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SUMMARY REPORT ABM University Health Board

Quality & Safety Committee Date of Meeting: 25th June 2015

Agenda item: 4.2

Subject Report of the Clinical Audit Lead

Prepared by Anne Biffin, Clinical Effectiveness & Governance Manager Sharon Rağbetli, Clinical Audit & Effectiveness Manager

Approved by:

Presented by:

Mr Hamish Laing, Medical Director

Dr Sharon Evans, Associate Medical Director, Clinical Audit & Effectiveness

Purpose

The purpose of this report is to provide the Quality and Safety Committee (the Committee) with:

an update on the Health Board’s compliance with the NHS Wales National Clinical Audit and Outcome Review Advisory Committee (NCA&ORAC) programme for 2014-15;

information in relation to the NCA&ORAC’s national audit programme for 2015-16, which was published in April 2015;

a summary of the presentations received at the recent Clinical

Outcomes Steering Group (COSG) meetings and agreed actions; and

a summary of the Health Board’s response to the National Lung Cancer Audit Report.

Decision

Approval

Information X

Other

Corporate Objectives

Healthier Communities

Excellent Patient

Outcomes & Experiences

Sustainable &

Accessible Services

Strong Partnerships

A fully Engaged

and Skilled

Worforce

Effective Governance

X X X

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Executive Summary Since the last report to the Quality & Safety Committee, the NCA&ORAC has published a new list of audit topics. In addition there have been three National audit presentations to the COSG. The key points and actions arising from these were;

NCEPOD Lower Limb Amputation

Further work to be undertaken to confirm what impact the age and frailty profile of our patients is having on the proportion of above knee amputations being undertaken.

Development of an enhanced multidisciplinary team to include specialist Diabetes and Anaesthetics input.

Review of non-Vascular trainees’ experience in major amputation to ensure that all major lower limb amputations are carried out by surgeons who have the necessary experience.

National Vascular Registry

Development of a training package for anaesthetists who do not usually work on vascular lists.

Work towards extending the ABMU Transient Ischaemic Attack (TIA) Pathway in to Hywel Dda

Heavy Menstrual Bleeding

Development of a Heavy Menstrual Bleeding Pathway in collaboration with Primary Care.

Key Recommendations

The Quality & Safety Committee is asked to note the:

Health Board’s level of compliance with the NCA&ORAC Programme for 2014-15;

audits that comprise the 2015-16 NHS NCA&ORAC Programme;

key points relating to presentations made at the COSG on 30th March;

Health Board’s response to the National Lung Cancer Audit Report.

Assurance Framework

The NCA&ORAC and audits initiated by Health Board Committee are an integral part of the Health Board’s assurance framework.

Next Steps

Full participation in the NCEPOD Acute Pancreatitis Study and the Royal College of Surgeons Falls and Fragility Audit.

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1. PURPOSE The purpose of this report is to provide the Quality and Safety Committee with:

an update on the Health Board’s compliance with the NHS Wales National Clinical Audit and Outcome Review Advisory Committee (NCA&ORAC) programme for 2014-15;

information in relation to the NCA&ORAC’s national audit programme for 2015-16;

a summary of the presentations received at the recent Clinical Outcomes

Steering Group (COSG) meetings and agreed actions; and a summary of the Health Board’s response to the National Lung Cancer Audit

Report.

2. BACKGROUND As the Committee will be aware from previous reports, the mandated All-Wales NCA&ORAC programme is the basis of the Health Board’s clinical audit work programme. The programme consists of planned audit programmes related to a condition or intervention, and also registries that collect data on a continuous basis. These are aligned with the programme of national audit undertaken in NHS England. Each audit and registry publishes a report at a prescribed time interval which can be annually or less frequently. The reports are presented at the Clinical Outcomes Steering Group (COSG) by the Health Board Lead(s). The work programme also includes audits initiated by Board committees in response to a patient safety or quality issue, or as part of the Health Board’s assurance processes.

In future locally-initiated audit projects will be monitored as part of the new operational units and not centrally. A log of all registered audit activity will be maintained and will be available on the Clinical Audit & Effectiveness Department (CA&ED) intranet pages for reference.

