Commissioning Patient Centered Care & Improving Outcomes for People with

Cancer

Di Riley

Associate Director, Clinical Outcomes

NCIN

To cover:

• Improving Outcomes

• Long Term Conditions in Cancer

• Commissioning Patient Centred Services

What are Outcomes

Clinical v Patient

Survival Quality of Life Stage of disease Return to normality Co-morbidity

Treatment Toxicity & side effects

Role of

National Cancer Intelligence Network?

NCIN Goal

Goal for NCIN: To develop the best cancer information service of any large country in the world

Why?• To provide feedback on performance to clinical teams• To promote stronger commissioning• To provide informed choice for patients• To provide a unique opportunity for health services

research

i.e. To improve outcomes

NCIS Example: Trends in one year cancer survival, breast cancer, females, England, 1985-2004 (five-year moving average)

YearNumber in

CohortCumulative

Deaths Crude RateRelative Survival

1985-1989 115,172 15,559 86.5 88.9 88.7 - 89.11986-1990 119,114 15,547 86.9 89.3 89.1 - 89.51987-1991 124,244 15,370 87.6 89.9 89.7 - 90.11988-1992 129,482 15,379 88.1 90.4 90.3 - 90.61989-1993 133,081 15,422 88.4 90.7 90.6 - 90.91990-1994 135,249 15,064 88.9 91.2 91.0 - 91.41991-1995 137,167 14,890 89.1 91.5 91.3 - 91.71992-1996 138,737 14,829 89.3 91.7 91.5 - 91.91993-1997 140,591 14,485 89.7 92.1 91.9 - 92.21994-1998 143,894 13,911 90.3 92.7 92.6 - 92.91995-1999 148,009 13,696 90.7 93.1 93.0 - 93.31996-2000 151,320 13,222 91.3 93.6 93.5 - 93.81997-2001 153,862 12,835 91.7 94.1 93.9 - 94.21998-2002 155,571 12,546 91.9 94.4 94.2 - 94.51999-2003 158,404 12,306 92.2 94.7 94.5 - 94.82000-2004 160,007 11,947 92.5 95.0 94.8 - 95.1

95%Confidence Interval

0

10

20

30

40

50

60

70

80

90

100

NCIN PublicationsCancer Incidence by Ethnicity **June 2009**Cancer Incidence by Deprivation, England, 95-2004 **NEW** Cancer Prevalence (undertaken by Thames Cancer Registry)Cancer Incidence and Mortality by Cancer Network, UK, 2005 1 Year Survival Trends (incl. 1 year Survival by Cancer Network), Eng, 1985-2004

Improving Outcomes

• Public awareness• Stage at diagnosis• Co-morbidities

– at & after diagnosis

• Children and Young Peole• ‘Outcomes Measures’

– clinical

– patient reported

• International Benchmarking

Long Term Conditions:

....... A condition that cannot at present be cured, but can be controlled by medication and other therapies

e.g. Diabetes

Heart Disease

Chronic obstructive pulmonary disease

Over 15.4 million people in England with a LTC (~30%)

UK Population

Between 1983 & 2008 % >65 and over, inc. from 15% to16%, an increase of 1.5 m people.

Population by age, UK, 1983, 2008 and 2033, ONS

By 2033, 23% of population will be >65 years of age

By 2033, only 18% will be <16 years

In 2008, median agesWomen 40 years

Men 38 years

Population aged 65+ years

Cancer Incidence

Since 1977, incidence rate for cancer has increased in Great Britain, by 25%

14% increase in men 32% increase in women

Lung Cancer Incidence

Prostate Cancer Survival

5 year relative survival ratesIncreased by an average of 12%

every 5 years between 1986 & 199942% to 65%

Breast Cancer Survival

CR-UK

For women diagnosed with breast cancer in 2001-2006 (England)

5-year relative survival rates - 82%

compared with only 52% thirty years earlier in

1971-75

Incidence and Mortality

UK Cancer Prevalence

 UK 2008 estimates

(based on diagnoses 1971-2004 applied to 2008 population; Thames Cancer Registry, 2008)

Breast (female) 550,000Large bowel 250,000Prostate 215,000Lung 65,000Other 920,000   All cancers 2,000,000

So.....the implications!

• Ageing population• Increasing presence of long term conditions

• Increasing risk of cancer• Increasing cancer incidence• Increased survival• Reductions in mortality• More living with cancer

So, more people with LTC will also have cancer

What about treatment effects?

Treatment Effects

Treatment Long-term side effects Late side effects

Chemotherapy

Fatigue Menopausal symptoms Neuropathy Heart failure Kidney failure Infertility Liver problems

Cataracts Infertility Liver problems Lung disease Osteoporosis Reduced lung capacity Second primary cancers

Radiotherapy Fatigue Skin sensitivity

Cataracts Cavities and tooth decay Heart problems Hypothyroidism Infertility Lung disease Intestinal problems Memory problems Second primary cancers

Surgery Scars / Chronic pain Lymphoedema

Commissioning considerations

What drives Commissioning – cancer or condition?

Patient Centred Commissioning

Strong cancer commissioning is vital to ensure:

• high quality services are delivered

• reflect needs of local populations

• reflect national priorities

• cost effective

Commissioning is Complex?

• Many types of cancer• Many different care pathways • Clinical teams in the community, DGHs and

specialist centres. • Some aspects require highly specialised

commissioning at a national or SHA level.• Other aspects overlap with non-cancer services

(diagnostics & ?LTC) and commissioned at a more local level.

An example?

• A known cancer patient visits GP with breathlessness– Refer back to oncology team?– Refer to a cardiologist?– Refer to a respiratory physician?

• Commissioners view:– Commission patient pathways– Underlying cause identified and treated– Establish a ‘MDT breathlessness clinic’– Cancer MDT involved

The Cancer Commissioning Toolkit (CCT)

Programme Budgeting

25

Cancer Commissioning Guidance was launched in January 2009 as a ‘sister’ product to the CCT

Sets out the key issues and questions for commissioners for:

Assessing health needs

Reviewing services

Monitoring performance

Service specifications

Sets out the key issues and questions for commissioners for:

Assessing health needs

Reviewing services

Monitoring performance

Service specifications• Easy to

use format

• Interactive

• Quick links

Each section of the Cancer Commissioning Guidance contains Key Questions for commissioners – and where to find the answers

Long Term Conditions

Late Effects

Long Term Effects

Rehabilitation Services

Holistic Needs

Survivorship

Patient Centred Care

Pat. Reported Outcomes

Commissioning considerations

What drives Commissioning – Patient Pathways?

Any Questions?

www.ncin.org.uk