Blueprint v1.0 Final 310316

1 Mid Notts Cancer Programme – Redesign Service Blueprint Final 310316

Better Together Mid Nottinghamshire Cancer Programme

Blueprint

30th March 2016


Foreword

“We have a bold vision for health and care services for the next five years, based on our

population needs and public and staff feedback about current services.

Whole system integration of hospital, community, social and primary care is central to the

vision because people tell us that services are currently too fragmented and difficult to

navigate. We are building on our model of proactive care, to move more people from a

reliance on reacting to their illnesses to one of where we can intervene earlier in their care.

This will eliminate some hospital admissions as a default for people who are not acutely

unwell but need help and support. Delays will be reduced significantly by changing the way

that people work in partnership on a day-to-day basis and by removing barriers to cross-

system working. Planned care will be delivered in a more effective and sustainable way,

reducing the complexity for professionals and patients, whilst reinvigorating working

relationships and dialogue between primary and secondary care clinicians. The impact will

be an improvement in the quality of care received and better outcomes for the patient,

overall an improved total patient experience.” 1

In 2014, Mid Nottinghamshire CCGs proposed the whole system transformation of health and social

care services to deliver proactive, patient centred care in order to secure sustainable services to

meet growing demand into the next decade. As part of the vision, it was anticipated that Cancer

would be included within the transformational programme, although the vision and evidence to

underpin the developments was just emerging at that point and required further development of

the vision.

Over the past 2 years, the Mid Nottinghamshire CCGs with key stakeholders including Sherwood

Forest Hospitals, Nottingham University Hospitals, Macmillan Cancer Support, patients and carers

have defined the vision and strategic plans for the transformation of Cancer Services across Mid

Nottinghamshire. The strategic plans were approved by both CCGs in March 2015, and the Mid Notts

Cancer programme was established as a component of the Elective Care Workstream within the

Better Together programme.

The models of care described in the Blueprint have been developed in partnership and alignment

across the system and agreed at the Mid Nottinghamshire Cancer Programme Steering Group and

shared with respective partners.

1 Mid Nottinghamshire CCGs Urgent Care and Proactive & Long Term Conditions Proposal 31st January 2014


Executive Summary

“The health and social care system in the Mansfield, Ashfield, Newark and Sherwood area is facing

some very significant challenges. Namely, how does the system deliver care to the quality /

outcomes required within the limited (but still very substantial) funds available? The current models

of care are not delivering best health outcomes and are not affordable if scaled up to address the

anticipated growth in population demand.

Phase one developed a future blueprint for how the physical health and social care services should

look in 3 to 5 years’ time, driven by:

A desire to deliver better health and social care outcomes for the population and an

improved experience of the services people receive; and

Recognition that the way care is currently delivered is not sustainable for the expanding and

ageing population2

Diagram 1. Model to deliver Integrated Care

Key features of the interventions that made up the blueprint included:

A proactive, co-ordinated multidisciplinary and properly resourced team based in the

community to help maintain wellbeing – particularly for frail and elderly people;

Maintain personal independence and increase community care

Support allowing people to return to their normal place of residence sooner and reduce the

risk of losing the ability, support structures and confidence to live independently;

2 A Blueprint for a safe and sustainable health and social care economy for Mid Nottinghamshire, ICTP, April

2013


Integrated urgent care services centred around the patient, with care professionals working

seamlessly between acute, primary, community and social care under a single structure;

Care professionals able to access the right services at all times – with social, community and

primary care as accessible and responsive as A&E;

Elective care focussed on those patients most likely to benefit from it, and provided where

there are enough patients to run a high quality, sustainable service; and

Maternity and paediatric services that provide access to expert opinions earlier and only

admit where necessary.

When aggregated together, these interventions create a strategically different model of care, with a

greater proportion of care provided out of acute hospital settings, with care professionals working

across organisational and professional boundaries”3.

The ICTP Blueprint provides the local strategic context for the development of the Mid

Nottinghamshire Cancer Programme and provides the framework, drivers and opportunities

required to support a transformational change in the way Cancer Services across Mid

Nottinghamshire are delivered and accessed, and the same values, attitudes and behaviours needed

to deliver sustainable services delivering person centred cancer care.

3 A Blueprint for a safe and sustainable health and social care economy for Mid Nottinghamshire, ICTP, April

2013


Contents

Page 1. Strategic Case for Change of Cancer Services

6

2. Cancer Programme Priorities

8

2.1. Earlier Diagnosis

9

2.2. Review and redesign of Common Cancer Pathways

16

2.3. Living with Cancer

25

2.4. Emergency Care, including Late Presentation through Accident and Emergency

32

2.5 Workforce Review

36

2.6. IM+T

37

2.7. Communications and Engagement

39

2.8 Programme Team Resource Requirements

40

Appendix 1.


1. Strategic Case for Change of Cancer Services

1.1. Incidence and prevalence

As people are living longer, treatments improve and people are diagnosed earlier, the incidence of

cancer across England and Mid Nottinghamshire is increasing at more than 3.8% per annum4. Earlier

diagnosis and improvements in treatment are demonstrated as survival rates at 1, 5 and 10 years are

increasing. This good news does mean, however, that prevalence set to double from 2010 levels by

20305 placing a significant burden on existing models of care.

The increase in prevalence of all cancers and increased complexity of needs of those living longer

with their cancer, has produced a significant and sustained increase in demand on secondary care

services, which is not sustainable for health services, nor meeting the needs of patients.

While overall, cancer outcomes are improving, for most cancers, outcomes for some cancers across

Mid Notts remain worse than the England average and that of the Area Team.

1.2. Earlier Diagnosis- increase in demand and costs

While more people are living longer and survival rates are improving, England has some of the

poorest survival rates for cancer in the world. Screening Programmes, Be Clear on Cancer

Campaigns and Cancer Waiting times all contribute to improving cancer survival rates at 1 year. In

2015, NICE reviewed and revised guidance for suspected Cancer. The revised guidelines make

recommendation for a lower threshold for investigations of concerning symptoms and anticipate

and increase in demand for key diagnostics. It is anticipated that the increased demand will increase

costs nationally by between £18 -£36m and referrals for some tumour sites to increase by 15% over

and above the existing annual growth in referrals for 2ww (currently between 10%-18% in Mid

Nottinghamshire).

The cost benefits of earlier diagnosis, over late diagnosis at stage 4, are described in Appendix 2 Cost

Comparisons

The Mid Nottinghamshire Cancer Programme proposes the development of new models and

pathways for earlier diagnosis, with an increased role for primary care services in pre-diagnostic

testing, Direct to Test (DTT) diagnostics and safety netting of patients.

1.3. Outcomes and Expenditure across existing cancer pathways (excluding diagnostic

pathways)

In May 2014, Greater East Midlands Commissioning Support Unit (GEM CSU) presented the findings

of the commissioned ‘Cancer Deep Dive’ to Mid Nottinghamshire Health community. The report and

presentation confirmed that across Mid Nottinghamshire, cancer outcomes and spend when

compared against comparator CCGs, demonstrated potential opportunity to improve cancer

4 Cancer Research UK (2015)

5 Macmillan Cancer Support (2015)


outcomes and release resources from secondary care. While the report defined particular

interventions, it also confirmed, with further discussion during the presentation, the added benefit

of commissioning across ‘whole pathways of care’ with specific focus on primary prevention, early

detection, improved cancer treatments, survivorship pathways and end of life care.

The report defined key tumour site outliers, for outcomes and spends, by CCG, in particular but not

exclusively, lung, breast, prostate and Lower Gastro-Intestinal across Mid Nottinghamshire. The

findings were further substantiated by the RightCare Commissioning for Value Packs presented to

the CCGs during 2014, identifying that Lung Breast and colorectal cancers are outliers for quality and

expenditure, when compared to comparator CCGs. In addition, the Deep Dive report identified that

further development of the pathways can improve the survival rates at 5 years for prostate cancer.

During 2015, the Independent Cancer Taskforce, commissioned by the Department of Health,

published its Cancer Strategy for England6 . The strategy made numerous recommendations to CCGs,

providers and NHS England on the actions required to deliver sustainable services and improve the

outcomes for cancer patients. The recommendations, which reflected those described within the

NCSI report7 published in 2013, are mandated through the Planning Guidance for 16/17 with aims

defined to be achieved by 2020.

The NCSI Report suggests resources tied up in secondary care follow-up, are estimated to be £1554

per patient over 5 years (excluding inpatient costs). For low and medium risk patients, the use of

follow up can be reduced, by unlocking of this resource and redirecting it to support self-

management interventions, care planning and coordinated care. A study in Manchester suggests

that once inpatient, outpatient and emergency costs are considered, it should be possible to unlock

savings of £1,000 per patient through a stratified approach to follow-up, pathway;

“Current face-to-face out-patient follow up is not meeting patients’ needs, isn’t good value for

money, and won’t cope with increasing numbers. Routine follow up appointments are not effective

in terms of detection of recurrence. In practice the large majority of recurrences are detected either

by patients themselves or on investigations which can be planned without a patient having to attend

a clinic.” “Models of aftercare support for the majority of cancer survivors are generic with other

long-term conditions. In some areas, specialist cancer specific services and programmes are

needed.”