3. KEY ISSUES

3.1 NCA&OR and Clinical Outcomes Review Programme Projects 2015/16

MAIN REPORT ABM University Health Board

Quality & Safety Committee Date of Meeting: 25th June 2015

Agenda item: 4.2

Subject Report of the Clinical Audit Lead

Prepared by Anne Biffin, Clinical Effectiveness & Governance Manager Sharon Rağbetli, Clinical Audit & Effectiveness Manager

Approved by Presented by

Mr Hamish Laing, Medical Director

Dr Sharon Evans, AMD Clinical Audit & Effectiveness

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The NCA&ORAC published its list of audit topics for 2015-16 in April 2015. Its new programme comprises of a total of 31 projects, 30 of which relate to the services that are provided by the Health Board (Appendix 1). Each national audit project requires a nominated clinical lead to drive full compliance and to liaise with the group that is running the audit nationally so that operational issues specific to NHS Wales are fed back into the process to inform future project development and commissioning. NHS Wales has a representative on each National Audit Project Board. These are drawn from the pool of NHS organisations’ clinical leads. Health Boards are also required to fully participate in the Clinical Outcomes Review Programme of audits (CORP) that were formerly known as “Confidential Enquiries”. New additions to the CORP programme in 2015-16 are ‘Non-Invasive Ventilation’ and ‘Cancer in Children and Young People’. Scotland will also be contributing to these and to future CORP audits included in the work programme.

Updates on specific national audit projects

NCEPOD Acute Pancreatitis Study – Clinical Questionnaires have been

received for distribution to the discharging consultants of a sample of five patients at both Princess of Wales and Morriston hospitals. The samples have been selected by the NCEPOD team. Completed questionnaires and photocopies of the relevant case-note extracts will be sent to NCEPOD securely within the specified timeframe.

In September 2014, the Deputy Minister for Health was appointed with direct

responsibility for NHS performance. As a result, national clinical audit results are under increasing scrutiny and, in response to a recent briefing on the Lung Cancer Audit, the Deputy Minister requested additional information on;

o why health boards are not meeting the appropriate clinical standards identified in the audit; and

o what actions are being undertaken in each health board (with timescales) to ensure they meet the required standards in the future.

The ABMU response provided by Martin Rolles, ABMU cancer lead, is attached as Appendix 2.

The Falls and Fragility Fractures Audit has commenced. The project run by the Royal College of Physicians is designed to audit the care that patients with fragility fractures and inpatient falls receive in hospital and to facilitate quality improvement initiatives. ABMU’s leads are consultant in medicine, Dr Anthony James, and consultant orthogeriatrician, Dr Praveen Pathmanaban.

3.2 Presentations to Clinical Outcomes Steering Group (COSG) Three presentations have been received at COSG since the last report to the Committee; NCEPOD Lower Limb Amputation, the National Vascular Registry and Heavy Menstrual Bleeding. Key points from the discussion and agreed actions are summarised and attached as Appendix 3.

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Presentations scheduled for future COSG meetings are listed in Appendix 4.

3.3 Patient Safety Projects

No new projects have been initiated since the last report to the Committee . Data collection for the audit of the use of Consent to Treatment forms has been completed. The report is in draft and will be finalised in readiness for the August meeting of the Committee.

4. RECOMMENDATIONS

The Quality & Safety Committee is asked to note the: audits that compose the 2015-16 NCA&ORAC Programme;

key points relating to presentations made to the COSG on 30th March;

Health Board’s response to the National Lung Cancer Audit Report.

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Appendix 1. - NHS Wales National Clinical Audit and Outcome Review Advisory Committee (NCA&ORAC) Programme 2015/16

No. Audit Topic/Registry/Database Relevant

to ABMU Identified Leads/Contacts for ABMU

1 National Bowel Cancer Audit YES TV Chandra Sekaran, Joanna Hilton

2 National Head and Neck Cancer Audit YES Conor Marnane, Rob Evans

3 National Lung Cancer Audit YES Emrys Evans, Rhian Finn, Martin Sevenoaks

4 National Oesophago-gastric Cancer Audit YES James Manson, Tim Brown

5 National Prostate Cancer Audit YES Jon Featherstone, Pradeep Bose

6 National Heart Failure Audit YES Aaron Wong, Stephen Dorman, Geraint Jenkins, Jonathan Goodfellow

7 Myocardial Ischaemia National Audit Project (MINAP) YES Jonathan Goodfellow, Stephen Dorman

8 National Adult Cardiac Surgery Audit YES Aprim Youhana

9 Cardiac Rhythm Management YES Mark Anderson

10 National Audit of Percutaneous Coronary Intervention (PCI) Procedures YES Stephen Dorman, Clive Weston, Geraint Jenkins

