Slide 1

London Cancer – Our Objectives

London Cancer is committed to improving cancer survival rates and patient experience, and optimising the quality of life of people living with and beyond cancer.

Our objectives

• Improve early diagnosis of cancer

• Improve patient experience

• Improve the whole patient pathway

Achieving the above will lead to improved ‘value’ for the health care system

London Cancer is now being taken forward as part of the UCLH-led Cancer

Vanguard

Slide 2

Why we need to change - cancer

• RISING PREVALENCE OF CANCER: 1 in 2 will get cancer in our lifetimes

• high rates of modifiable lifestyle factors that affect cancer risk in Londoners

• OUTCOMES: UK cancer survival rates are worse than commensurate

countries, and many London CCGs are worse than England average

• Cancers are diagnosed at a later stage in UK generally and in London vs England

• too much variation with some current services not meeting national standards for care

and unequal access to latest technologies and trials

• PATIENT EXPERIENCE: Londoners report worse cancer patient experience

than in many parts of England

• Care is too fragmented, with few providers able to offer 24/7 expert care and advice

• Higher proportion of cancers diagnosed through an emergency presentation in London.

• UNSUSTAINABLE COSTS & DEMAND:

• costs rising at 9% pa, urgent GP referrals increasing at 3% per quarter

Slide 3

Data from Independent Cancer Task Force Strategy for England

Slide 4Numbers of cancer survivors are increasing and many have other LTCs and some have long term side effects of their cancer treatment

Data from Independent Cancer Task Force Strategy for England

Prevalence of childhood obesity by London borough

Source: London The Information Capital, James Chesire & Oliver Uberti, Particular Books, London, 2014

One year survival trends all cancers by CCG

57

59

61

63

65

67

69

71

73

75

2007 2008 2009 2010 2011 2012

1 Y

ear

Surv

ival

1 year survival for all cancers combined (ages 15-99 yrs), by CCG

Barking and Dagenham

Barnet

Camden

City and Hackney

Enfield

Haringey

Havering

Islington

Newham

Redbridge

Tower Hamlets

Waltham Forest

West Essex

England

Slide 7

The Problem

Cancer survival rates in the UK are behind many of our European Counterparts.

Reasons include:• Late diagnosis • Variation in treatment

London has much higher rates of emergency presentations than the rest of England.

Most Recent Data (For Chart)

CCG

2012 Jul-

Dec

NHS West Essex CCG 17.2

NHS Enfield CCG 19.4

NHS Islington CCG 19.8

NHS Camden CCG 19.9

NHS Haringey CCG 20

NHS Barnet CCG 21.2

NHS Waltham Forest CCG 21.5

NHS Redbridge CCG 21.9

NHS City and Hackney CCG 24.4

NHS Havering CCG 25

NHS Tower Hamlets CCG 27.8

NHS Newham CCG 28.6

NHS Barking and Dagenham CCG 29.2

Source: Interpretation:

Cancer Commissioning Toolkit (www.cancertoolkit.co.uk) Increased rate suggests potential GP access issues, however local review should take into account casemix

0

5

10

15

20

25

30

35

%

Emergency Presentations - 2012 July-December (All Cancers)

ENGLAND

EAST OF

ENGLAND

LONDON

Inc. by route - SCNs by Site

Screen

detected

Two Week

Wait

GP

referral

Other

Outpatient

Inpatient

Elective

Emergency

presentation

Death Certificate

Only Unknown

21% 0% 5%

24% 1% 7%

6% 27% 29% 9% 3%

5% 21% 29% 11% 2%

4%5% 27% 27% 10% 3% 23% 0%

Slide 8Emergency Presentation –The Implications

An analysis of patients first diagnosed with cancer after an emergency presentation found:

• 25% of patients were dead within 2 months

• Only 36% survived to one year.

• 1yr survival rates were half those of patients presenting through a managed referral route for colorectal cancer*

*Figures based on data from 12 A&E departments, over 9 months, in 2013. Part of a system wide service evaluation undertaken by London Cancer.

Slide 9

A&E Audit – Key Findings

London Cancer conducted an A&E audit of 953 patients.

One third of emergency presentations of colorectal cancer were in people under 60 years of age (below national screening age).

A Primary Care root cause analysis of 138 patients showed:

• 78% of patients had one or more co-morbidities

• 63% of patients had seen their GP for the same problem prior to A&E. Over half of these patients deteriorated whilst waiting for tests.

• complexity of patient pathway to A&E and poor access of GP’s to rapid diagnostics and expert advice

In depth interviews found the most common reason for patient’s delay in seeking medical advice was not thinking the problem was serious.