(NCSI 2013).

1.4. Patient Experience

The National Cancer Patient Experience Surveys (NCPES) findings from 2010 onwards for NUH and

SFHFT, supported by local patient, carer and public engagement, identifies that while some aspects

of patient care are improving, less than 28% patients received a written care plan during their

treatment or follow up, less than 60% reported having insufficient information about what to expect

6 Achieving World Class Cancer Outcomes: A Strategy for England 2015

7 NCSI 2013: Living with and Beyond Cancer – Taking Action to Improve Outcomes’


or where to get support following discharge, and over 30% reported they received inadequate

support from Practice staff with their condition.

Local stakeholder events underpinning the programme of integration of services for Long Term

Conditions (LTCs) across Newark and Sherwood during the past 2 years clearly articulated the case

for change; a move towards integrated patient centred services that proactively support self-

management, access to timely information and support, care coordination and shared decision

making.

1.5. Sustainable Services

Traditional models of care are under increasing pressure and will not be sustainable in the near

future. As people live longer, more are experiencing the consequences and late effects of cancer and

its treatment, with many people experiencing complex health and social care needs that are not

currently systematically addressed by existing services.

Current service models require a transformational approach to delivery of sustainable cancer

services, with a focus on primary prevention, delivery of earlier diagnosis with a stronger role for

Primary Care, delivery of evidence based reviewed and risk stratified pathways with information

sharing across Primary and Secondary Care to provide coordinated and proactive care.

Improvements in both quality and cost effectiveness are aimed at all people with cancer, with 5 key

tumour sites specifically targeted that account for more than 54% of all cancers. There is increasing

evidence that improved outcomes and cost effectiveness can be achieved specifically for Lung,

Prostate, Lower Gastro Intestinal, Upper Gastro Intestinal and Breast Cancer pathways. Targeting

these tumour sites will improve outcomes for patients and release investment in secondary care to

support development in community and primary care services.

2. Cancer Programme Priorities The Blueprint proposes new models of care from diagnosis through to follow-up and aftercare for

cancer patients, underpinned by on-going care coordination across the patient pathway. The

developments will support delivery of improved cancer outcomes at years 1, 5 and 10 years, as

earlier diagnosis pathways and implementation of the EMSCN approved pathways and follow-up

arrangements are embedded and full benefits realised.

Interventions will support the delivery of proactive planned care for patients, reducing avoidable

planned and unplanned activity, improved patient experience and outcomes, and support the

effective use of resources in the right place at the right time first time.

The proposals place an increased role for Primary Care in the diagnosis and coordination of care of

patients from their first contact, diagnosis, through to follow-up, and aftercare; Community and Self

Care Services will provide supportive services for patients across the pathway, determined by


regular holistic assessment and care planning of patients’ needs to meet the on-going unmet needs

through the cancer pathways.

2.1. Earlier Diagnosis

Delivering services that diagnose more patients at an earlier stage of their cancer (i.e. more

at stages 1+2, rather than later at stages 3+4) is central to improving patient outcomes and

reducing the rate of increased expenditure of cancer services.

Late presentation to services is a poor prognostic indicator, and therefore service

developments are aimed at reducing late presentation through a range of interventions:

2.1.1. Two Week Wait Referral Pathways.

Approximately 28% of all cancers are diagnosed through the 2ww pathway8 . The number of 2ww

referrals to SFHFT for suspected cancer have continued to increase by more than 10% between

2013/14 and 2014/15, while NUH has seen referrals increase by 18%9 (See Appendix 1)

While referral rates are increasing, the proportion of positive cancer diagnoses (Conversion Rates)

for all cancers remains about the same at about 8%, reflecting the increased incidence of cancer in

the population:

Table 2. SFHFT 2WW and Conversion rates by Tumour site

The Planning Guidance for 2016/17 mandates delivery of the 28 day to diagnosis standard to be

delivered by 2020. In addition, the NICE Guidance for Suspected Cancer released in 2015 reduced

the threshold for investigation for suspected cancer, with anticipated increase in referrals for key

tumour sites in addition to the existing 10-18% annual increase in total 2ww referrals:

It is anticipated that referrals in the following tumour groups will increase by

Lower GI 5-15%

8 NCIN: Routes to Diagnosis (Mar 2014 vb)

9 Increased referral rates on 2ww pathways are in line with national findings


Urology 5-10%

Lung 10-15%

Lower GI, Urology and Lung cancer are three of the four top cancers, they account for 38% of all

cancers diagnosed in Mid Nottinghamshire and approximately 46% of all 2ww referrals.

During 2014/15 there were approximately 26,000 2ww referrals to NUH and SFHFT.

Nationally, the NICE Costing Report10 suggests that implementation of the Guidelines will cost the

NHS between £17.8 and £36.3m to implement. Costs are derived from additional FOPA and

increased demand on Diagnostics.

Table 3. Anticipated 2WW referral rates for NUH and SFHFT

2ww referrals to NUH and SFHFT 2014/15 and estimated 2015/16

NUH SFHFT Combined

Expected growth @

10%

+ NICE Guidelines

Expected growth @

18%

+ NICE Guidelines

All referrals

15,428 10,730 26,158 28,774 - 34,406 -

Lower GI

1,496 1,744 3,240 3,564 @ 15% 4,099 3,823 4,399

Urology 1,961 1,350 3,311 3,642 @ 10% 4,006 4,298 4,728

Lung 892 521 1,413 1,554 @ 15% 1,787 1,834 2,109

The guidelines assume

Greater focus on pre-diagnostic work up of patients with low risk but not no risk symptoms

Increased Primary Care access to direct diagnostic tests:

o Lung CT

o Abdominal CT

o MRI Head

o Non-obstetric Ultrasound scan

o Colonoscopy/ Flexi Sigmoidoscopy and OGD

The Achieving World Class Cancer Outcomes: A Strategy for England describes the need to;

Move towards diagnosis within 28 days. (by 2020)

Commission direct access diagnostics for Primary Care.

The Cancer Programme will work with local, regional and national colleagues where they exist, to

undertake the modelling required determining the impact on diagnostic services and capacity and

informing the development of new service models to support delivery of the 28 days to diagnosis

standard, with an initial focus on Urology, Lung and Lower GI symptoms. The developments will be

aligned to the emerging Primary Care Model and Diagnostic Workstream.

10

NICE (2014): Costing Report to support NICE Clinical Guideline on Suspected Cancer


Table 4. Cost Impact of increased 2WW referrals on FOPA only.

(Effect of annual increase and NICE guidance)

Cost Impact of 2ww referrals only FOPA to "WF01B First Attendance - Single Professional" 2015/16

Combined NUH and

SFHFT referrals

Expected growth @

10%pa

+ NICE Guidelines

Cost Increase for total activity

growth £s

Expected growth @

18%pa

+ NICE Guidelines

Cost increase for total activity

growth £s

All referrals

26,158 28,774 - - 34,406 - -

Lower GI 3,240 3,564 @ 15% 4,099

154,620 3,823 4,399 208,620

Urology 3,311 3,642 @ 10% 4,006

91,045 4,298 4,728 185,627

Lung 1,413 1,554 @ 15%

1,787

67,320 1,834 2,109 125,280

Total 313,260 519,527

(Assume tariff: Gastroenterology 301 @ £180, Urology – 101 @ £131, Respiratory 340 @ £180).

The Earlier Diagnosis Workstream has identified and agreed a number of developments to address

the challenges identified above and below in the tables shown.

Currently, approx. 28%11 patients are diagnosed through the 2ww pathway, with increasing numbers

diagnosed late through Emergency Routes including 23% through A+E. Presentation at A+E with

undiagnosed cancer is an indicator of late diagnosis, poor prognosis and low survival rates at 1 year.

Many patients who present at A+E with undiagnosed cancer have a history of vague but concerning

symptoms that may not have triggered a 2ww referral for further investigation.

2.1.2. Review of existing 2ww processes

The Clinical Reference Group (CRG) membership (Site Specific Leads) will review the site specific

templates, proforma and protocols against the NICE Guidance (2015) to ensure that they reflect

current guidance and best practice. The group will also explore the possibility of including site

specific pre-diagnostic tests that can be undertaken in Primary Care to support expedition of the

pathways and early exclusion from the pathways.

2.1.3. Increased access to Direct Access diagnostic testing

The CRG will review the existing access and make recommendation for further direct access

diagnostics for Primary Care to support the delivery of 2ww and towards 28 days to diagnosis.