11 National Congenital Heart Disease Audit YES Aprim Youhana

12 National Dementia Audit YES Robert Colgate, Wyn Harris

13 Sentinel Stroke National Audit Programme YES Harish Bhat, Diptarup Mukhopadhyay, Mushtaq Wani

14 Falls & Fragility Fractures Audit (inc. National Hip Fracture Database) YES Praveen Pathmanaban, Tony James

15 Trauma Audit and Research Network (TARN) YES Ian Pallister, Amanda Farrow

16 Comparative Audit of Critical Care Unit Adult Patient Outcomes (ICNARC) YES Dawn Apsee, Fiona Benjamin

17 National Joint Registry YES Dave Woodnutt & Mukund Deglurkar

18 Renal Registry YES James Chess

19 National Diabetes Audit (Adult) (inc. Primary Care, Foot Care, Inpatient &

Diabetes in Pregnancy projects) YES

Steve Bain, Richard Chudleigh, Rajesh Peter, Lawrence Cozma, Jeffrey Stephens, Carl Verrecchia, Margery Morgan, Gail Griffiths

20 National Diabetes Audit (Children) YES Nirupa D'Souza, Cathy White

21 Inflammatory Bowel Disease YES Gary Constable, Praveen Eadala, Mike Cosgrove

22 Rheumatoid & Early Inflammatory Arthritis YES Eleri Thomas

23 All Wales Audiology Audit YES Rhys Meredith

24 National Chronic Kidney Disease YES Being managed centrally during the Pilot Phase

25 National Vascular Registry Audit (inc. Carotid Endarterectomy) YES Louis Fligelstone

26 National Chronic Obstructive Pulmonary Disease YES Martin Sevenoaks, Stuart Packham, David Vardill

27 National Emergency Laparotomy Audit YES Vummiti Muralikrishnan, Mike Bretland, Harri Jones, Scott Caplin, Nicola Harris, Richard Self, Ben Griffiths

28 SHOT - Serious Hazards of Blood Transfusion YES Ahmed Salamat

29 UK Obstetric Surveillance YES Dawn Apsee, Dermot Nicholson

30 National Neonatal Audit Programme YES Arun Ramachandran, Kate Creese

31 Paediatric Intensive Care (PICANet) NO Not Applicable *Note – Fundamentals of Care dealt with via Nursing forums

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Appendix 2. Abertawe Bro Morgannwg UHB Comments on the All Wales key findings

from the National Lung Cancer Audit 2014 Martin Rolles, ABMU Cancer Lead. April 2015. ABMU HB has 2 lung MDTs:

Swansea, meeting in Morriston Hospital and covering Morriston (MH), Singleton(SH), and Neath Port Talbot Hospital (NPTH). Separate clinics are held in each of these hospitals. Following the 2013 lung cancer peer review a separate NPTH lung MDT was merged with the Swansea MDT. Chaired by Dr Emrys Evans.

Bridgend, meeting in Princess of Wales Hospital and chaired by Dr Martin Sevenoaks. Surgical and Non-surgical oncology is provided by C&V and Velindre, respectively.

In relation to Clinical Indicators (target)

1. Percentage of patients discussed at MDT meeting. (95%). All ABMU hospitals exceed the 95% target.

2. %Histological/cytological confirmation rate for lung cancer. (75%). 2 hospitals exceed this target: NPTH (76.2%) and MH (80.8%), whilst the other 2 hospitals fell below the target: POW (61.9%), SH (68.7%)

3. % of all patients seen by CNS. (80%) All 4 hospitals exceed this target.

4. % patients receiving active treatment for lung cancer (60%) SH (54.2%) and POW (59.3%) fall below this target. See point 5.

5. % patients with a lung cancer diagnosis having a resection (Not specified) ABMU resection rates are low by UK standards, particularly for patients presenting at SH. Resection rates are relatively greater for patients seen in NPTH. This may reflect the fact that NPTH has no acute medical take: acute patients are admitted to Swansea hospitals, in particular to SH. It is recognised that a significant proportion of first diagnoses of lung cancer are made following acute medical admission. The cohort of patients diagnosed following acute medical admission are likely to differ from those seen electively in an outpatient clinic. Differences in fitness, tumour stage at presentation, may be reflected in the variation in recommended treatment options, including surgical resection.

