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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) 1985-1989 1986-1990 1987-1991 1988-1992 1989-1993 1990-1994 1991-1995 1992-1996 1993-1997 1994-1998 1995-1999 1996-2000 1997-2001 1998-2002 1999-2003 2000-2004 Number in Cohort 115,172 119,114 124,244 129,482 133,081 135,249 137,167 138,737 140,591 143,894 148,009 151,320 153,862 155,571 158,404 160,007 Cumulative Deaths Crude Rate 15,559 15,547 15,370 15,379 15,422 15,064 14,890 14,829 14,485 13,911 13,696 13,222 12,835 12,546 12,306 11,947 86.5 86.9 87.6 88.1 88.4 88.9 89.1 89.3 89.7 90.3 90.7 91.3 91.7 91.9 92.2 92.5 Relative 95% Survival Confidence Interval 88.9 88.7 89.1 89.3 89.1 89.5 89.9 89.7 90.1 90.4 90.3 90.6 90.7 90.6 90.9 91.2 91.0 91.4 91.5 91.3 91.7 91.7 91.5 91.9 92.1 91.9 92.2 92.7 92.6 92.9 93.1 93.0 93.3 93.6 93.5 93.8 94.1 93.9 94.2 94.4 94.2 94.5 94.7 94.5 94.8 95.0 94.8 95.1 100 90 80 70 60 50 40 30 20 10 0 19 85 -1 98 19 9 86 -1 99 19 0 87 -1 99 19 1 88 -1 99 19 2 89 -1 99 19 3 90 -1 99 19 4 91 -1 99 19 5 92 -1 99 19 6 93 -1 99 19 7 94 -1 99 19 8 95 -1 99 19 9 96 -2 00 19 0 97 -2 00 19 1 98 -2 00 19 2 99 -2 00 20 3 00 -2 00 4 Year NCIN Publications Cancer 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. By 2033, 23% of population will be >65 years of age By 2033, only 18% will be <16 years Population by age, UK, 1983, 2008 and 2033, ONS In 2008, median ages Women 40 years Men 38 years Population aged 65+ years Cancer Incidence Figure 6.1: Age-standardised (European) incidence rates, all cancers males 450 females persons 400 300 250 200 Since 1977, incidence rate for cancer has increased in Great Britain, by 25% 150 100 14% increase in men 32% increase in women 50 Year of diagnosis 2005 2002 1999 1996 1993 1990 1987 1984 1981 1978 0 1975 Rate per 100,000 population 350 Number of new cases and rates, by age and sex, all malignant neoplasms (exc NMSC), UK, 2006 3,500 50,000 3,000 Female cases Male rates 40,000 2,500 Female rates 2,000 30,000 1,500 20,000 1,000 10,000 500 Age at diagnosis 75+ 65-74 55-64 45-54 35-44 25-34 0 15-24 0 under 15 Number of new cases Male cases Rate per 100,000 population 60,000 Lung Cancer Incidence Prostate Cancer Survival 5 year relative survival rates Increased by an average of 12% every 5 years between 1986 & 1999 42% to 65% Breast Cancer Survival 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 CR-UK Incidence and Mortality Figure 6.3: Age-standardised (European) incidence and mortality rates, all 400.0 350.0 300.0 250.0 200.0 150.0 100.0 Persons Incidence 50.0 Persons Mortality Year of diagnosis/death 2007 2005 2003 2001 1999 1997 1995 1993 1991 1989 1987 1985 1983 1981 1979 1977 0.0 1975 Rate per 100,000 population 450.0 UK Cancer Prevalence UK 2008 estimates (based on diagnoses 1971-2004 applied to 2008 population; Thames Cancer Registry, 2008) Breast (female) Large bowel Prostate Lung Other All cancers 550,000 250,000 215,000 65,000 920,000 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 Radiotherapy Fatigue Skin sensitivity Cataracts Infertility Liver problems Lung disease Osteoporosis Reduced lung capacity Second primary cancers 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 Long term conditions (Ageing population) Inc. cancer incidence Increasing survival Increasing prevalence Late effects Long term effects/conditions 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 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 • Easy to use format • Interactive • Quick links 25 Each section of the Cancer Commissioning Guidance contains Key Questions for commissioners – and where to find the answers Patient Centred Care Late Effects Long Term Effects Holistic Needs Survivorship Long Term Conditions Pat. Reported Outcomes Rehabilitation Services Commissioning considerations Long term conditions (Ageing population) Inc. cancer incidence Increasing survival Increasing prevalence Late effects Long term effects/conditions What drives Commissioning – Patient Pathways? Any Questions? www.ncin.org.uk