11

National Cancer Intelligence Network: Routes to Diagnosis (2006-10)v2b 2014


2.1.4. Vague and Concerning Symptoms – The Third Pathway

During the summer of 2015, Vedsted and Olesen12 published their findings of developing a ‘Three

Legged Pathway’ to support Primary Care in the earlier diagnosis of cancer in Denmark, with a

particular focus on vague symptoms. Their findings have gained significant interest nationally and

locally the Cancer Programme has developed a draft ‘Third Pathway and model’ to test across Mid

Notts for 3 groups of symptoms – Lower GI, Lung and Vague Symptoms.

It is important to note that these groups of symptoms are vague in nature are not ‘red-flag’ and

therefore do not meet the 2ww referral criteria, but do require further investigation. The

development of a Third Pathway to enable further investigation may be beneficial for this group of

patients in diagnosing cancer earlier and also, reducing avoidable referral onto 2ww or late

presentation to A+E.

The Pathway is timed and aims to support Specialist teams to review and potentially confirm a

diagnosis within the proposed 28 days, based on the findings of the Danish model.

Day 1 – 4: patient attends GP. Pre-diagnostic work-up and GP review of results.

Day 4 – 12: Direct to test diagnostics. Results reviewed by GP if inconclusive or

non/malignant. Potential development for Diagnosticians to escalate to Specialist MDT /

Consultant upgrade if results suggestive of malignancy.

Screening patients through pre- diagnostics and direct to test diagnostic investigation may

potentially reduce demand on the existing 2ww referrals and FOPA, through increased routine and

tumour marking testing and increased Direct to Test CT, Endoscopy and MRI. The potential for a

One-Stop Shop for diagnostics will be explored to ensure appropriate testing.

The proposed model for Mid Nottinghamshire is described below. The testing of the model has been

be developed in partnership across Primary and Secondary Care colleagues and has been shared

with the EMSCN to secure a grant to support the development of testing the model, alongside other

sites in the East Midlands. Currently there is no proven approach or model nationally to support

local developments. The national ACE Earlier Diagnosis Pilot Programme is yet to publish findings

from Phase 1.

12

Vedsted and Olesen, A differentiated approach to referrals from general practice to support early cancer diagnosis – the Danish three-legged strategy (2015)


Diagram 5. Draft Mid Notts. Early Diagnosis Pathway for Vague and Concerning Symptoms

To maximise cost efficiency, it may be necessary to consider unbundling of diagnostic procedures to

support increased Primary Care investigations and diagnostics.

2ww referral YES

NO

YES

PRIMARY CARE RESPONSIBILITY

2ww referral YES

SECONDARY CARE RESPONSIBILITY

NO

Clear 'Red flag' symptoms or signs

History & Examination

MID-NOTTS PROPROSED EARL DIAGNOSIS PATHWAY

GP review Alternate diagnosis / watchful

wait / refer for further

investigations or speciality(Fast-track)

(Consultant upgrade)

As agreed with Trust based on local priorities & agreed protocols for pathway selection

YES

Malignancy

YESNO

Referral back to GP with summary

of investigations, advice & guidance

NO

GP reviewAbnormal results

NO

Clear evidence of specific tumour site

NO

Alternate diagnosis

YES GP review

Abnormal results

Patient presents with vague or non-specific symptoms. Eg:-- Non specific abdominal pain- Unexplained weight loss- Tiredness- Appetite loss- Unexplained DVT- GP gut feeling / concerned about underlying malignancy - Blood test anomalies –unexplained hyponatraemia, raised platelets, high ESR, abnormal LFTs, unexplained hypercalcaemia

- Run Cancer Risk Assessment e.g. QRisk /eCDS

Primary Investigations:- Bloods

- Urinalysis- CXR- Abdominal USS- Tumour markers? PSA/ CA125/ CA19-9(Investigation sets to be agreed with secondary-care)

Lung Pathway

- Direct access Lung CT

GI Pathway

- Direct access CT Abdomen

- OGD +/- Colonoscopy

MDC (Vague sxs Pathway)


The model will be further developed and tested in Mid Notts in the context of the emerging Primary

Care Model and Diagnostic Work-streams.

2.1.5. Primary Care Screening for Familial Breast Cancer

The FaHRAS Genetic Breast Cancer Risk Screening Tool is an evidence based tool aimed at

determining the risk of familial breast cancer and enable preventative measures to be considered by

the patient and consultant. The tool is currently used within secondary and will be tested and rolled

out in Primary Care to reduce avoidable referral to hospital, increase detection of familial breast

cancer in the local population and improve 1 year survival rates.

The FaHRAS team suggest that successful implementation of the tool may potentially lead to further

innovations in Primary care for familial colorectal cancer in the near future.

2.1.6. Improved pick up of the Cancer Screening Programmes for Breast Bowel and Cervical

Cancers.

Working with the PHE Screening Programmes, the Cancer programme is exploring the opportunities

to improve pick up of the existing screening programmes, which are shown to increase identification

of pre-cancerous changes and early diagnosis of cancers, improving cancer outcomes and reducing

demand on complex treatment and follow-up resources.

2.1.7. Earlier Diagnosis Outcomes

Development and implementation of the Earlier Diagnosis pathways aims to deliver both quality and

financial benefits;

a. Quality

Improve the 1 year survival rates for all cancers

Reduce late presentation of cancer including through A+E of key cancers through

increased rates of earlier diagnosis. (Domain 1 Population Health – reduction in U75

mortality from Cancer).

Support the delivery of the CWT standards with particular reference to the 2ww and 62

day standards.

Support the delivery of 28 days to diagnosis standard by 2020.

Reduce avoidable demand on diagnostics and secondary care capacity through the

robust delivery of pre-diagnostic screening and Direct to Test diagnostics, led by Primary

Care.

Improve the experience of care people receive (Domain 3 – Quality of Care – improved

access to timely and responsive services

Improve the Effectiveness of Care (Domain 4 – Services are effective and reduce the

need for readmissions)


b. Finance

Referral rates are increasing at a significant rate (10-18% pa). The implementation of the NICE

guidelines is likely to increase referral rates by more than 30%pa for some tumour sites. (See Table 4

above).

The development of revised Earlier Diagnosis pathways will

Reduce the rate of demand on secondary care FOPAs for 2ww

Improve access to Primary Care pre-diagnostic investigation and potential to screen out

non cancer earlier in the pathway

Improve access to Primary Care Diagnostics in:

o Lung CT

o Abdominal CT

o Flexi sigmoidoscopy / OGD

o Head MRI

o Non-obstetric Ultrasound Scan (USS)

Further detailed work up is needed to understand the impact of the NICE Guidelines for Suspected

Cancer (2015) including

Increased demand on Diagnostics – pathology, endoscopy and radiology13

Impact of screening patients in Primary Care (Routine and tumour marker blood testing)

Access to and maximising capacity of Primary Care and ‘other providers’ of USS, CT and

endoscopy in particular.

Delivery of the Earlier Diagnosis work-stream for Cancer will contribute to Better Together Financial

Outcomes:

Objective 1: 15.1% reduction in ED attendances

Objective 2: 19.5% reduction in ED Admissions

Objective 3: 30.5% reduction in Acute bed days

Improving the numbers of patients diagnosed at stages 1+2 cancer will reduce treatment costs along

the pathway, as more patients will be treated with curative intent.

Fewer patients will be diagnosed with advanced disease requiring complex treatment plans and

associated health consequences of treatment.

Implementation of the FaHRAS Breast Screening Tool:

Initial roll out of the tool will incur no cost to the CCGs. At the end of the roll out timeframe, costs

will be incurred for risk analysis licences which will be offset against the projected savings achieved

through reduced referrals to secondary care:

Costing (100% uptake):

Current cost of Primary Care Referral: £218.40

13

NICE Costing Report to support NICE Clinical Guideline for Suspected Cancer (2015)


Estimated number of Annual Referrals: 182

Annual Referral Cost: £39802.88

Cost of Risk Analysis: £95

Annual Risk Analysis Cost: £17313.52

Savings (100% uptake):

FaHRAS Referral Rate: 25%

Saved referrals: 136

Annual Referral Savings: £29767.59

Net Annual Referral Savings: £12454.07

Net Annual Referral Savings: £12,454.07

c. Risks and Constraints

Significant pressures currently exist within the current 62 day pathways at both NUH

and SFHFT – changes to the diagnostic pathways may create a ‘surge’ in demand that

could negatively impact on the 62 day CWT standards.

Both Trusts have developed and implemented 62 day Recovery plans. Potential

reduction in referrals through the 2ww and demand on avoidable diagnostics through

increased pre-diagnostics and Primary care DTT for Lung CT, OGD and Flexi

sigmoidoscopy in particular, may support delivery of the 62 day recovery plans.

