Transcript Significant Event Audit on Lung Cancer

GP Significant Event Audit Report
North of England Cancer Network
December 2012
Title
North of England Cancer SEA Report
Reference
SEA _GP Audit_NECN
Version
V03 Final
Date
08.01.2013
Author
Parry Lothian Consultancy
Change History
5/9/12
V01 Draft for Clients
12/09/2012
V02 Final Draft
08/01/13
V03 Final
North of England Cancer Network SEA Report
2
Contents
1.
2.
3.
4.
5.
6.
7.
8.
Introduction
Context and Background
Methodology
•
The Approach
•
Practice Participation
•
The Participating Practices
•
Practice Locations and Population
The Audit Process
Analysis
•
Overview
•
Audits by Cancer Site
•
Age Profile
•
Attendances
•
Referrals
•
2WW
•
Avoidable Delays in the Patient Journey
•
Lessons Learned
•
Changes Made
•
Perceptions of the effectiveness of the audit
Learning, Messages and Reflections
•
All Cancer Sites
•
‘Top 4’ Cancer Sites
Recommendations
Acknowledgements
North of England Cancer Network SEA Report
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Introduction
North of England Cancer Network SEA Report
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Introduction
Initial
presentation in
Primary Care
Reducing the time delay and waste in the patient journey to
support earlier cancer diagnosis
Diagnosis
This report describes the process and outcomes from the North of England Cancer
Networks’ (NECN) GP Practice Significant Event Audits. This is another element of work
progressed under the umbrella of National Awareness and Early Diagnosis Initiative
(NAEDI).
Cancer in Primary Care
- the initial NAEDI
work
Lung Cancer Significant
Event Audit and The
National GP Audit
GP Practice Significant
Event Audits – the
subject of this report
The report highlights the specific findings, the issues raised and the local actions taken to
improve specific elements of the care pathway both at practice level and within interfaces
with secondary care.
It makes recommendations on the transference of learning, local communication and
further work that will require action.
North of England Cancer Network SEA Report
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Context and Background
North of England Cancer Network SEA Report
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Context and Background
Building on the progress from the NHS Cancer Plan, the Cancer Reform Strategy 2007 identified one of the key areas for action was diagnosing
cancer earlier. From this main theme the National Awareness on Early Diagnosis Initiative (NAEDI) was launched, one element of which, was
to reduce delays in primary care.
This forms the back drop to the work in the North East.
Cancer in
Primary Care the initial
NAEDI work
As part of the NAEDI to promote timely diagnosis of cancer, a national significant event audit of cancer diagnosis in primary
care was commissioned and reported in 2009. This audit in the north east of England was carried out by a collaboration
between Durham, Glasgow and Dundee Universities. This primary care audit study was specifically to gain insight into the
events that surround the diagnostic process for two groups in cancer (lung cancer and cancer affecting teenagers and young
adults). The full report can be found on www.cancernorth.nhs.uk
The second
project on
NAEDI
From the initial study above a further project was initiated by NHS County Durham and Darlington and extended to NHS
South of Tyne and Wear. This project was to work more closely with primary care to identify, analyse and find solutions to
issues that prevented quick diagnosis as identified in the significant event audit (SEA).
As NHS North East were already well advanced in their application of the Virginia Mason Production System the proposal
suggested that this vehicle was used to carry out this ‘new ‘work building on from and using the initial findings for lung
cancer.
Durham University, School of Medicine and Health has evaluated the Virginia Mason Production System as it is applied to
this primary care work.
Both reports can be found on www.cancernorth.nhs.uk
The third
project on
NAEDI
Building on the previous NAEDI work the Network participated in the National GP Audit developed by the Royal College of
General Practitioners and the National Cancer Action Team. The overall aim was to build on current good practice and inform
service improvements thereby ensuring that individuals with symptoms suspicious of cancer are referred appropriately and
early. 22 practices participated in the first round of this audit.
The report can be found on www.cancernorth.nhs.uk
The fourth
project on
NAEDI
General Practice Profiles were developed by National Cancer Intelligence Network (NCIN), National Cancer Action Team
(NCAT) and Association of Public Health Observatories (APHO) and were first released in 2010. The profiles provide practices
with comparative information for benchmarking and reviewing variation. GP Leads in NECN identified practices in their
respective localities which varied from the PCT average on certain key indicators. GP Leads visited these practices to help
them reflect on their data and invited them to participate in an audit of cancer diagnoses over a 2 year period. 26 practices
participated in this audit.
