2016 / 17 Commissioning Intentions/ Quality Requirements ... · PDF file2016 / 17 Commissioning Intentions/ Quality Requirements/ Information Requirements / KPIs Cancer services will

2016 / 17

Commissioning Intentions/ Quality Requirements/ Information Requirements / KPIs

Cancer services will be commissioned in line with a number of national and regional cancer priorities and quality standards. In 2016/17 quality requirements for cancer have been refined to provide clarity on actions to reduce variation. The KPIs have been aligned to the Model of Care and the work programmes of the integrated cancer systems. In summary:-

1. All cancer services will be commissioned in line with the requirements of NICE Improving Outcomes Guidance and NICE quality standards (QS), the London Model of Care for cancer services and the National Cancer Survivorship Initiative (NCSI). Where there is new guidance or QS these will be identified below.

2. These commissioning intentions will support the delivery of cancer waiting times across London. They include the changes to services required to meet the new

NICE suspected cancer guideline (2015). This will enable GPs to have direct access to a greater range of diagnostic tests to support them to identify which patients

need to be referred under the two week standard. Improvements to pathways are also included in the CIs (e.g. Straight to test in Lower GI) which will support

sustainable achievement of the targets. All services will also be commissioned against timed tumour level pathways. Each timed pathway will be required to have

clear escalation points and include adoption of the ICS inter-trust transfer policy. Timed pathways must ensure inter trust patients are referred by day 42 at the

latest.

3. A number of services will be commissioned to support the earlier diagnosis of cancer in line with the Pan London Early Detection pathways. 4. Some services will be commissioned to manage the consequences of anti-cancer treatment (late effects).

Commissioning Intentions 16_17_CCB Page 2 of 15

Ref Commissioning

intention Quality requirement Information requirement Reference/rationale Comments

1 Endoscopy

1.1 All GPs to have straight to test access to lower GI endoscopy via a diagnostic triage service (flexible sigmoidoscopy and colonoscopy) for both low risk, not no risk of cancer referrals and two week referrals.

- Maximum access time of 2 weeks for urgent referrals by end of 16/17.

- Services are expected to be JAG accredited or have plans to achieve JAG accreditation.

- 6 week waiting times reported via existing monthly data return to Unify

- Outcome of any JAG assessment to be shared with commissioners within 5 working days.

- Provider to provide evidence of a policy that ensures Named Medical Practitioner with Clinical

- Responsibility for referrals to a diagnostic service (Peer review measure 14-1C-113d)

- Provider required to submit evidence of the straight to test pathway provided for GPs

- Straight to test for two week patients is a key improvement in the colorectal pathway to achieve the 62 day cancer waits standard. - NICE Suspected cancer guideline:

Recognition and referral (2015) is

expected to lead to an increase of

Lower GI referrals which is via this

straight to test pathway

- Access to straight to test endoscopy via a diagnostic triage service is key component of the pan London Best Practice Commissioning Pathway for the early detection of colorectal cancer

- Combines CIs on flexible sigmoidoscopy and colonoscopy from 15/16. Also formally confirms requirement to implement STT for TWW referrals

- The aim of commissioners is that all services are JAG accredited.

1.2 Surveillance of lower GI patients in line with agreed pan-London surveillance guidelines

Implementation of agreed surveillance guidelines

- Provider required to submit evidence that guideline implemented

- Evidence that the trust has undertaken a robust list cleaning exercise

Pan London surveillance guidelines (TBC) This is aimed at reducing the variation across London in surveillance endoscopies

1.3 GP direct access to gastroscopy tests for the investigation of specific upper GI symptoms.

Maximum access time of 2 weeks for urgent referrals by end of 16/17 Maximum access time of 6 weeks for non-urgent referrals.

Additional provider quarterly return on urgent gastroscopy access will be required.

NICE Suspected cancer guideline: Recognition and referral (2015) requires direct access to gastroscopy, with defined patient cohorts for urgent and non-urgent referrals.

The urgent direct access patients would previously have been referred under TWW.