Guidelines suggest increased demand of diagnostics and additional capacity will be

needed and procured. Initial pilot of the pathway and review of existing evidence will

inform capacity requirements. National and regional scoping of existing diagnostic

capacity suggests insufficient capacity, in particular, radiology.

Close monitoring of the pathway and referral patterns will be essential to avoid

negative impact on delivery of the 62 day pathway.

Capacity within Primary Care to deliver increased pre-diagnostic work-up and ‘safety

netting’ of patients (i.e. monitoring the patients pathway through initial screening

and on referral to the Multi-Disciplinary Diagnostic Centre (MDC)

The development of the Model, and demand on diagnostics will also be in

consideration of the wider RTT pathways, also under significant pressure at both

SFHFT and NUH.

Potential to review / innovate shared models of care and support with emerging

community / Primary Care teams.

Potential need to unbundle tariff for some diagnostics to avoid double payments of

DTT and pre-diagnostic work up in Primary Care.

Potential need to work with surrounding health communities to maximise potential

diagnostic capacity

Impact of the changes to the Primary Care workload and skills base. Need to review

the existing skills and capacity with recommendation for skills development needed

in Primary Care within the emerging Primary Care model


2.2. Review and redesign of Common Cancer Pathways

Traditional cancer pathways and models of follow-up have remained largely unchanged over the

past 40 years. The incidence and prevalence of cancer and the needs of cancer patients have

considerably changed as described above and existing models are no longer the most clinically or

cost effective.

Diagram 7 Median Cancer Survival Times14

Since the early 1970s the demand on cancer services has continued to increase, and it is expected

that by 2020, 50% people living with cancer will survive for more than 10 years, many with more

complex needs due to the consequences and late effects of cancer and treatment.

In response to increasing demand, growing evidence base and need for sustainable services, Cancer

pathways from the point of diagnosis have been under increasing review and scrutiny through

National Cancer Survivorship Initiative (2013)

Cancer Deep Dive (Mid Notts 2014)

RightCare Commissioning for Value (2014)

EM Strategic Clinical Network Expert Clinical Advisory Groups (On-going)

With recommendations made for CCGs to

Implement High Value Population Pathways (as approved by the EMSCN, e.g. Prostate and

Upper Gastro Intestinal pathways) Including 62 day treatment pathways and surveillance

protocols

Review and redesign common cancer pathways and introduce stratified follow-up ( as

approved by the local network)

14

Macmillan Cancer Support (2011)


Review and redesign existing defined tumour site pathways to reduce variations in clinical

and cost effectiveness, e.g. move to day care, ambulatory care and OPA interventions where

clinically appropriate to do so.

Redirect cost efficiencies to deliver community based services to support people living with

cancer (including community based surveillance, monitoring and support for unmet needs)

Development of Self Care Services to support cancer patients to maximise and maintain

optimum levels of health and wellness

Implementation of the NICE Guidelines for follow- up (e.g. Nurse Led Follow-up for Lung

Cancer)

The reports collectively suggest that review and redesign of cancer pathways will support improved

patient outcomes and reduction in geographical variations for patients with Lower Gastrointestinal,

Prostate, Upper Gastro Intestinal and Lung cancers and support greater cost efficiencies.

2.2.1. Review and redesign of pathways to reduce variation in cost and outcomes

Diagrams 10 and 11 are excerpts from the M+A and N+S Deep Dive ‘Opportunities Table’ which the

authors suggest should be investigated further locally to identify further cost benefits.

Many of the figures appear to be aggregated across the whole tumour specific pathway and require

deeper understanding of the scale of opportunities that can be realised. The Pathways workstream

will undertake a review of the data and make recommendations to the Mid Notts Cancer

Programme Steering Group.

The RightCare Commissioning for Value Packs focus on the variations in Breast, Upper GI and Lower

GI and recommend further investigation.

a. Risks and Dependencies

The defined assumptions need to be tested locally and financial impact assessed.

Base-lining of the existing pathways has started and further work is needed over the

coming weeks

Agreement across Secondary and Tertiary Services of the current EMSCN approved /

developing pathways. (Challenge exists re shared care FU protocols for Breast and

prostate cancer )

Capacity within the system to deliver concurrent / subsequent pathway redesign and

impact of other developments within the programme e.g. Earlier Diagnosis

NUH has progressed some risk stratified pathways ahead of SFHFT creating potential

inequity. SFHFT and DFT to agree to adopt EMSCN pathways (e.g. prostate)Alignment

with other programmes of work within the Cancer Programme, e.g. Pathways review in

response to the Commissioning for Value Packs15 and Cancer Deep Dive.

15

Commissioning for Value – Pathways on a Page NHSE, RightCare PHE. 2014 (N+S and M+A)


Diagram 10 Mansfield and Ashfield Deep Dive Opportunities excerpt.

Diagram 11 Newark and Sherwood Deep Dive Opportunities excerpt

Further detailed scoping of individual pathways is needed and locally interpreted to confirm the

ambitious cost savings and outcomes described for the CCGs to achieve the minimum benefits of the

comparator groups.

Pathway Step/

Cancer Type

Indicators in the bottom quintile (ranked <=20) in the benchmark cluster group

CCG value against benchmark group average value shown in brackets

Opportunity if CCG

were to equal the

benchmark cluster

group average

Cancer incidence: Female (PCT) (409.4 per 100,000, 376.7 per 100,000) 51 fewer cancers

Patients diagnosed with cancer in last 18 months with patient review within 6 months (CCG) (89.71%, 92.8%) 19 more reviewed

Cancer secondary care spend per 1000 population (CCG) (£39,030 per 1000, £30,344 per 1000) £1686618 reduction

Cancer secondary care admissions per 1000 population (CCG) (27 per 1000, 21.4 per 1000) 1071 fewer admissions

Cancer secondary care admissions Mean LOS (CCG) (7 per 1000, 6.2 per 1000) 1439 fewer bed days

Cancer Inpatient spend per 1000 population (CCG) (£15,139 per 1000, £12,851 per 1000) £445123 reduction

Cancer Inpatient admissions per 1000 population (CCG) (5.2 per 1000, 4.6 per 1000) 121 fewer admissions

Cancer Inpatient admissions Mean LOS (CCG) (4.3 per 1000, 4 per 1000) 382 fewer bed days

Cancer Daycase spend per 1000 population (CCG) (£10,501 per 1000, £8,531 per 1000) £381528 reduction

Cancer Daycase admissions per 1000 population (CCG) (18.1 per 1000, 14.3 per 1000) 739 fewer admissions

Cancer Emergency spend per 1000 population (CCG) (£11,251 per 1000, £8,352 per 1000) £562814 reduction

Cancer Emergency admissions per 1000 population (CCG) (3.2 per 1000, 2.4 per 1000) 150 fewer admissions

Breast cancer incidence: Female (PCT) (143.5 per 100,000, 119.5 per 100,000) 38 fewer cancers

Mortality Breast: Female (PCT) (31.4 per 100,000, 24.72 per 100,000) 10 fewer deaths

Cancer Inpatient spend - Lung per 1000 population (CCG) (£1,665 per 1000, £525 per 1000) £225236 reduction

Cancer Daycase spend - Lung per 1000 population (CCG) (£516 per 1000, £301 per 1000) £42494 reduction

Colorectal cancer incidence: Male (PCT) (68.8 per 100,000, 58.4 per 100,000) 16 fewer cancers

Colorectal cancer incidence: Female (PCT) (45.3 per 100,000, 33.9 per 100,000) 18 fewer cancers

Cancer Inpatient spend - Upper GI per 1000 population (CCG) (£1,232 per 1000, £855 per 1000) £74199 reduction

Cancer Emergency spend - Upper GI per 1000 population (CCG) (£1,599 per 1000, £1,143 per 1000) £88905 reduction

Cancer Inpatient spend - Lower GI per 1000 population (CCG) (£2,807 per 1000, £2,208 per 1000) £117287 reduction

SHMI: Colorectal (CCG) (149.6 obs:exp ratio, 109.6 obs:exp ratio) 8 fewer deaths

Prostate cancer incidence: Male (PCT) (118.3 per 100,000, 94.4 per 100,000) 37 fewer cancers

Mortality Prostate: Male (PCT) (28.8 per 100,000, 24.1 per 100,000) 7 fewer deaths

Prostate survival 5yr Male (PCT) (64.9%, 76.6%) 65 fewer deaths

All Cancers

Breast and Cervical Cancer

Lung Cancer

Colorectal Cancer

Prostate Cancer

Pathway Step/

Cancer Type

Indicators in the bottom quintile (ranked <=20) in the benchmark cluster group

CCG value against benchmark group average value shown in brackets

Opportunity if CCG

were to equal the

benchmark cluster

group average

Cancer incidence: Female (PCT) (409.4 per 100,000, 376.7 per 100,000) 35 fewer cancers