6. %NSCLC IA, IB, IIA, IIB patients having surgery (52%) NPTH (52.6%) just passes this standard, and is the only hospital in Wales to do so. POW (42.3%), SH (40%), MH (37%) all fall below the standard, but are above the Welsh average of 36.5%.

7. %PS0-1 stage III or IV NSCLC patients having chemotherapy (60%). All 4 ABMU hospitals fall below the recommended level: POW (50.6%), NPTH (56.1%), SH 50.6%), MH (55.1%). ABMU falls below the all-Wales average of 56.4%. Neither Wales, England (57.5%) nor Scotland (50.2%) reach the recommended level for this metric.

8. % small cell lung cancer patients receiving chemotherapy at any stage (Not specified) There is variation between the 4 ABMU hospitals: POW(61.5%), NPTH (80%), SH (50%), MH (66.7%). The Welsh and English averages are 64.9% and 68.6% respectively.

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9. % patients receiving radiotherapy (Not specified) The Welsh average is 37.6%. The English average is 28.3%. Apart from MH (35.4%) all ABMU hospitals treat patients with radiotherapy at a rate higher than the Welsh average.

Discussion

There is significant variation in all metrics between hospitals within ABMU, across Wales, and between Wales, England, and Scotland. The reasons for these inequalities are complex and include:

Socioeconomic factors

Public health

Geographical access to health services

Cancer stage at presentation.

GP diagnostic and referral issues

Hospital diagnostic pathway issues

Hospital MDT staffing, including lung cancer CNSs, respiratory physicians, pathologists, oncologists, thoracic surgeons

Organisation of thoracic surgical and allied services

Variable access to non-surgical therapeutic oncological techniques (SABR etc)

The population of the UK is heterogeneous, and ABMU is no exception, and so generalisations may

overlook important detail.

ABMU HB area contains some of the most and least deprived areas in Wales. Overall 25% of Lower Super

Output Areas (LSOAs) in ABMU HB fall within the most deprived quintile of LSOAs in Wales.

Lifestyle factors are strongly associated with the development of lung cancer. There is a considerable variation in percentage of the population leading a healthy lifestyle across ABMU HB area. The percentage point difference for key indicators between best and worst ABMU HB Upper Super Output Areas: Obesity 15.7%, Inactivity 15.1%, Smoking 23%, Drinking above recommended limits 8.8%.

There has been an increase in the cancer mortality inequality gap between the least and most deprived communities between 2002-2006 and 2009-2013

Cancer management decisions, especially surgery vs. chemotherapy vs. radiotherapy are influenced by patient fitness. South Wales has a high proportion of patients presenting with Performance Status 2-4:

NLCA report 2014 p 50. http://www.hqip.org.uk/assets/NCAPOP-Library/NCAPOP-2014-15/HSCICNLCA-

2014finalinteractivereport.pdf. Accessed 27.04.2014.

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Based on a sample of ABMU cases (all NSCLC presenting to MH in 2014 n=117), nearly 1 in 3 (27%) cases of

small cell lung cancer are detected following an emergency admission. Over 1 in 2 (56%) cases are stage 4 at

the point of detection. ABMU is gathering data for its other hospitals, for comparison.

Non-Small Cell Lung Cancer, Source of referral, Morriston Hospital 2014

Non-Small Cell Lung Cancer, Stage at presentation, Morriston Hospital 2014

Most lung cancers are related to lifestyle, in particular exposure to tobacco smoke. Prevention is always

better where possible. A key part of the ABMU strategy is to develop and improve public health in this

respect.

ABMU is actively trying to understand the differences in lung cancer presentation across its catchment,

looking at referrals by stage and route for each GP practice and each of its hospitals. At present, it is not clear

to what extent the variation in treatments between ABMU hospitals reflects differences in practice or

variable patient populations.