North of England Cancer Network SEA Report
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Context and Background continued
Building on the progress from the NHS Cancer Plan, the Cancer Reform Strategy 2007 identified one of the key areas for action was
diagnosing cancer earlier. From this main theme the National Awareness on Early Diagnosis Initiative (NAEDI) was launched, one element
of which, was to reduce delays in primary care
This forms the back drop to the work in the North East.
The North of England Cancer Network (NECN) are now building upon the previous NAEDI
work by encouraging constituent GP practices to carry out regular significant event
audits on all cancers. This work has been developed and facilitated by the NECN GP
Cancer Leads.
The aim of these audits is:
The fifth project on
NAEDI – the subject
of this report
• To identify any avoidable delays in patient pathways
• To use the findings to plan interventions to improve early diagnosis within the practice
and across the North of England Cancer Network
• To develop good clinical practice and raise awareness of early diagnosis
• To identify lessons learnt and changes made that can be transferred to other practices
Overall the aim is to build on current good practice and inform service improvements
thereby ensuring that individuals with symptoms suspicious of cancer are referred
appropriately and early.
North of England Cancer Network SEA Report
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Methodology
North of England Cancer Network SEA Report
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Methodology – The Approach
Phase 1- Project
Initiation
A SEA Audit by the
North of England
Cancer Network agreed
by the Cancer in the
Community Group.
Aims and objectives of
the SEA audit agreed.
Audit parameters
agreed.
Phase 2 – Planning and
Recruiting
Scope of practice
participants agreed.
Remuneration for
practices agreed.
Project Group and
Activity Plan developed.
Briefing Pack and
Practice agreement
developed.
Timelines and GP
practice responsibilities
agreed.
Output
Output
Phase 3 – Date Collection
and Cleansing
Each participating
GP/practice was given
from December 2010 to
January 2012 to
complete and submit
the audits.
The records were
validated and the data
cleansed and
amendments agreed
with each participating
GP where appropriate.
Phase 4 – Data Analysis
and Reporting
The data was analysed
and the main findings
agreed with the Cancer
in the Community
Group
The report developed
and signed off in
September 2012
Output
Output
• Project Plan
• Audit parameters
and timelines.
• Briefing notes for
participating
practices and GPs
• Completed,
Validated Audits.
North of England Cancer Network SEA Report
• Data analysis
• Final Report
10
Methodology – Practice Participation
The Cancer Network was keen to ensure involvement from Primary Care in all localities and therefore from the outset of
the project the GP Cancer Leads were involved in the decision making around the project , its implementation
and the Audit Template
GP Participation
Practice Participation
The Practices
GP Practice roles and
responsibilities
GP/ Practice remuneration
All GPs had an opportunity to complete and submit SEA audits from their practice.
170 audits were received and after validation 162 were accepted and used for analysis.
Audits were received from across 55 practices representing an uptake across the
Network of approximately 11.5 %. Participating practices varied in registered list size
from small < 2500 registered list size to large > 5000 registered list size. There was a
mixture of both rural and urban practices . The majority of the audits stated they were a
training practice and that also trained medical students.
The GPs were asked to complete an audit template for each patient case. Each GP also
agreed to conduct a practice meeting/learning event to discuss the audit, and share
learning and changes from the process.
The GP/Practice received £50 for each completed, validated audit. There was a maximum
limit of two audits per GP.