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2 Imaging / Pathology

2.1 All GPs to have direct access to diagnostic services - non-obstetric ultrasound for low risk, not no risk of cancer

Maximum access time of 2 weeks by end of 16/17 48 hours for possible soft tissue sarcoma in children. Reporting Turnaround Time: Next working day (tolerance 90%)

Ultrasound to be measured from data already supplied by the provider to the diagnostic imaging dataset (DIDs).

Access and report turnaround time available in accordance with RCGP/RCR 2013 guidance (RCR applies to all imaging modalities):- Waiting times: Urgent 1 week Maximum Routine 1 week desirable, 2 week maximum Reporting Turnaround times: Next working day (Tolerance 90%) http://www.rcgp.org.uk/revalidation-and-cpd/~/media/Files/CfC/RCGP-Quality-imaging-services-for-Primary-Care.ashx NICE Suspected Cancer Guideline: Recognition and Referral (2015) requires GP Direct Access within two weeks for possible soft tissue sarcoma (within 48 hours for children), gynaecological, testicular, gall bladder and liver cancer

All diagnostic imaging / pathology requirements are shown in this commissioning intention

2.2 All GPs to have access to CA125 concurrently with trans vaginal US to support earlier diagnosis of ovarian cancer

Maximum access time of 2 weeks by end of 16/17 Reporting Turnaround Time: Next working day (tolerance 90%)

Provider quarterly information return on CA125 access times and report turnaround times.

Concurrent access to CA125 and US is a key component of the Pan London Best Practice Commissioning Pathway for the early detection of ovarian cancer.

Note: This is over and above NICE referral guidance (June 2015) which suggests CA125 first and if this is high refer for US.

http://www.rcgp.org.uk/revalidation-and-cpd/~/media/Files/CfC/RCGP-Quality-imaging-services-for-Primary-Care.ashx




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2.3

All GPs to have direct access to same day chest x-ray and x ray for high suspicion of cancer

High Suspicion: Same day access and report for chest x ray. 48 hour access for x ray for suspected bone sarcoma

X-ray to be measured from data already supplied by the provider to the diagnostic imaging dataset (DIDs).

RCGP/RCR 2013 guidance (see above) NICE Suspected cancer guideline: Recognition and referral (2015) require 48 hour access for suspected bone sarcoma

Requirement for low risk access to chest x-ray removed as this is already in place.

2.4 Formally report A&E, Urgent care centres and inpatient chest x-rays (CxR)

Reporting Turnaround times: Next working day (Tolerance 90%)

Provider quarterly information return on % reported plus turnaround times for reporting of chest x-rays in A&E, Urgent care centres and inpatient setting.

This requirement is to support the reduction of the risk of delayed diagnosis and is a key part of the Best Practice Commissioning Pathway for the early detection of lung cancer The turnaround times are in line with recommendations of the National Imaging Clinical Advisory group.

Evidence that not all CxR are reported, leading to potential missed cancers

2.5 Ensure that trusts have fully implemented NPSA safety alert 16/2007 - Failure to act on test results

Evidence of safety netting in place as described in NPSA safety alert 16/2007

Providers will provide evidence of full implementation across the trust for the three areas of responsibility identified: - Radiology departments - Individual referrers - Medical directors

To reduce the number of Sis across London on failure to act on test results.

Extend requirement to cover all radiology tests

2.6 Endobronchial US (EBUS) services are commissioned to an agreed service specification and tariff.

Service meets the requirements of the specification. (British Thoracic society “Quality Standards for Diagnostic Flexible Bronchoscopy in Adults” )

Trusts to provide evidence of an agreed pathway Annual outcome audit of 30 cases

EBUS services are expanding and in order to avoid service creep and maintain quality a service spec is required. BTS Audit template expected in Q4 2015/16

Service spec currently being developed and expect it to be available for gap analysis in Q4 15/16


Ref Commissioning


2.7

Direct access to CT scan of the abdomen in order to support early diagnosis of pancreatic cancers

Maximum access time of 2 weeks by end of 16/17

Available from DiDs iView tool

NICE Suspected cancer guideline: Recognition and referral (2015)

2.8 Direct Access MRI scanning for GPs for a specific group of patients in order to improve the early detection of brain cancer

Maximum access time of 2 weeks by end of 16/17

Available from DiDs iView tool

NICE Suspected cancer guideline: Recognition and referral (2015) For patients who are contraindicated for MRI access required to CT scan for brain

NICE now has a defined cohort for Brain MRI access.