48.7

7.7

27.4

7.7

4.33.4

0.9 GP - urgent referral

GP - non-urgent referral

Following emergency admission

Referral from OP (other than A&E)

A & E attendance

Other

Referral of an IP from a consultant

7%

2%

1%

3%3%

8%

12%

56%

8%1a

1b

2a

2b

3

3a

3b

4

Not recorded

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It is notable that whilst the all-Wales summary looks at rates for certain interventions, it does not consider

outcomes. Outcome measures are critical in deciding how well ABMU, and other Welsh LHBs deliver lung

cancer services. Seemingly basic information, such as patient-specific presentation and survival statistics, are

surprisingly difficult to access. This hampers strategic planning and service commissioning. The overall

survival figures for all lung cancers, presented in the NLCA 2014 report, show a difference in median survival

of approximately 1 month between South Wales and the UK best, London Cancer Alliance:

NLCA report 2014 p 47. http://www.hqip.org.uk/assets/NCAPOP-Library/NCAPOP-2014-15/HSCICNLCA-

2014finalinteractivereport.pdf. Accessed 27.04.2014.

Overall UK median survival is less than 7 months, but this represents a generalisation which misses the point.

Some patient subgroups can do better than this, given access to the appropriate treatment. Conversely,

some patient subgroups will not gain any advantage from more intensive treatments. What is necessary is to

understand in detail the individual patient and population demographics of our patients, in order to

understand the most appropriate commissioning model for lung cancer in ABMU. This work is ongoing.

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Appendix 3 - Recent Presentations to the Clinical Outcomes Steering Group (COSG)

Title Presented at

Meeting Comments/Actions Agreed

NCEPOD - Lower Limb Amputation 30th March 2015

All major lower limb amputations for ABMU and Hywel Dda patients are undertaken at Morriston. The Interim Assistant Medical Director confirmed that there were Executive level discussions underway between the two Health Boards to improve links and increase funding.

The presenting Consultant was asked to interrogate the Theatre IT system to confirm the patient age and frailty profile which will have an impact on the proportion of above knee amputations undertaken.

Regarding procedures which were carried out by a non-vascular trainee it was agreed that further investigation by the presenting Consultant was needed to establish what experience in major amputation these trainees have and to ensure that all major lower limb amputations are carried out by surgeons who have the necessary experience.

An enhanced MDT is required, particularly in relation to Diabetes specialist input and Anaesthetics. It was agreed that this must be fed back to the Directorate by the presenting Consultant so that the issue can be included in the IMTP.

It was agreed that representatives from the Information and Clinical Audit & Effectiveness teams would meet with the Directorate to explore how best to plug the data gaps from existing Health Board data.

National Vascular Registry Audit (Inc Carotid Interventions Audit)

30th March 2015

The presenting Consultant highlighted that, in order to meet the need for prompt intervention, some of these procedures are carried out on the CEPOD lists without specialist vascular anaesthetists. The Interim Assistant Medical Director suggested that a training package be developed and provided to anaesthetists who do not usually work on vascular lists. To be discussed with the Anaesthetics Department.

Hywel Dda patients - there is no agreed pathway in place, referral and carotid duplex scanning is on an ad hoc basis. Ideally the ABMU TIA Pathway should be extended to Hywel Dda*.

ABMU data collection is reliant on one or two individuals. CF suggested that data collection should be centralised. No data on Hywel Dda patients is submitted to the NVR*.

The Interim Assistant Medical Director asked that the presenting Consultant email him to provide more background to the issues referred to it the two bullet points above (*)

Engagement with Primary Care needs revisiting, to be actioned by the presenting Consultant.

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Heavy Menstrual Bleeding 30th March 2015

It was confirmed that there is NICE Pathway that could be used as starting point for a local pathway. Directorate to revisit the collaborative development of a pathway. Assistant Medical Director, Primary Care to contact Swansea Locality to determine what the barriers to success were in the past.Directorate to identify Clinical Lead(s) for HMB to champion the pathway development.

The Assistant Medical Director, Primary Care encouraged the presenting Consultants to

contribute to GP learning sessions. It was agreed that the Directorate should set out exactly what information was needed for referral and communicate this to GPs via the GP Portal.

Directorate to develop a web-based information page for patient information that can be accessed by patients and Primary Care.

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Appendix 4 - Presentations Scheduled for May & June COSG Meetings

Title Date Report Published Date for

Presentation at COSG

UK Obstetric Surveillance October 2014 29th May

Diabetes in Pregnancy October 2014 29th May

Epilepsy 12 November 2014 29th May

Memory Clinic & Memory Assessment Services August 2014 30th June

Irritable Bowel Disease (Paediatric) June 2014 30th June

Irritable Bowel Disease (Adult) June 2014 30th June

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