Patients diagnosed with cancer in last 18 months with patient review within 6 months (CCG) (89.78%, 93.4%)16 more reviewed

Two-week referrals with cancer (% of all TWW referrals with cancer) (CCG) (9.2%, 11.7%) 448 more diagnosed

Cancer secondary care spend per 1000 population (CCG) (£33,237 per 1000, £30,150 per 1000)£446529 reduction

Cancer secondary care admissions per 1000 population (CCG) (24.2 per 1000, 22 per 1000) 315 fewer admissions

Breast cancer incidence: Female (PCT) (143.5 per 100,000, 119.5 per 100,000) 26 fewer cancers

Mortality Breast: Female (PCT) (31.4 per 100,000, 24.72 per 100,000) 7 fewer deaths

Cancer Inpatient spend - Lung per 1000 population (CCG) (£771 per 1000, £476 per 1000) £44126 reduction

Cancer Daycase spend - Lung per 1000 population (CCG) (£323 per 1000, £239 per 1000) £12544 reduction

Colorectal cancer incidence: Male (PCT) (68.8 per 100,000, 58.4 per 100,000) 11 fewer cancers

Colorectal cancer incidence: Female (PCT) (45.3 per 100,000, 33.9 per 100,000) 12 fewer cancers

Cancer Inpatient spend - Lower GI per 1000 population (CCG) (£2,625 per 1000, £2,270 per 1000)£52634 reduction

Prostate cancer incidence: Male (PCT) (118.3 per 100,000, 94.4 per 100,000) 26 fewer cancers

Mortality Prostate: Male (PCT) (28.8 per 100,000, 24.1 per 100,000) 5 fewer deaths

Prostate survival 5yr Male (PCT) (64.9%, 76.6%) 65 fewer deaths

All Cancers

Breast and

Cervical Cancer

Lung Cancer

Colorectal

Cancer

Prostate Cancer


The East Midlands Strategic Clinical Network has developed and approved the costed pathway for

Upper Gastro Intestinal Cancer. The pathway aims to reduce inequality of cancer care across the East

Midlands.

b. Quality

Improved cancer outcomes for patients in Mid Nottinghamshire, to the comparator

group average

Reduce avoidable admission to hospital

Reduce avoidable unplanned care

Domain 2 – Quality of Life Indicators, Improved quality of Care – closer to home,

good experience of care;

Domain 3 Quality of Care Improved effectiveness of care – responsive to changing

patient needs – Domain 4 Effectiveness of care

c. Activity and Finance

Cost efficiencies as defined within the Opportunities Tables (excerpts above)

Total cost benefits for Mid Notts £324,400 – £491,842 (requires further investigation and evidence)

2.2.2. Risk stratification of cancer pathways

Cancer follow up pathways will be delivered based on the patients assessed clinical needs, choices

and ability to manage their cancer and related conditions

Diagram 7. NCSI Risk Stratified Model of Cancer Care (2013)

Risk stratified pathways will provide individualised packages of care based on regular assessment

and review of patient clinical and holistic needs:


Self-Care and open access. Patients are assessed as on a ‘curative intent pathway’ and are

assessed as suitable for on-going surveillance of their condition in line with NICE Guidelines

(or regionally agreed protocols), with additional support to self-care.

Shared Care Protocols. Patients are assessed as requiring on-going surveillance that can be

provided through Primary Care, with on-going support and advice from the specialists on a

less frequent basis.

Specialist Led Follow up. These patients may continue to have active or advanced disease,

but not at end of life. Their needs may be highly complex, requiring on-going specialist

surveillance or intervention. While support from Primary Care and Community services for

this group of patients may be essential, clinical responsibility remains with the Oncologist or

other consultant leading the patients care.

Diagram 8 below is the NCSI Breast Risk Stratified Pathway. It is a representative pathway for risk

stratification for all common cancers with minor amendments needed to reflect the specific needs of

patients with particular tumour types.

The NICE Proven case studies support the work of the NCSI and suggests that risk stratification of key

cancer pathways, delivering ‘tailor made’ follow-up based on assessed patient need will improve

outcomes for patients and release resources from secondary care, while improving productivity.

Released resources will be available to reinvest in community and primary care services, and those

supporting Self-Care.

a. Stratification and Quality

Risk stratification, supported by the delivery of the Recovery Package (see Living with Cancer below)

and support from Primary and Community Care aims to provide improved patient outcomes and

experience of care. A system wide transformational approach is essential to support the redesign of

cancer pathways.

Implementation of Risk stratified pathways aims to;

Deliver tailor made follow-up based on their needs and preferences – Domain 1

Population Health – People are able to stay physically and mentally well, Domain 2

Quality of Life - People can remain independent, with or without support, and are

able to manage the risks associated with this, people are able to have choice and

control over their condition and the services they receive, people can manage their

condition and/or frailty to prevent complications. Domain 3 Quality of Care – people

have access to timely and responsive services. People who use services have a good

experience of care.


Diagram 8.


With the recovery package, deliver proactive tailor made follow up and proactive

assessment and care planning, promote health and wellness through support to self-

care and rapid access in the event of recurrence or late effects.

b. Stratification and Finance

Table 9 below describes the potential financial and productivity benefits of stratifying key tumour

sites, described in the NICE Quality and Productivity Proven Case Study for Risk Stratification of

Cancer Pathways16 and applied to local cancer incidence.

Table 9. Financial and Productivity Benefits of Risk Stratification

NB. The majority of lung patients are assessed as needing palliative or end of life care. However,

increasing numbers of patients are living longer with lung cancer and not assessed as at need of End

of Life care and may benefit from additional support not traditionally provided by community

services.

16

NICE Quality and Productivity Proven Case Study, Stratified Cancer Pathways; Redesigning Services for those living with and beyond cancer. NHS Improving Quality 2013


The modelling for Mid Notts to achieve maximum financial benefit makes several assumptions:

The existing cancer pathways through SFHFT are comparable with those used elsewhere,

nationally

Local pathways are based on NICE guidance and no local / regional pathways are in

place.

Local patient staging and grading profile is comparable to the areas included within the

studies and that similar levels of risk stratification are achievable.

Costs are based on the OPPROC tariff identified (Not described in the NICE paper).

Contributing to the Better Together Objective 3: 30.5% reduction in acute bed days.

c. Benefits Realisation

Nationally, risk stratification of pathways takes between 18- 36 months. EMSCN has approved a

number of pathways for local implementation and base-lining of existing pathways has been

undertaken at SFHFT and NUH.

The Cancer Programme reviewed the local and national evidence and recommend review and

redesign of the following pathways

Breast

Lung

Prostate

Lower Gastro Intestinal

Upper Gastro Intestinal

From the point of diagnosis through to follow-up and aftercare to ensure the optimum clinical and

cost effectiveness as compared to comparator CCGs.

The Programme Steering Group has agreed the priorities as

1. Prostate Cancer

2. Lung Cancer

3. Breast

4. Lower and Upper Gastrointestinal

Prostate and Lung Cancer review is underway and redesign will commence within 2016/17. It is

anticipated may take 2 years or more for full implementation of revised pathways and maximum

benefits to be realised. Discussions are underway with SFHFT and NUH to agree the timelines and for

review and redesign of the 3 remaining pathways. Base lining against 62 day pathways has been

undertaken.

The existing pathways span 2 or 3 secondary care providers including NUH, SFHFT and DFT. The work

of the Pathways workstream will link with and build on the existing work-plans developed across the

Network to maximise benefits realisation and reduce avoidable variation in pathway delivery


models. NUH and SFHFT have established the Cancer Clinical Partnership Board, which will be the

vehicle to drive many of the changes required across the local network.

The diagram below represents the new generic cancer pathway demonstrating regular points for

holistic assessment and care planning, MDT review and stratified follow-up that will inform the

development of primary and community care based support services.

d. Benefits realisation

Nationally, risk stratification of pathways takes between 18- 36 months. Across Mid Notts,

significant work has started to risk stratify existing pathways, particularly at NUH.

Key pathways for risk stratification will include:

Breast

Prostate

Colorectal

?Gynaecology – endometrial Cancer

Timelines for delivery of Benefits will be dependent on the review of each of the pathways, and

system capacity to delivery concurrent pathways developments.

e. Risks and Dependencies for combined pathways redesign

The defined assumptions need to be tested locally and financial impact assessed.

Base-lining of the existing pathways needed to confirm patient flow, and existing

models of care.