3 Quality Assurance

All commissioned cancer services will participate in the National Cancer Peer Review Programme (NCPR) or other quality assurance programme as defined by commissioners (if not covered by NCPR)

Compliance threshold of 75% No immediate risks or serious concerns All cancer MDTs to be quorate with core membership present at 95% of meetings and that individual core members attend 66% of meetings.

Action plans to address failure to meet the quality requirements provided to commissioners in line with timescales set out in the NCPR handbook Provider to submit attendance records every six months for all cancer MDTs Baseline position (based on 15/16) to be submitted in April 2016 and every six months thereafter Action plan for improving attendance provided where not met.

http://www.cquins.nhs.uk/ To support a reduction in unwarranted variation in treatment.

The Quality Surveillance Team will continue the National peer review of cancer services.

http://www.cquins.nhs.uk/


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4 Lung Cancer

All lung cancer services will be commissioned in line with best practice through a timed pathway

A thoracic surgeon is present at all MDTs Any abnormal CxRs with a suspicion of lung cancer are flagged to the MDT and GP. CT prior to first OPA CT scan prior to bronchoscopy Clinical nurse specialist present at diagnosis

Attendance record of thoracic surgeon Trusts to provide evidence of an agreed pathway. Measured by National Lung Cancer Audit Measured by National Lung Cancer Audit (Threshold 95%) Measured by National Lung Cancer Audit (Threshold 80%)

To support an increase in resection rates and a more timely pathway to improve outcomes. To achieve recommendations of the National lung cancer audit. http://www.hscic.gov.uk/lung

Presentation of trust position against the national clinical audit at CQRM/G

National Service Specification for lung cancer expected in Sept 2015. Key KPIs from this would be included in quality requirements.

5 Breast Cancer

All breast cancer services will be commissioned in line with best practice through a timed pathway and follow up in line with the NCSI

That an individual surgeon has a caseload of 50 per annum That each service provides a one stop triple assessment service That the service is delivered through the 23-hour stay model That patients have

Provider information return on the caseload per surgeon annually. Baseline position (based on 15/16) to be submitted in April 2016 and quarterly thereafter. Provider required to submit evidence of an agreed pathway (annually) The 23hour stay model and access to immediate reconstruction will be assessed via provider data already submitted to SUS/HES

In line with the Model of Care/NICE/NCSI NICE improving Outcomes guidance(IOG) 2002 http://www.nice.org.uk/guidance/CSGBC/resources

National Service Specification for breast cancer expected in Sept 2015. Key KPIs from this would be included in quality requirements.

http://www.hscic.gov.uk/lung

http://www.nice.org.uk/guidance/CSGBC/resources

http://www.nice.org.uk/guidance/CSGBC/resources


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access to immediate reconstruction That 70% of new patients are followed up through a stratified pathway of supported self-management

Provider to complete the Pan London NCSI template for reporting of stratified pathway of supported self-management (quarterly)

biopsy will be developed for introduction should the PROMIS trial report favourably.

6 Prostate Cancer

All services for prostate cancer will be commissioned in line with NICE guidance through the agreed best practice pathway for London with follow up in line with the NCSI

- MRI is performed pre-TRUS Bx for a given cohort.

- 40% of new patients are followed up through a stratified pathway of

Cohort of cases for MRI pre TRUS as defined in ICS clinical guidelines Completion of Pan London NCSI template. Provider required to share relevant fields in the national prostate audit to measure MRI pre TRUS requirement

REF NICE Guidance for Prostate Cancer Jan 2014 http://www.nice.org.uk/guidance/CG175

A commissioning case for the use of multi-parametric MRI pre-biopsy will be developed for introduction should the PROMIS trial report favourably.

