient Consultation Record is being used effectively to confirm and communicate with patients at diagnosis. There are challenges with copying the document for the patient record but the patient always has their copy. A carbonated triplicate form has been developed and is currently awaited from the printers and this will mean the CNS does not have to leave patients to find a photocopier having just given them significant news. Nine of the 16 appropriate core MDT members have attended Advanced Communication Skills training. The remaining seven are on a waiting list awaiting places. GP communication re new diagnosis of lung cancer is robust as the CNS usually rings the GP surgery as well as the MDT ensuring that outcomes and treatment plans are uploaded onto the electronic case record (ECR) system that is instantly available to GPS if they look. Clinical outcomes/indicators There were 228 new patients diagnosed with lung cancer in 2016 which represents a year on year increase in referrals. The MDT analyses breaches of the 31 and 62 day cancer waiting times targets to assess the root cause. Waits for chemotherapy, radiotherapy and surgery accounted for 10 of the 12 patients who waited more than 62 days for their first treatments. The development of the NWCC will help alleviate the first and second causes. The surgical pathway remains challenging with the pressure on beds and the service at Belfast HSCT. CaPPs is well utilised with staging information well documented in anticipation of the MDT meetings although with current work pressures the lead clinician informed the review team that this is currently being undertaken at the weekend to ensure the MDT meeting runs smoothly. The review team noted that the surgical resection rate, which had been the best in the province, had dropped significantly since the last review. The MDT has reviewed their data and believes that with the advent of PET scanning and EBUS, patients are being up staged so that surgery is no longer the best treatment option. Also the increased use of Stereotactic ablative radiotherapy (SABR), which delivers very high doses of radiotherapy to a tumour and can offer some patients longer disease and symptom control and an improved quality of life will be influential as it can be used as an alternative to surgery, or where surgery isn t an option, for example, if a tumour is located in an area which is difficult to operate on. Given the good thoracic surgeon attendance at the MDT, it is clear that all patients are being considered for surgery in the treatment planning discussion. Northern Ireland and therefore the MDT, does not contribute to the National Lung Cancer Audit Database due to information sharing legislation issues that remain unresolved. The ECR is a welcome development for local accessibility of MDT reports and letters for primary and secondary care. Manual posted letters also follow. The ongoing issue mentioned in all previous peer reviews of the incompatible Belfast x-ray systems remains. This is well documented with appropriate actions being undertaken. Quality Surveillance Team, MDT Peer Review Visit Report 5
There was evidence provided of good quality network and local audits and these have been discussed by the MDT and appropriate actions taken. There are currently no local clinical trials available but patients can access trials at Belfast HSCT however the travelling remains a barrier to many patients although there is a flyer bus that travels between the two cancer centres as long as local patients are able to get to the WHSCT. A local clinical trial lead has now been identified and work on establishing a trial portfolio is underway and accrual is expected to rise over the coming year. There is only one clinical trial nurse in post at present funded by Cancer Research UK, but interviews for a second research nurse funded by the Trust are imminent. The Trust is also looking at funding for a trials radiographer to support radiotherapy clinical trials in the future. Good Practice/Significant Achievement Opening of the NWCC which is an exceptional facility. Appointment of local consultant clinical and medical oncologists. Development of a local AOS service. Completeness of the CNS documentation on CaPPs is exceptional. Demonstrable good team relationships with evidenced respect for each other. Flexibility and accessibility of clinical staff is laudable. Specify Immediate Risks An Immediate Risk is an issue that is likely to result in significant harm to patients or staff or have a direct serious adverse impact on clinical outcomes and therefore requires immediate action. At the time of the peer review visit it was reported that there are no consultant respiratory physicians on the South West Acute Hospital (SWAH) site. The substantive consultant is on long term sick leave and the locum consultant covering the second post was reported as having finished the post the day before the visit and as not being available for at least two weeks. This puts patients, staff and the service at major risk. It also puts additional pressure on the Altnagelvin site. This will create significant delays for patients diagnosis and treatment and could affect patient outcomes. Trust response. Respiratory consultant recruitment remains a challenge locally. The existing substantive Respiratory Consultant at (currently on unplanned leave) is a single handed consultant on the SWAH site and the Trust fully acknowledges this is not a sustainable model. Until recently, the service was being delivered via a Locum Consultant, however he required to take some unplanned leave which commenced on 12 September 2017. This issue has been highlighted to the local commissioner. Quality Surveillance Team, MDT Peer Review Visit Report 6
The Trust is working at both a local and at a regional level to address this issue in the short term and to formulate a longer term plan, to ensure service sustainability going forward. The following actions can be noted: one locum consultant on-site from 2 October 2017; a second locum is currently going through Trust processes and is due to commence 23 October 2017; the Trust is continuing to work towards agreeing a return to work for the substantive consultant; there continues to be attempts to recruit to the substantive consultant vacancies; an advert has been placed for a Locum position with various agencies and at present, there is one potential local candidate who has advised that he would be willing to take up a locum post from 23rd October 2017; international recruitment attempts are ongoing. The issue of local recruitment challenges has been escalated to HSCB via the Director of Acute Services, WHSCT. The Trust has already commenced discussions at a senior management level and options are being explored, taking account of the totality of the service. These discussions will continue in the coming weeks. Specify Serious Concerns A Serious Concern is an issue that, whilst not presenting an immediate risk to patient or staff safety, is likely to seriously compromise the quality of patient care, and therefore requires urgent action to resolve. 1. There are currently only three substantive consultant respiratory physicians, 2.9 WTE, available out of the six commissioned posts across the Trust. The Trust has been unable to recruit to the two substantive vacant posts, one on each hospital site and there are now no locum consultants in post either. The lead clinician is also currently the single handed Endobronchial ultrasound (EBUS) provider. He is therefore under significant pressure to maintain the overall service and the EBUS service. This could create significant delays for patients diagnosis and treatment and could affect patient outcomes. Trust response. Partially addressed in the response above. It is acknowledged that currently as the substantive Consultant respiratory Physician, SWAH is on unplanned leave, this does result in there being a single handed EBUS service across the Trust. However, this issue will be addressed once the substantive consultant has returned to work, as the EBUS service will then be reinstated within SWAH, thus ensuring a Trust wide service across 2 providers. An audit has been agreed as part of 17/18 work plan to look at capacity/demand of EBUS to inform future service planning/delivery. 2. There is also only one EBUS scope on the Altnagelvin Area Hospital site which is an additional vulnerability for the EBUS service. This was reported at the previous peer review visit in 2014 and has not been resolved. In addition, given the lack of EBUS service currently at SWAH this will add to the pressures and could create significant delays for patients diagnosis and treatment and could affect patient outcomes. Quality Surveillance Team, MDT Peer Review Visit Report 7
Trust response. There are currently 2 available EBUS scopes within the SWAH site. It has recently been agreed that one of the scopes can be transferred to Altnagelvin as interim measure. This will ensure a fail safe within the Altnagelvin service and is likely to have an impact on productivity. The Trust will explore the cost/funding options for the purchase of a 2nd EBUS scope for the Altnagelvin site as a longer term option. Future service requirements will be informed via the audit detailed above. Concerns A concern is an issue that is affecting the delivery or quality of the service that does not require immediate action, but can be addressed through the work programmes of the services. PET scan availability in Belfast HSCT and the necessity for some patients to travel to Dublin. Lack of CNS cover for patients on the SWAH and Omagh Hospital and Primary Care Complex sites. No clinical trials currently provided locally. Not all appropriate core members have undertaken Advanced Communication Skills training. Quality Surveillance Team, MDT Peer Review Visit Report 8