Agreement across Secondary and Tertiary Services of the current EMSCN approved /

developing pathways. (Challenge exists re shared care FU protocols for Breast cancer)

Capacity within the system to deliver concurrent / subsequent pathway redesign and

impact of other developments within the programme e.g. Earlier Diagnosis

NUH has progressed some risk stratified pathways ahead of SFHFT creating potential

inequity. SFHFT to agree to adopt EMSCN pathways (e.g. Gynaecology pathway for

endometrial cancer, not included in above financial modelling).

Alignment with other programmes of work within the Cancer Programme, e.g. Pathways review in

response to the Commissioning for Value Packs17 and Cancer Deep Dive.

2.3. Living with Cancer

The 2016/17 Planning Guidance, recommends stratifying Cancer follow-up for the common cancers

by 2020 to enable the resources to be reinvested into services that support people to ‘live well’ after

cancer.

17

Commissioning for Value – Pathways on a Page NHSE, RightCare PHE. 2014 (N+S and M+A)


Patients consistently report more than 5 unmet needs at the end of treatment: A person with a

cancer diagnosis is twice as likely as the wider population to use A&E services, 30% more likely to

see their GP and report poorer quality of life than the wider population. 49% people with a cancer

diagnosis also have at least one other long term condition, and unplanned use of services increases

as patients have more LTCs.

Diagram 9. Unmet needs of Patients living with Cancer18

Stratification of pathways alone will not deliver the improvements to sustainability, capacity or

patient outcomes without the implementation of the ‘Recovery Package’, with access to information

and support services for on-going health and social care needs of patients.

Comprehensive Holistic Needs Assessment, care planning and care coordination are essential to

supporting patients to maximise their health and wellness, reduce risk of recurrence and improve

their quality of life.

Care and support is needed into the long term as more patients live longer following cancer and

experience late effects, consequences and recurrence of their disease. Increasingly being considered

as a long term condition, proactive care planning and assessment can help cancer patients

understand how to reduce risk of these events, manage symptoms effectively, access the right help

when needed and reduce avoidable unplanned care activity, while improving patient experience and

outcomes.

Self-Care is central to supporting people living with Cancer, enabling people to make the life style

choices that are best for them and their life and is a central theme of the Living with Cancer work-

stream.

18

Macmillan Cancer Support (2011) Health and Wellbeing Survey


The Living with Cancer work-stream will

Develop pathways that provide integrated and holistic care for people living with and beyond their cancer diagnosis, providing support for cancer as a Long Term Condition.

Deliver services that are coordinated, proactive and based on individual assessed needs and preferences, underpinned by shared decision making and empowerment.

Implement interventions of the interventions of recovery package across the cancer pathways

o Holistic Needs Assessment o Treatment Summary o Cancer Care Review o Health & Wellbeing Event

Ensure that assessments, care plans and treatment summaries are shared across providers to support on-going proactive patient centred care through community and primary care.

Promote and actively support the development of Flo applications that support patients across pathways (in particular, consider prompts for appointments, psychological interventions, self-care prompts, etc).

Develop and coordinate services which work collaboratively to support the patient across the pathway.

Ensure that self-care and shared decision-making underpin the delivery of cancer care. Establish access to comprehensive training and development as part of initial workforce

training as well as continuing professional development. Support patients and their carers to access information, support and learning to empower

them through their cancer journey and beyond.

Living with Cancer workstream developments assumes:

Regular holistic needs assessment and care planning at key points along the pathway

Care coordination for patients and carers

Regular information sharing between primary and community care services to support

proactive care

Access to a range of therapies and support services to support patients’ preparation for or

recovery from cancer and its treatments. (e.g. Rehabilitation services, continence,

psychological support, information and support).

Risk stratification of follow-up arrangements based on clinical needs and patient preferences

Most patients complete treatment with on-going needs requiring coordinated care and rapid

access to secondary care in the event of recurrence, acute oncological complications

metastatic disease.

Active promotion and delivery of support to Self- Care to maximise health and wellness and reduce

the risk of disease recurrence.

The NCSI19 makes recommendation to introduce systematic assessment and care planning across

secondary and Primary Care (Recovery Package) with a strong focus on coordinated care and

support to self-manage, funded by the resources locked in secondary care and re-invested in

19

NCSI Living with and Beyond Cancer – Taking Action to Improve Outcomes 2013


community, primary and self-care services to enable to proactive care planning, improved patient

experience and outcomes, and reduction in avoidable unplanned care activity.

2.3.1. Recovery Package20

The Recovery Package is a series of interventions aimed at improving the outcomes and coordination

of care for people living beyond their cancer diagnosis. During 2015/16 Mid Nottinghamshire CCGs

commissioned SFHFT to deliver Holistic Needs Assessments, care plans and Treatment summaries (at

the end of each definitive treatment), with a full roll out plan across all tumour sites to be agreed by

the end of 2015/16.

Diagram 10. The Recovery Package Model

During 2016/17, the Workstream will work to further embed the components of the recovery

package building on the progress to date, to deliver comprehensive assessment and care planning

pathways from the point of diagnosis through treatment to aftercare.

NUH and SFHFT are working in partnership to coordinate the approach to HNAs and care plans. In

addition, both Trusts are working with Macmillan Cancer Support to test and roll out electronic

HNAs and care plans to support ease of use and time effectiveness for both patients and carers and

staff. The e-HNA pilot is expected to launch during the summer of 2016.

A Cancer Care Review, (CCR) conducted by the patient’s GP is a key intervention within the Recovery

Package and is currently incentivised through QOF. Further development is needed to ensure that

20

NCSI Living with and Beyond Cancer – Taking Action to Improve Outcomes 2013 – Recovery Package


the CCR meets the patients proactive care needs and is included within the emerging Primary Care

Model as part of the Long Term Conditions workstream.

“The ‘recovery package’ is potentially the most important building block for achieving good

outcomes. Providers and commissioners who wish to achieve good patient outcomes will want to

implement these measures. These interventions can deliver immediate benefits to patients, as well

as supporting improvements in care further down the survivorship pathway. Re-allocate any cost

efficiencies, achieved through follow-up, to other areas of the survivorship pathway, such as

assessment and care planning, or community support.” NCSI 2013

a. Quality

Implementation of the Recovery package ensures that patients are offered a Holistic Needs

Assessment and Care plan, at key points along their pathway that is based on shared decision

making and shared with Primary Care to support continuity and coordinated care. It ensures that the

GP is aware of the patient’s needs and wishes relating to their holistic needs, and provides the

patient and carer with the information they need to support them to meet their needs.

The Recovery Package aims to support delivery of each of the 4 domains of the Outcomes

Framework:

Domain 1 Population Health: Ensuring patients and carers know how to access

services in the event of recurrence or new symptoms, and what to do to maintain

personal health and wellness.

Domain 2 Quality of Life: People are able to have choice and control over their

condition and services they receive.

Domain 3 Quality of Care: People have access to timely and responsive services

Domain 4 Effectiveness of Services: Services are effective and reduce the need for

readmission.

b. Activity and Finance

Holistic Needs Assessment and Care planning are existing components of community

and Self Care Services. The Living with Cancer Workstream is working to align the

recovery package into existing care planning systems and processes where possible.

Treatment Summaries will be included within the Pathways redesign through

Secondary Care, while Cancer Care Reviews will be included within Primary Care

Model negotiations.

Delivery of the Health and Well-being Events is included within the Self-Care Hub

Service Specification, with specialist support to be negotiated within the redesigned

cancer follow-ups pathway design.



Holistic Needs Assessments, Care planning and Treatment Summaries have been delivered at SFHFT

for defined tumour sites through a CQUIN during 2016/7, and work is underway to explore the

potential use of HNA and Care planning in Primary Care.

Good progress has been made in embedding the practice, and the Living with Cancer Workstream

will build further on the foundations through their workstreams.

The Cancer Care Review is being offered at a number of Practices by GPs and Practice Nurses, and

further work is needed within the context of the Primary Care Developments to embed Cancer care

and coordination as if another Long Term Condition. Proactive Care Planning and coordination of

patients with Cancer is subject to the Primary Care Development Plan that describes the aims and

objectives of cancer care in Primary Care and the support required to deliver those aims.

d. Risks and dependencies

Appointment of the M+A PCCL and Macmillan GPs to support Primary Care Clinical

Engagement to support the Cancer Programme as a whole, and Primary Care Cancer

care in particular.

Self-Care Hub – development of the Cancer Self Care Pathways that meet the needs

of people affected by cancer

Development, approval and delivery of the Primary Care Development Plan to

support Primary Care cancer care and management consistently across the patch

Primary Care capacity to deliver the Recovery Package and other elements of the

Cancer Programme – workforce review to take into account role of Primary Care and

the changing context of Primary Care delivery.

Timely progression of the Pathways review and risk stratification to support the

patient flow.

Workforce Review to be undertaken to determine the skills and workforce

requirements to support the Cancer Programme Redesign and Primary Care Model.