0%

5%

10%

15%

20%

25%

30%

35%

Cancers most commonly identified by emergency

presentation

Slide 10

London Cancer – Progress so far

London Cancer’s work is already helping to address some of the causes of emergency presentation. This work includes:

Introducing a multi-disciplinary diagnostic centre at UCLH and BHRUT

Improving the lung diagnostic pathway at BHURT, plus lung diagnostic pathway specification

Leading ‘Straight to Test’ for patients with colorectal symptoms at some Trusts

Symptom awareness raising with Camden CCG

Delivering GP educational events

What used to happen

Consultant triage

GP referral

Out-patients

Lower GI investigation

Out-patients

8 weeks

6 weeks

3 months

Straight To Test Colonoscopy - A Viable Means Of Shortening Time To A Definitive Diagnosis

Aim: To introduce a novel pathway for patients with colorectal symptoms that is patient centred and rationalises the patient journey

What will now happen

Nurse telephone assessment

GP referral

Lower GI investigation

? Out-patient review

3 days

2-4 weeks

How does it work?• Nurse assessment and triage

• Given as a ‘choose and book’ appointment

• List of questions, including symptoms and any anticipated problems with bowel prep. Simple algorithm to follow

• Able to book in for an appointment

Results from pilot (WX)

• Substantial reduction in waiting time to see both 2WW and 18 weeks referrals

• 448 patients – mean age 55, 57% female

• 16 Cancers

• 23 IBD

• 67 patients with polyps

• 213 with haemorrhoids /diverticular disease/ normal

Pathway and Outcomes Savings to Commissioners:

• Over £57,000 saved

• One clinic less per week

• Halved the number of DNAs

• 53% discharged back to GP

• 85% of patients reported high level

of satisfaction

Slide 14

Multidisciplinary Diagnostic Centres

Queen’s, RomfordUCLH

Straight To TestBarts – Whipps CrossHomertonUCLHWhittingtonBHR

HIFUPrincess Alexandra HospitalUCLH

Princess Alexandra

Queen’s, Romford

Whittington

Whipps Cross

UCLH

Homerton

Lung CT Pilot UCLHHomerton (Phase 2)

Slide 15

MDC Pilot – Wave 1 Project Outline

• To provide a more structured diagnostic pathway

for defined groups of patient with abdominal

symptoms

• To improve flow and avoid unnecessary admission

• Assessed by clinicians, supported by pathway

coordinator

• 2 pilot sites at UCLH (from June 2015) and Queen’s

Hospital, Romford (from September 2015)

Slide 16

Referral Criteria for MDC Pilot

• Painless jaundice with bilirubin >80 mmol/l

• Unexplained weight loss >3Kg or 5% of documented weight lossnot previously investigated

• Significant abdominal pain resulting in 2 ED visits presented

to A&E with abdo pain at least twice in a monthnot previously investigated, not a chronic recurring problemunexpected presentation of patient

• Non-specific abdominal symptoms lasting 3 weeks, but under 6 months not a chronic recurring problemunexpected presentation of patient

If there is a strong likelihood of a known benign diagnosis please consider and alternative pathway

Slide 17

PatientPathway Bloods

CT

Management Plan

Endoscopy

A&E

Letter to GP & patient

Refer to MDT Admit Discharge

Primary Care

MDC ClinicSpecialist History and Examination + Navigator

Slide 18

Improving our Communications Plan with GPs

Slide 19

Patient Choice on first appointment

Lung Cancer national audit data

Non 2WW Other Trusts

2WWLung CA

confirmedTx Plan

Suspected Lung CA

No Lung CA>80% Bronch CT-Bx EBUS

Tx

Phase 1 Phase 2 Phase 3

Staging/PET

Pathway and Breaches

London Cancer Pathway Specification • Local Lung Units

• Diagnosis/staging Centres (smaller No)

• Treatment Centre

• Diagnostic/Staging MDT: 2 Chest Phys (1 EBUS), 2 Chest Radiol., 1 Surgeon

• Decision to Treat MDT (<2/52): ≥2 Chest Phys, ≥2 Chest Radiologists, ≥1 Surgeon, ≥1 Pathologist, ≥2 Med Oncs, ≥2 Clin Oncs

<1 week

Trials/Research• All patients access to the same trials • Majority of patients on trial• ≥1 Onc with dedicated research time

<1 week

Slide 23

Anticipated contributions to growth of demand for CT scanning

Slide 24

Treatment costs of Lung, Colorectal and UGI cancers in NCEL

New diagnostic

pathway models

that promote early

diagnosis lead to:

Stage shift from 4

to 1 - reduces

cost/patient

Removal of polyps

prevents cancer

Slide 25

Vision for cancer care

Create an integrated system of care providing:

– Local care where possible, specialist care where necessary

– High performing multi-disciplinary teams of surgeons, specialist nurses, anesthetists and therapists

– High capacity specialist teams that strengthen local services

– Training and research opportunities for staff

– Open and transparent data collection

Specialist centres would work with local hospitals and GPs to improve the

patient journey from diagnosis to follow-up care

Slide 26

What it would mean for patients

• Better chance of survival

• Quicker recovery and better quality of life

• Support from specialist care teams

• Joined-up, sustainable 24/7 care

• More access to clinical trials with the opportunity to access the latest treatments

Cancer: the opportunities of redesigning services for a large population

What volume confers:

• Improved outcomes for patients

• Efficiency and resilience of service

• Increases Clinical trials & Innovation

• Accelerates knowledge transfer

• Attracts talent at all levels

• High quality training opportunities

• Metrics with sufficient precision

Developing proposals for Bladder-Prostate complex surgery

Proposed by the London Model of Care:• Centres should serve a population of at least 2 million

• Teams should do at least 100 bladder/prostate operations annually

Now implementing high volume specialist centres in 6 areas

• Prostate and bladder cancer – UCLH

• Functional outcomes by surgeon

• Renal Cancer – Royal Free

• High partial nephrectomy rates

• New pathway for small renal masses

• Haematology and BMT – UCLH

• 7/7 specialist care x 4 pathways

• Upper GI – UCLH (& BHRUT)

• Head and Neck surgery – UCLH

• Brain cancer surgery – UCLH (2017)