- supported self-management

- Use of multi parametric MRI (dependent on outcome of current trial)

http://www.nice.org.uk/guidance/CG175


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7 Colorectal Cancer

All services for colorectal cancer (CRC) will be commissioned in line with NICE guidance through a timed pathway with follow up in line with the NCSI

- All surgeons are completing the required minimum numbers of 20 cases with curative intent per annum

- Each MDT completes a minimum of 60 cases with curative intent per annum.

- Enhanced recovery programme embedded

- All suitable patients to be offered laparoscopic surgery and resection rates to match the England average.

- Age of referral for low risk, but not no risk of cancer lowered to 45

Annual numbers per team and per surgeon annually. All teams are required to submit data to NBOCAP for all colorectal cancer patients (as per service condition SC26.1 in NHS standard contract). The following will be assessed via provider data already submitted to NBOCAP - Completeness of data submitted to

NBOCAP - Audit of which patients have/don’t

have laparoscopic colorectal surgery

- The following will be assessed via provider data already submitted to SUS/HES - % of colorectal surgical cancer

patients admitted on the day of surgery.

- LOS for colorectal surgical cancer patients

% of patients having laparoscopic surgery.

NICE Guidance Colorectal Cancer 2011. http://www.nice.org.uk/guidance/CG131 NICE IOG CRC 2002. http://www.nice.org.uk/guidance/csgcc SC26.1 in NHS standard contract requires participate in the national clinical audits within the National Clinical Audit and Patient Outcomes Programme (NCAPOP) relevant to the Services. In cancer these are: - Colorectal cancer audit (NBOCAP) - Head and Neck Cancer audit - Lung Cancer Audit - Oesophago-Gastric Cancer Audit - Prostate Cancer Audit

Assurance given annually at CQRM in line with the publication of the national colorectal cancer audit. National Service Specification for colorectal cancer expected in Sept 2015. Key KPIs from this would be included in quality requirements.


http://www.nice.org.uk/guidance/csgcc


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- 40% of new patients are followed up through stratified pathway of supported self-management

- Barium enema is not to be used as a first diagnostic test for suspected colorectal cancer

- People who need emergency treatment should be treated by a colorectal cancer team

Emergency laparotomy audit will be used to highlight variation in emergency treatment across London. Additional data from providers may be required.

8 Agree and implement service consolidation plans – providers will work with their ICS and commissioners to implement the cancer Model of Care

Compliance with implementation gateways(NE&NC only in 2015/16) Provider attendance at ICS pathway groups/Quarterly Clinical Fora.

Provider to share information on compliance with implementation gateways(NE&NC only)

Providers will be required to pass through implementation gateways at part of specialist services reconfiguration.

Implementation gateways managed through NHSE programme board.

9 Living with and Beyond Cancer


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All cancer services will be commissioned to deliver the recovery package as described in the NCSI. Inclusion of requirement to share HNA, care plans and treatment summaries with primary care within a specified timeframe.

All new patients will have a completed recovery package by March 2016 consisting of:-

70% receive A Holistic Needs Assessment and care plan.

70% attend at a health and well-being event

70% receive a treatment summary

HNA and TS are to be shared with the GP Practice within 48 hours of completion, preferably electronically. Information should include the top concerns as identified in eHNA and are likely to include:

Completion of the London HNA template and data returned to LC/LCA within 25 working days of month end or data submitted via COSD monthly. Completion of the NCSI TS template and data returned to LC/LCA within 25 working days of month end. Completion of HWBE data sent to LC/LCA within 25 working days of month end.

National Cancer Survivorship Initiative(NCSI) http://www.ncsi.org.uk/ National Cancer Taskforce Strategy (2015) states that all patients with a new cancer diagnosis will receive all elements of the recovery package by 2020. http://www.cancerresearchuk.org/about-us/cancer-taskforce NCSI Treatment Summary User Guide (2011) states that TS should be sent to the patient and their GP practice within 6 weeks of the end of active treatment. LC/LCA/TCST guidance has been produced to support implementation and commissioning of the recovery package. Macmillan also has best practice guides for each element of the recovery package. Macmillan eHNA national data – top 4 concerns identified. http://www.macmillan.org.uk/Aboutus/News/Latest_News/REVEALEDTHETOPTENCONCERNSBURDENINGPEOPLEWITHCANCER.aspx

