Cancer Networks Inception to Completion

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Cancer Networks Inception to Completion

• Anna Gregor
• Lead Clinician for Cancer in Scotland

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Why is change necessary .

• Numbers in SCAN
• 8000-9600 NP
• 4200-3900 death
• Patient power
• , technology, WTD
• Sustainability
• Status quo not an option

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Lung Cancer
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Cancer in ScotlandInvestments in Lung Cancer

• () 2001-02 2002-03 2003-04
• North 52,000 75,000
  33,000
• South-East 140,000 724,500
  462,000
• West 106,000 465,000 465,000
• Sub-Totals 298,000 1,264,500 960,000
• TOTAL 2,522,500

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Cancer care process

• Outcome determined by weakest link
• Patients experience and outcome
• Multidisciplinary
• Multiple sites
• Long term
• Evidence based Coordinated and explicit

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Regional Cancer Networks

• MEL (1999)10, HDL(2001)71
• Lead Clinician manager, structure, RCAG
• Improvements expected, documented evidence base
• Multidisciplinary patients
• QA programme, education, audit,
• Effective, value for
• Annual Report

NoSCAN
WoSCAN
SCAN
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Networks are

• Groups of people aligning their action to
  particular purpose
• Bridges between people as well as organisations
• Safety nets for patients and professionals

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Networks like bridges

• Strong foundations
• Flexibility
• Rigidity
• A system of traffic management
• To lead somewhere attractive

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Foundations

• EB guideline
• Local protocols
• National service standards
• Audit
• Quality improvement

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Service maps, protocols, information

• Certainty and choice for patients
• Preplan and pre-schedule
• Reduce delays and restrictions
• Improve patient satisfaction
• Best care, in the best place, by the best
  person/team