IT Interoperability – the impact of the Recovery Package is maximised when shared

between providers. IT systems across the Health and Social Care Community need

to be able to communicate in order to share data and information.

2.3.2. Support to Self-Care.

The Self Care Hub, commissioned through the Better Together Proactive and Urgent work-stream is

testing the model for self-care with Cancer and Diabetes during 2015-17. Evidence from the NCSI

suggests that patient and carer outcomes are improved when they have access to self-care

resources and interventions. The Mid Notts Cancer Self Care pathway21 is an integral element of the

cancer pathways for all cancer patients and their carers.

21

Pathway developed, based on the Mid Notts. Self Care Strategy and NCSI Generic Cancer Pathways (2013)


Where cancer specific interventions are needed, the service is working closely with the Macmillan

Information and Support Services at Kings Treatment Centre and other Macmillan Projects in place

across Mid Nottinghamshire, with a view to maximising utilisation and monitoring of unmet needs.

Through the Macmillan Cancer Partnership (Nottinghamshire) partners are working together to

develop a range of comprehensive services to support people with cancer at no additional set –up

cost to the CCGs. Interventions include but not limited to:

Self Help and Support Groups

Volunteer schemes to provide emotional, practical and social support

Education and information resources – physical and on-line

Development of protocols for FLO for cancer patients

Health and wellness information and activities.

Peer to peer support

HOPE programme (cancer specific programme based on an Expert Patient Programme)

Unmet needs will be collated through the Self Care Hub for regular reporting to the CCG.

a. Quality, Activity and Finance and KPIs

The Quality, Activity and Finance and KPIs for the Self Care Hub are monitored through the contract

and will not report to the Cancer Programme to avoid double counting. Progress updates, risks and

milestones will continue to be reported to the Steering Group

The cancer self-care pathways will contribute to the overall KPIs for the Hub, the KPIs for which are

included within the Service Specification.

The Living with Cancer Workstream has defined the expected outcomes from the Workstream, in

addition to those defined for the Self Care Hub and in the process of determining the KPIs to

measure the impact of the Cancer pathways.

The Pathways Workstream has agreed that Prostate and Lung pathways will be reviewed during

2016/17 with the potential for Breast to be included in the same year. It is anticipated that 100%

newly diagnosed patients (2015/16 2332 new patients) will be signposted to the Self-Care Hub, with

a proportion of those referred for needs based intervention or support. (To be determined through

the HNAs and Care planning outputs delivered by the existing and then redesigned cancer

workforce).

2.3.3. Primary and Community workforce development

Delivery of the Transformational Cancer Services is dependent on a suitably skilled,

knowledgeable and placed workforce. The emergent workstreams identify a series of

interventions that require skills in secondary, primary, community and voluntary services - a


significant shift from current models of care provision requiring a behavioural and cultural

shift for professionals and patients.

The programme has commissioned a Workforce Review across the system that will inform

the workforce requirements to deliver the aims and outcomes of the Cancer Programme.

Further details are described in section 2.6 below.

Diagram 11. Mid Notts Cancer Self-Care Pathway

2.4. Emergency Care, including Late Presentation through Accident and Emergency

Patients with cancer attend A+E for several reasons related to their cancer:

Late presentation with significant symptoms, to later be diagnosed with cancer.

Presentation with Acute Oncological emergencies requiring urgent intervention including

MSCC and neutropaenic sepsis

Management of symptoms as a consequence of cancer or its treatment.

The interaction of the interventions described in this paper aims to contribute to the reduction in

avoidable A+E attendances. While it is essential that people with oncological emergency do access


care to meet their needs, it is clear that for many patients, A+E is inappropriate for their presenting

needs.

Acute Oncology Services (AOS) were established at NUH and SFHFT during 2012/13, following the

publication of the National Chemotherapy Advisory Group22 recommendations for every emergency

department to have AOS to improve the outcomes for cancer patients in A+E. The development of

the Acute Oncology Teams at both NUH and SFHFT aim to ensure that patients with a cancer

diagnosis are seen by a cancer specialist and receive appropriate care within defined parameters.

AOS services are non-commissioned. The service models at SFHFT and NUH differ in scale and skill

mix. Notably, oncology support is provided by NUH to SFHFT on a sessional basis. (SFHFT as a cancer

unit does not have resident oncology). The Acute Oncology service at NUH has recently expanded as

part of the Admissions Avoidance Scheme at City Campus. Charts 14 and 15 demonstrate the trends

for emergency cancer admissions at both trusts;

Chart 14 NUH Cancer Admissions

22

National Chemotherapy Advisory Group: Chemotherapy Services in England- Ensuring quality and safety. (2009).


Chart 15 SFHFT Cancer Admissions

The reasons for the variation between the two trusts needs further exploration and understanding

to ensure equity of services for patients attending either hospital and related support, e.g. access to

AOS advice and support, triage, information and education to the wider community and primary

care services.

The Cancer Clinical Partnership Board between NUH and SFHFT was established to address the

Oncology provision issues between the two Trusts and are actively addressing the issues of equitable

Oncology Service provision including for AOS. The Cancer Programme Clinical Lead attends the

meeting on behalf of the programme, and the Partnership Board reports minutes to the Cancer

Programme Steering Group.

The impact of Acute Oncology Service Improvement and the development of the Earlier Diagnosis

pathways and model are the interventions that will deliver improvements to the Cancer Emergency

Admissions rates for both CCGs.

At this point, the Programme has integrated emergency care into existing workstreams and will

monitor emergency care rates at the Steering Group. However, should the Emergency Admissions

rates continue to diverge, the Programme will review the need for a separate Emergency Care

workstream.

2.4.1. Emergency Care Outcomes

a. Quality

The Cancer Programme aims to improve the quality of life, quality of care and effectiveness of care

as:

People are able to have choice and control over their condition and the services they

receive

Users are safeguarded against unintended or potential harms

People have access to timely and responsive services


People who use services have a good experience of care

Services are effective and reduce the need for readmissions


Review of current Emergency Presentations of the 5 key tumour sites suggests that both CCGs A+E

activity is currently over the SARS of 100 and that potential savings are possible from current activity

(see diagrams 16 and 17 below):

The key areas for improvement to support the Emergency care pathways include

Lung Cancer, suggesting the need for earlier diagnosis, proactive management and rapid

referral to specialist palliative care services.

LGI, suggests the need for earlier diagnosis and improved pick up of Bowel screening.

The Cancer Deep Dive suggests between 150 -218 less admissions are possible for all cancers, (M+A

only) saving between £562,814 and £773,889. This may suggest that people with ‘other’ cancers

account for more than 2/3 of all admissions and needs further investigation.

Further investigation of the potential reductions in A+E admissions will be undertaken through the

workstream.


Development of the Earlier Diagnosis workstream and Acute Oncology Service improvements will

deliver improvements in the SARS rates for cancer admissions. Review of the variation between

SFHFT and NUH readmission rates is underway currently and reporting due before the end of March

2016 which will inform the development of action plans aimed at providing equitable service

delivery and improvement in SARS at both sites.

d. Risks and Dependencies

Capacity within the system to effectively impact on earlier diagnosis in particular for Lung

and GI cancers. ( in particular, CT and endoscopy)

Further detail is needed to understand the 2/3 of patients admitted with ‘other cancers’

Capacity for NUH to provide SFHFT with consistent Oncology cover to support the service

delivery of AOS services and support roll out to community and primary care services.


Diagram 16. Cost benefit if Mid Notts achieves A+E SAR of 100 Diagram 17 - Cost benefit if Mid Notts achieves A+E SAR of 90

Financial Benefit of achiving SAR's of 100 for each Cancer diagnosis and each CCG

Emergency Admissions July 2014 to June 2015

Mansfield & Ashfield CCG

Cancer Diagnosis

SpellsExpected

SpellsSAR

Reduction in

Spells to achive

SAR of 100

Av cost of

Spell

Cost Saving if

SAR of 100

achieved

Breast 9 22 40.6 0 £2,575 £0

Lung 105 64 164.1 41 £2,705 £110,905

Prostate 19 19 101.6 0 £4,005 £0

Upper GI and HpB 40 36 111.6 4 £3,126 £12,504

Lower GI 62 63 99.1 0 £6,709 £0

Total 45 £123,409

Newark and Sherwood CCG

Cancer Diagnosis

SpellsExpected

SpellsSAR

Reduction in

Spells to achive

SAR of 100

Av cost of

Spell

Cost Saving if

Sar of 100

achieved

Breast 6 16 38.3 0 £2,575 £0

Lung 38 48 79.4 0 £2,705 £0

Prostate 9 14 62.4 0 £4,005 £0

Upper GI and HpB 25 36 69.4 0 £3,126 £0

Lower GI 59 49 121.1 10 £6,709 £67,090

Total 10 £67,090

Mid Notts Total

Cost saving SAR of 100 £190,499


2.5. Cancer Workforce Review

The Transformation of Cancer Services, and delivery of new ways of working across the system to

deliver coordinated and integrated care pathways, requires a significant shift in skills, knowledge and

behaviours.