North of England Cancer Network SEA Report
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Methodology – The Participating Practices
Participating Practices
Springwell Medical
Group,
Sunderland
Auckland Medical
Group,
Dales
Brandon Lane Surgery,
Durham and Chester le
Street
Coquet Medical Group,
Morpeth
Northumberland
Lane End Surgery,
North Tyneside
Harbottle Surgery
Northumberland
Cockfield Surgery,
Dales
Victoria Road Surgery,
Dales
Hinnings Road,
North Cumbria
Tennant Street Practice,
North Tees
North House Surgery,
Dales
Burn Brae,
Northumberland
Peaseway Medical
Centre,
Sedgefield
Station View Health
Centre,
Dales
Murton Surgery
Murton,
Easington
Denmark St Surgery,
Darlington
Middle Chare Medical
Group,
Durham and Chester le
Street
Spennymoor Health
Centre,
Sedgefield
Adrian Clark House and
McKenzie House,
Durham and Chester le
Street
Brunswick House
Medical Group
Carlisle
Cumbria
Jubilee Medical Group,
Sedgefield
Oakfields Health Centre,
Derwentside
Stanwix Medical
Practice,
North Cumbria
Queens Road Surgery,
Derwentside
Falcon Medical Group,
Newcastle upon Tyne
Seascale Health
Centre,
North Cumbria
Shildon Health Centre,
Sedgefield
Greystoke Surgery,
Northumberland
Haltwhisle Medical
Group,
Northumberland
St Anthony’s Health
Centre,
Newcastle upon Tyne
The Gateway Practice,
Newcastle upon Tyne
The Surgery, Bellingham,
Northumberland
Lowther Medical Centre,
North Cumbria
Dr Cloak and Partners
Sunderland
Millfield Medical Group,
Sunderland
North of England Cancer Network SEA Report
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Methodology – The Participating Practices
Participating Practices
The Surgery,
Newcastle upon Tyne
West Road Medical
Group,
Newcastle upon Tyne
3, Eden Terrace,
Sunderland
10 Bewick Road,
Gateshead
Walker Medical Group,
Newcastle upon Tyne
Fell Cottage Surgery,
Gateshead
Fulwell Medical
Centre,
Sunderland
Herrington Medical Centre,
Sunderland
78 Imeary Street,
South Tyneside
Maritime Surgery,
Sunderland
Marsden Road,
South Tyneside
Rickleton Medical
Centre,
Sunderland
Second Street,
Gateshead
Silksworth Health
Centre,
Sunderland
Dr Obanna, Sunderland
Victoria Medical
Practice,
Hartlepool
St Albans Medical
Group,
Gateshead
Whickham Health Centre,
Gateshead
Deerness Park,
Sunderland
Martonside Medical
Centre,
Middlesbrough
This total number of 55 practices is a significant increase from the total of 22 practices who participated
in the last NECN audit – The National GP SEA Audit.
The National Cancer SEA audit template was used for this project which facilitated participation by GPs
as these can also be used towards individual personal appraisal portfolios – thus making it part of a GP’s
‘day job’.
It is also reasonable to assume that the increase in participation is due to the increase numbers of GP
Cancer Leads working in NECN and the continuing work of the Network to engage with primary care and
the new Clinical Commissioning Groups.
North of England Cancer Network SEA Report
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Methodology – Practice Locations and Population
55 Practices from across the NECN
participated in this audit
Commissioning
Cluster
Participating Practice
Cumbria
5
Co. Durham and
Darlington
16
North of Tyne
13
South of Tyne
18
Tees
3
Total NECN Population = > 3 million
Dotted Eyes © Crown copyright and/or database right 2008. All rights reserved. Licence number 100019918
North of England Cancer Network SEA Report
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The Audit Process
North of England Cancer Network SEA Report
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The Audit Process
Stage 1- Template
completion and
Submission
This project used the national
Cancer SEA Template, jointly
developed by the RCGP and
the National Patient Safety
Agency. The template allows
for structured narrative
analysis by asking five key
questions:
• What happened?
• Why did happen?
• What has been learnt?
• What has been changed?
• What was the effectiveness
of the audit?
Audit parameters were:
Stage 2 – Defining the
Data Set for Analysis
Qualitative analysis focuses on
generic key learning , changes and
messages extract from the very
specific narratives of the
completed audits.
In order to report across these
narratives, specific to each
completed audit, a data set was
defined. This data set was used to
restructure the narrative into a
format more conducive to
quantitative analysis.
Stage 3 – Agreeing the
Focus and Content of the
Report
Two meetings were held with the
NECN to agree the focus and
content of the report.
The first meeting agreed the data
set and definitions. It also agreed
the analysis and the focus of the
report from the initial findings
Stage 4 - Report
development and sign
off
Further development of the
report was undertaken and
submitted to the Cancer in the
Community Group and finalised
in October 2012.