HNA recording as part of COSD from April 2015. Patient consent to share HNA/CP will need to be obtained. Annual assurance of pathways through CQRM/G.

http://www.ncsi.org.uk/

http://www.cancerresearchuk.org/about-us/cancer-taskforce


http://www.macmillan.org.uk/Aboutus/News/Latest_News/REVEALEDTHETOPTENCONCERNSBURDENINGPEOPLEWITHCANCER.aspx




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1. Fear/worry/anxiety

2. Cancer related fatigue

3. Pain management 4. Sleep

management

10 Consequences of treatment

Services will be commissioned to manage some of the consequences of anti-cancer treatment specifically: 1. Services for the 2. management of

GI late effects. 3. Services for

lymphedema 4. Services for

psychological and physical sexual related problems.

5. Services for psychological support (reference CI 15)

6. Services for managing hormonal symptoms

All MDTs that use pelvic RT will have agreed pathways in place for the management of GI late effects All MDTs where treatments may result in lymphoedema have agreed pathways in place to access services including exercise as per NICE guidance All MDTs where treatments may result in sexual function problems both male and female have clear referral pathways in

Details of pathways to be provided, including operational policies in Q1

To provide support for those living with cancer as a long term condition. National Cancer Taskforce Strategy (2015) states that all patients will be supported to manage the consequences of their cancer treatment effectively http://www.cancerresearchuk.org/about-us/cancer-taskforce NEW: NICE Guidance for Exercise to Reduce Lymphoedema 2014 in advanced breast cancer http://www.nice.org.uk/guidance/CG81 NCAT (2013), Cancer Rehabilitation: Making Excellent Cancer Care Possible http://webarchive.nationalarchives.gov.uk/20130513211237/http:/www.ncat.nhs.uk/sites/default/files/work-docs/Cancer_rehab-making_excellent_cancer_care_possible.2013.pdf




http://webarchive.nationalarchives.gov.uk/20130513211237/http:/www.ncat.nhs.uk/sites/default/files/work-docs/Cancer_rehab-making_excellent_cancer_care_possible.2013.pdf






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place for management All MDTs are required to have clear referral pathways in place for management of patients requiring psychological support and hormonal symptoms as a consequence of cancer treatment.

Macmillan (2013), Throwing the Light on Consequences of Treatment http://www.ncsi.org.uk/wp-content/uploads/MAC14312_CoT_Throwing-light_report_FINAL.pdf London TCST & Mental Health SCN (2015) Psychological support for people living with cancer: a guide for commissioners http://nhs.us4.list-manage1.com/track/click?u=6b4247ab96a4a1dd020e92350&id=2886667b0e&e=1bcd4baf07

11

Services will be commissioned to provide pathways for the management of treatment related fertility issues

Providers to demonstrate pathways in place for the management of treatment related fertility issues

Details of pathways to be provided, including operational policies in Q1.

NICE Guidance for Fertility 2013 www.nice.org.uk/guidance/CG156

LCA published clinical guidelines in 2014. Annual assurance through CQRM/G

12

Services will be commissioned for the management of those with a family history of moderate risk breast cancer to a Pan London specification

Services delivered against the service specification

Insert key metrics from the agreed service specification (expected September 2015)

RE: NICE Familial Breast Cancer 2013 www.nice.org.uk/guidance/CG164

Separate paper outlining costings available.

http://www.ncsi.org.uk/wp-content/uploads/MAC14312_CoT_Throwing-light_report_FINAL.pdf



http://nhs.us4.list-manage1.com/track/click?u=6b4247ab96a4a1dd020e92350&id=2886667b0e&e=1bcd4baf07







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13

Services for the provision of MSCC will be commissioned in line with NICE QS56

Rapid access for MRI in place. An agreed treatment plan Care coordinated by an MSCC Coordinator Definitive treatment commenced within 24 hours.