Key changes to service delivery include:

Increased role for Primary Care teams in delivery of Earlier Diagnosis of Cancer and safety

netting of patients undergoing pre-diagnostic investigation and Direct to Test Diagnostics.

Primary /Community care delivery of some diagnostic tests and investigations to support

earlier diagnosis (e.g. USS, endoscopy within the context of wider diagnostic workstream)

Increased role of specialist cancer teams in Secondary Care to deliver on-going assessment

and care planning at key points along the pathway

Delivery of coordinated care from the point of diagnosis with access to specialist support at

all points along the pathway, including supporting health and wellbeing events as part of

stratified follow-up pathways

Increased role in Primary / Community services to deliver on-going surveillance as defined

within tumour site specific follow-up protocols ( e.g., community based Prostate Monitoring

Services)

Development of cancer capacity within community services will provide ongoing opportunity

for further cancer service improvements to be delivered in the community that are currently

secondary care based e.g. Delivery of oral chemotherapy and IV treatments in the patients

home

Development of Acute Oncology outreach services as part of on-going service improvements

at both SFHFT and NUH

The Cancer Programme has reviewed the scope of the transformational changes and commissioned

an external Organisational Development expert to deliver a workforce review across the Cancer

pathways. The review will align with the Primary Care workforce planning and is being planned in

partnership with SFHFT, HP, and other partners.

The transformational change to the cancer pathways will require a significant culture shift across the

system. The review will consider the outcomes of the programme and make recommendation for

the skills and learning required to ensure delivery of the system wide outcomes and benefits

including sustainable and integrated services.

The system wide Cancer workforce review will be designed by the Cancer Programme Steering

Group membership in partnership with Macmillan Cancer Support. The Partnership Agreement

between the Mid Notts CCGs and Macmillan has secured a series of grants that were reviewed and

as part of the process, it was agreed that the existing grants will contribute to the review costs. The

Cancer workforce review will be undertaken in the context of the wider Primary Care Workforce


review that is currently being considered and planned. Recommendations will be prepared by the

Cancer programme for consideration by the Elective Care Steering Group and respective CCGs.

2.6.1. Primary Care Development Plan for Cancer

In recognition of the increased role and demands for Primary Care within the Cancer Pathways, the

Cancer programme has drafted a Primary Care Development Plan that details the key deliverables

and outcomes needed from Primary Care to support the transformation of Cancer Services.

The Plan describes the impact and demands on Primary Care in addition to the resources required to

support Primary care in their delivery.

The Cancer Programme recognises the development of Primary Care that is now underway, and

plans are in place to support the development of the Primary Care Model and the Primary Care

Cancer Plans in tandem.

Both CCGs have committed to invest in Primary Care Cancer Lead roles to support the Cancer

Programme development and delivery. Macmillan Cancer Support has also invested in supporting

the role of Macmillan GPs (completed funding in Newark and Sherwood, now picked up by the CCG)

and outline agreement to secure funding for 2 Macmillan GPs in Mansfield and Ashfield (2 x sessions

per week for 2 years) to support Primary Care.

The Programme is currently developing a Primary Care Development Plan to detail the interventions

and developments needed within Primary Care to support delivery of an integrated care model for

cancer across Secondary, Primary and Community Services. The strategy is being consulted upon

currently, and will be aligned to / informed by the emerging Primary Care Strategies for Mid

Nottinghamshire CCGs. As part of the on-going partnership with Macmillan Cancer Support, a grant

will be available to support the Primary Care Developments in the context of the wider Primary Care

Strategy and Model Development.

a. Quality

Implementation of the Primary Care Engagement and Development Plan aims to support delivery of:

Population health – Domain 1, fewer people will die prematurely and more will be

able to stay well

Quality of Life – Domain 2 – more people will report an improved quality of life, and

have choice and control over their condition and the services they receive.

Quality of Care – Domain 3 – people have access to timely and responsive services

Effectiveness of Care – Domain 4 – services are effective and reduce the need for

readmission.


Review of the workforce aims to ensure that patients are supported in the right place at the right

time, and will reduce demand for avoidable care activity.

KPIs will be revised in line with the Pathways Work-stream Developments and will include:


Avoidable unplanned primary care activity

Avoidable unplanned secondary care activity

Reduced length of stay.


The workforce review is expected to start in the spring of 2016. The review process will be on-going

and initial timelines will be agreed over the coming weeks once the scale and scope of the review is

agreed.

d. Risks and Dependencies

Availability of the required skills and expertise to be recruited to safely deliver the

service

Timely progress with review and risk stratification of key tumour pathways

Robustness of the underlying data to support the system benefits.

2.6. IM+T Solutions for the Cancer Programme

Data management and information sharing across the system is managed through the Better

Together Programme. The IM+T and Cancer workstreams are aligned to ensure coordination of

developments and solutions and identify issues and solutions that may fall outside of the remit of

the BT IM+T workstream.

The Cancer Programme has identified a number of tools to support the transformation of Cancer

Services to date:

e-CDS – Integrated Cancer tool. Currently free to Practices to use and maintained within

SystmOne. Currently delayed to resolve compatibility issues with SystmOne. If unable to

resolve there are potentially a range of other tools that can be trialled.

FaHRAS assessment tool – currently non-integrated tool, but plans to integrate to SystmOne

in the medium term. Local testing has been completed -No current issues. Free during roll

out period. Costs included above with net savings for this discrete project.

Data sharing across Primary /Secondary Care interface – mainly being resolved through

existing IM+T work-plans. Cancer Specific issues being identified through the work-streams

and will be addressed by provider IT services or escalated through the programme.

2.7. Communications and Engagement

The Mid Nottinghamshire Cancer Programme has developed its visions and plans through a

comprehensive communications and engagement plan aimed at supporting all stakeholders,

partners and members of the public to be informed, engaged and involved in shaping and defining

the programmes aims, objectives and deliverables.

The Programme is a key work-stream within two change Programmes:


1. Better Together Mid Nottinghamshire Transformation

2. Macmillan Cancer Partnership (Nottinghamshire)

The development and delivery of the Cancer Programme Communications and engagement plans

are coordinated with those of the two Change programmes to ensure maximum coverage and

impact across Mid Nottinghamshire and the wider Cancer network of Nottinghamshire.

The Cancer Programme is included within the existing Better Together Communications and

Engagement plans, with support accessed from CCG communications and engagement teams when

needed. Macmillan Cancer Partnership events are funded through the existing grants attached to

the Partnership agreements in place with Mid Notts CCGs.

The development of the Patient Reference Group is currently using underspent funds from the 3Cs

Group through Mansfield and Ashfield CCG.

2.8. Cancer Programme Team Resource Requirements

The Cancer Programme is expected to complete delivery of key outcomes in 2018/19.

Significant costs associated with the programme have been funded through the Partnership with

Macmillan Cancer Support as detailed below.

Existing posts grants expire as detailed in the table 18 below and will require pick up funding from

the CCG to secure the future delivery of the programme.


Table 18 – Programme Costs

Post Sessions / WTE

Costs (including on costs) per annum

Funding Source Funding period Pick up costs Pick up month and year

Recurrent Costs

Programme Clinical Lead / N+S PCCL

1 session per week

£200 per session N+S CCG programme costs

On-going for length of Programme

- - -

Primary Care Cancer Lead

1 Session per week

TBA M+A CCG Primary Care

Initially for 1 year and review for continuation

- - -

Programme Manager Band 8a (from the end of secondment)

1.0 wte Circa £52,000 + travel

Macmillan Cancer Support

Secondment ends June 2016.

Circa £48,000 + travel

June 2016 £52,000 for 2 ¾ years

Service Development Manager Band 7


Newark and Sherwood CCG

2 Years to May 2017

Circa £45,000 + travel

June 2017 £45,000pa for 1 ¾ years

Service Development Manager Band 7


Macmillan Cancer Support

3 years to December 2018

- - -

Macmillan GPs x 2

2 per week x 2 = 4 sessions

£83,000 +travel Newark and Sherwood CCG (from Sept 15/ Jan 16)

On-going for length of programme (following 2 years funding by Macmillan)

- - -

Macmillan GPs x 2

2 per week x 2 = 4 sessions

£83,000 +travel Macmillan Cancer Support

2 years from recruitment? March 2016.

Circa £62,000

March 2018 -


Appendix 1

2WW Referrals to SFHFT 2014/15

2WW Referrals to NUH 2014/15


Appendix 2 Earlier Diagnosis v Late Diagnostics Cost comparison

Documents

Blueprint v1.0 Final 310316