Northern Cancer Network         To place the GP
urgent referral proforma on GP computer software
in Sunderland and to introduce an e-mail referral
system to the chest clinic for urgent
cases.         To carry out a random MDT audit
of 10 patients at three sites to compare
outcomes.         To create a dedicated space
and common list across the Trust for pleural
aspiration.     JACOB (Birmingham Hospitals
Cancer Network)         To co-ordinate efforts
within Heartlands on prevention and to find out
what city council/health authority initiatives
are in progress.         To improve GP referrals
by organising a further GP meeting with PGEA
points to increase involvement, and repeat in
March 2001. The British Lung Foundation and BACUP
to be invited.         To test out a nurse
specialist seeing some patients and ordering
investigations at the first clinic
visit.         To produce a first draft of a
passport leaflet on complementary
therapies.   Mid-Anglia Cancer Network        
To strengthen the MDT and involve the
radiologist.         To reduce waits of 46
weeks for CT by acquiring a second scanner and
process redesign.         To tackle delays in
palliative radiotherapy by organising a workshop
on capacity and demand.         To PDSA a
drop-in follow-up clinic run by a specialist
nurse to provide supportive care for outpatients
and to set up a support group for carers.  
Merseyside and Cheshire Cancer Network        
Agreed that project managers would not have to
take time out from project commitments in July
and August.         Each project will do work
over the next action period in at least one area
of constraint to ensure improvement.         One
project will concentrate on patient information
and satisfaction.         More detailed mapping
of tertiary services to be carried out.   South
East London Cancer Network         Programme
managers to write to PCG chairs to try to engage
GPs in the Collaborative.         Further
discussions to be held with clinicians, project
managers and Greenwich Hospital about
incorporating Greenwich in the Collaborative. It
is currently the only Trust in the Network that
is not involved.         Accelerating the
patient information project currently awaiting
delivery of the Personal Information
File.       Spreading the Improvements from the
CSC Professor Helen Bevan, National Patients'
Access Team   The CSCs approach has been to
create improvements across the whole process of
care for a small slice of patients, to spread
these improvements across the tumour specific
groups and then to other cancers within the
network. Up till now the CSC has concentrated on
delivering improvements at a local level. It is
now starting to develop plans for regional and
national spread and hopes to have a definitive
plan by November. The spread plan of the CSC
will be a key component of the National Cancer
Plan, which is due to be published in the autumn.
  As well as spreading these changes regionally
and nationally, the CSC also aims to spread them
over other services. Dermatologists have already
shown an interest in the CSCs collaborative
process and are adopting its methods. A similar
approach is also planned for CHD.   Around 23
of people are innovators. When any innovation is
introduced only 1314 of people will be early
adopters. These individuals are clinical
champions who are seeking to improve practice.
One of the criteria used in selecting the nine
participating networks for the CSC was the
presence of early adopters. Around a third of
people will be keen to adopt the change once
positive results have been demonstrated (the
early majority), another third will adopt these
changes later (the late majority) and the
remaining 16 will be laggards. If 1020
adoption can be achieved this provides a starting
point for spread to take off.   People have to be
convinced that there is a problem with the old
way of doing things and that there are advantages
of adopting the new practice. They need to be
shown examples of practical benefits. The more
simple the change the more likely it is to be
taken up. The language used is also important
and jargon should be avoided.   Approaches to
spread can be optional where the decision to
adopt new practice is made by an individual,
collective where there is a consensus decision
or authority where the leadership makes the
decision. Initially, the CSC plans to use the
optional approach but may use the other
approaches later on. Although national goals are
needed, spread should be regionally led and it is
important to have very strong local
ownership.   Measurement of spread and a system
for regular progress reporting are essential, as
is good communication. Leadership, however, is
the most critical aspect of a spread programme.
Clinical leaders and managers need to work
together and someone needs to be accountable for
each stage of the spread programme. The CSC
hopes that it will be able to retain key
individuals to help support the spread process.
  Summing Up Professor Helen Bevan   Several
key themes emerged from the programme team
meetings where action needed to be taken over the
next period, said Professor Helen Bevan. The
first was capacity and demand in 3 key areas
radiotherapy, diagnostic radiology and pathology.
Another was prebooking and prescheduling systems
in radiology.   There was a strong emphasis on
developing MDTs. Links with primary care and
also with supportive and palliative care need to
be strengthened. Work is needed on systems for
improving information and choice for patients
especially at the primary care/secondary care
interface.   Plans are needed to spread
examples of new practice systematically. The CSC
should be linked to mainstream planning and
improvement activities. Improvements achieved by
the CSC need to be linked to health improvement
plans and service and financial frameworks.
  Tasks for the next 45 months         To make
the connections across the patient
journey.         To rethink what is possible
it is important to keep testing new ideas and
implement what works.         To engage leaders
such as chief executives.         To achieve the
target for November of more than 90 of teams
scoring themselves at 4 or more (4 significant
progress, 5 outstanding sustainable
progress).   Critical areas to be developed
together         Primary/secondary care
interface.         Diagnostic radiology and
radiotherapy may have national
workshops.         The patient experience to
take it forward locally and nationally.        
Contribute to the national cancer improvement
programme.         Take the patient journey
forward.         Develop a national, regional
and local spread programme.         CSC should
be an integral part of the National Cancer
Institute programme.   Mr Hugh Rogers said he
felt that there had been a tremendous growth in
confidence since the last meeting. There was a
realisation that small changes could make a large
difference to the patient journey. More
attention should be paid to the GPs perspective
and a more formal dialogue established with
primary care.   There has been interest in
rolling out the programme from early adopters,
outside the collaborative. The improvements need
to be spread to other geographical and clinical
areas.   The gold standard pathway should not
be considered the outer limit. We need to aim
higher, said Mr Rogers. It will be important
to keep the momentum going over the summer when
key members of the teams are on holiday.   The
Fourth Learning Workshop will be held at the
Imperial Hotel, Blackpool on November 1617,
2000.  
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CSBS Standards 2001/2

• 90 seen by respiratory physician within 2 weeks
  of referral
• Met in 3 hospitals out of 31
• 90 considered for curative treatment to receive
  CT scan within 2 weeks
• Met in 2 hospitals out of 31
• 90 resected within 6 weeks of diagnosis
• Met in 2 hospitals out of 31

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1st Treatment (ISD)

• Surgery Radiotherapy Chemotherapy
• Scotland 10.1 35.7 17.7
• North 10.7 46.0 20.4
• South-East 8.9 37.0 17.4
• West 10.5 31.3 16.9

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Trends

• Factor 95 98 2000
• Histology 61 73 74
• Surgery 11 9 11
• RT 36 36 33
• CT 16 19 21

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Impact of multi-disciplinary working in patients
gt70 with NSCLC

• 8 increase in patients
• 4 fold CT
• 4 fold curative RT
• 10 fold HD PRT
• I year survival up by 6 p0.023

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Clinical change

• Possible
• Needs data
• Buy-in through investment service development
• May improve outcomes
• Will improve experience

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Organisational benefits

• Strategic
• Informs clinical governance targets, audit
  reports Performance Assessment Framework
• Peer review clarity
• Clinical managerial partnerships
• Reduces variations
• Improves effectiveness

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• Great health professionals do not make great
  health care
• Great health professionals inter-acting well
  with all of the other elements of the health care
  system make great health care
• Don Berwick,, BMJ, Vol 314, 1564 1565.
•