Annual completion of MSCC pathway audit in line with the guidance. Template available via NICE link. http://www.nice.org.uk/Guidance/CG75/Resources

NEW: NICE QS56 Feb 2014 www.nice.org.uk/guidance/QS56

AOS peer reviews still reporting unresolved issues with the MSCC pathway

14

Service providers of cancer services will be required to follow NICE guidance on smoking cessation

Providers to demonstrate compliance. Plus evidence of staff education in the “Every Contact Counts” recommendations.

Evidence of staff completing every contact counts E-learning.

New: NICE guidance PH48 2013 http://www.nice.org.uk/guidance/PH48

15 IAPT services will be commissioned to provide pathways for the management of psychological support for cancer patients (MENTAL HEALTH PROVIDERS)

All IAPT services will provide psychological support for cancer patients (and carers) following referral (GP/self/other) in the period after active treatment phase in hospital

Evidence of referral pathway in place. Numbers of patients and carers per CCG referred for psychological support which is related to cancer. Numbers of patients and carers referred to IAPT that complete the recommended course of treatment.

Improving Access to Psychological Therapies provides psychological treatment for people with mild to moderate anxiety and depression. National Cancer Taskforce Strategy (2015) states that all patients will be supported with their emotional and psychological health as a result of cancer diagnosis and/or

CCGs have already been investing in IAPT services which would support an increase in cancer referrals.

http://www.nice.org.uk/Guidance/CG75/Resources

http://www.nice.org.uk/Guidance/CG75/Resources

http://www.nice.org.uk/guidance/QS56

http://www.nice.org.uk/guidance/PH48


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their anti-cancer treatment http://www.cancerresearchuk.org/about-us/cancer-taskforce London TCST & Mental Health SCN (2015) Psychological support for people living with cancer: a guide for commissioners http://www.londonscn.nhs.uk/publication/psychological-support-for-people-living-with-cancer

16 Stratified follow-up in the community of stable or low risk prostate cancer patients who are under watchful waiting (ACUTE PROVIDER and PRIMARY CARE)

Commissioning intention would be included in Service Development and Data Improvement schedules for 2016/17

NICE Guideline: Prostate Cancer – Diagnosis and treatment

It is not expected that this will be adopted by every CCG across London. Key learning from project implementation in Croydon CCG. FAQs for commissioners are available from the TCST.



http://www.londonscn.nhs.uk/publication/psychological-support-for-people-living-with-cancer




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17 CNS and AHPs in cancer MDTs will attend advanced communications training and Level 2 psychological assessment skills training, and will have access to ongoing psychological support supervision.”

CNS and AHPs in cancer MDTs will attend Level 2 advanced communications training and have access to Level 3/4 supervision.

Trust to provide evidence of MDT members attending L2 training and accessed L3/4 supervision Clinical Quality Review Groups (in Q3)

Advanced communications skills and the ability to assess and manage non-complex psychological morbidity is a core part of the CNS/AHP role particularly in conducting HNA and end of treatment clinics. National Cancer Taskforce Strategy (2015) states that all patients will be supported with their emotional and psychological health as a result of cancer diagnosis and/or their anti-cancer treatment http://www.cancerresearchuk.org/about-us/cancer-taskforce London TCST & Mental Health SCN (2015) Psychological support for people living with cancer: a guide for commissioners http://www.londonscn.nhs.uk/publication/psychological-support-for-people-living-with-cancer

Capacity to attend training and “LWBC” clinics should come from the release of outpatient clinics through implementation of stratified follow up. Where access to level 3/4 psychological supervision is currently insufficient, Trusts may need to arrange agreements across providers.

18 Cancer Waits – Implementation of sustainable good practice

-Timed Pathway in every tumour site with clear escalation points -Adoption of ICS Inter Provider policy with referral to treating trust by day 42 at the latest (some pathways may require earlier referral) -First appointment within 7 days

Trust to provide evidence of timed pathways Trust to provide evidence of date of referral to treating trust Trust to agree plans with commissioners to reduce median wait to first appointment to 7 days for patients with suspected cancer.

These measures are all good practice to support sustainable achievement of the cancer waits targets.






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2016 / 17 Commissioning Intentions/ Quality Requirements ... · PDF file2016 / 17 Commissioning Intentions/ Quality Requirements/ Information Requirements / KPIs Cancer services will