The second meeting presented a
draft report to the ‘Cancer in the
Community Group’ to agree final
content and format
• Patients seen in the
previous 12 months
• The GP completing the audit
was required to be
personally involved with the
case
• Cases diagnosed through
screening were excluded
Timelines:
December 2011 to
January 2012
North of England Cancer Network SEA Report
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Analysis
North of England Cancer Network SEA Report
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Analysis – Overview
These Significant Event Audits have been designed as a quality improvement tool and are
already widely used in general practice. They facilitate GP engagement and help bring together
the practice team for reflective discussion around clinical practice.
By far the most important learning has occurred at Practice level. However, the challenge for
this report is to extract key learning and subsequent changes, occurring a practice level, that
may offer beneficial messages across the Network and encourage future and increased
participation in the National Cancer Action Teams’ audit programme. Comparative analysis is
not the focus of this report.
Quantitative metrics have been provided to offer the reader a sense of scope and range of the
submitted audits and shown in a series of graphical presentations.
Learning, messages and reflections have been extracted from the completed audits and
presented in a table format.
North of England Cancer Network SEA Report
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Analysis – Overview
55 Participating
Practices
11.5% of NECN
77% of the
audits identified
an avoidable
delay in
diagnosis
Wide variation
in levels of
description and
completion
162
Validated
Audits
12% failed to
respond to
‘what was
effective about
the audit’
70% of the
audits identified
lessons learnt
The ‘free text’ format of the audit
template provided an excellent vehicle for
discussion and reflection at local practice
level.
The ‘free text’ format, however, presented
a challenge in the extraction of global
issues and themes.
Where possible ‘free text’ from the audits
was structured and defined into a dataset
for analysis leaving a certain degree of
interpretation in the hands of the authors
of this report
57% of the
audits identified
changes made
North of England Cancer Network SEA Report
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Analysis – Audits by Cancer Site
Number of Audits within Cancer Site
33
21
12
12
10
8
6
6
6
6
5
5
4
4
3
3
3
3
North of England Cancer Network SEA Report
3
3
2
2
1
1
20
Analysis – Age Profile
Age Profile - All Audits (all persons)
58
40
23
13
1
1
2
0-10
11-20
21-30
11
11
2
31-40
41-50
51-60
61-70
71-80
81-90
90 +
Age Range
North of England Cancer Network SEA Report
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Analysis - Attendances
Number of Primary Care Attendances before being referred - all audits
42
42
Number of Audits
28
12
6
6
2
0
1
2
3
4
5
6
6
3
3
7
8
1
2
1
1
9
10
11
19
7
Uncertain On going
Number of Attendances
The majority of patients in this audit attended 1 – 3 times before referral. The 2 patients with no recorded attendances were
admitted or referred from another source. The ‘Uncertain’ category represents those records where it was difficult to determine the
number of attendances from the information provided. The ‘Ongoing’ category represents those patients who were accessing
secondary care prior to diagnosis. This accounts for the apparent discrepancies when viewing the ‘Top 4’ cancer site graphs below
North of England Cancer Network SEA Report
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Analysis - Attendances
Number of Primary Care Attendances before being
referred - Lung
9
Number of Primary Care Attendances before being
referred - Colorectal
Number of Lung Audits
8
5
4
4
Number of Colorectal Audits
5
4
4
3
1
1
0
1
2
3
1
4
5
6
10
1
2
3
5
1
1
6
10
Number of Attendances
Number of Attendances
Number of Primary Care Attendances before being
referred - Ovarian
Number of Primary Care Attendances before being
referred - Prostate
Number of Ovarian Audits
6
Number of Prostate Audits
5
4
2
1
1
2
Number of Attendances
3
1
1
5
1
1
2
3
19
Number of Attendances
North of England Cancer Network SEA Report
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Analysis - Referrals
Referral Analysis
Of the 162 records 85 were
identified as having been referred
under the 2WW rule.
3
53
4
4 records provided insufficient
detail to determine referral
(uncertain)
10
1
6
2WW
Uncertain
85
Did not match 2WW criteria
Of the 73 remaining records
reflective comments recorded
within the completed audit
identified:
• 10 should have been 2WW
referral
• 1 was a cancer without guidance
on referral
• 3 did not match referral criteria
• 6 acknowledged lessons learned
using referral guidance
Not 2WW
On Reflection should have been 2WW
Not 2WW but there is no current referral guidance
Not 2WW but the practice (s) have acknowldeged lessons have been learned regarding referral
North of England Cancer Network SEA Report
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Analysis – 2WW
Analysis to identify possible reasons for not using
the 2WW
26%
Other possible reasons for not referring on a
2WW
13%
Incomplete examination within primary care
38%
Presentation not suggestive of cancer
No delays in diagnosis identified
23%
Of the 53 records that did not use the 2WW
referral process some key reasons, identified in
the audit commentary, may have been deciding
factors .
These are presented as a % of the 53 records.
By far the most significant is the 38% of patients
not presenting with symptoms suggestive of
cancer and the 13% that acknowledged
incomplete examination in primary care
The 26% of other reasons includes a combination
of small numbers of reported factors such as:
•
•
•
•
Patient influence
Apparent normal test results
Multiple consultations with different clinicians
Failure to consider previous history
23% of the audits reported no delay in diagnosis
North of England Cancer Network SEA Report
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Analysis – Avoidable Delays in the Patient Journey
With most cancers, the earlier the diagnosis is made, the better the prognosis. One of the aims of the audit was to
identify whether there were any possible delays in the patient journey.
A wide range of factors possibly affecting the patient journey were reported. 125 records stated possible delays –
223 reasons in total.
For the purposes of this report these have been categorised within the context of “A Health System” modelled
below.
“Health System Model”
Clinical Decisions
and Actions
Communications
Issues
Factors relating to
the clinical
decisions
and actions made
in both primary and
secondary care
Factors relating to
poor or inappropriate
communication that
could have occurred
at any stage within
the patient journey
91
reported
13
reported
Investigations and
Reporting
Factors relating to
the failure, delay or
reporting of
investigations
including relevance
and timeliness
33
reported
Patient Decisions
and Actions
Factors relating to
decisions
and actions made by
the patient
Referral Processes
None Identified
Factors relating to
aspects of referral –
such as timeliness,
appropriateness and
the referral protocols
themselves
Individual records
with no stated delays
82
reported
North of England Cancer Network SEA Report
4
reported
37
Records
26
Analysis – Avoidable Delays in the Patient Journey
Possible Delays by Health System Categorisation
2%
37%
41%
Clinical Decisions and Actions
Communication Issues
Investigations and Reporting
15%
6%
Patient Decisions and Actions
Referral Processes
The above presents the “Health System Model” categories across all relevant records (125) and shows a summary of comments
made regarding possible delays (223)
North of England Cancer Network SEA Report
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Analysis – Avoidable Delays in the Patient Journey
Possible Delays by Top 5 Cancer Groups
Prostate
Patient Decisions and Actions
9
Investigations and Reporting
Communication Issues
2
1
Ovarian
Clinical Decisions and Actions
6
Patient Decisions and Actions
7
Investigations and Reporting
3
Clinical Decisions and Actions
8
Lung
Patient Decisions and Actions
17
Investigations and Reporting
8
Communication Issues
6
Clinical Decisions and Actions
13
Colorectal
Referral Processes
2
Patient Decisions and Actions
11
Investigations and Reporting
6
Communication Issues
2
Breast
Clinical Decisions and Actions
14
Patient Decisions and Actions
Communication Issues
7
1
North of England Cancer Network SEA Report
28
Analysis – Lessons Learned
Number of Audits identifying 'lessons
learned'
Lessons Learned by 'Health System' Groupings
78
49
Yes
113
29
No
22
13
4
Clinical
Communication Investigations
Decisions and
Issues
and Reporting
Actions
Patient
Decisions and
Actions
Referral
Processes
Of the 162 records 113 of the audits identified ‘lessons learned’ In restructuring the information some audits identified multiple
lessons - these have been categorised within the health system groupings resulting in a total of 146 lessons learned.
North of England Cancer Network SEA Report
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Analysis – Lessons Learned
Number of Lessons Learned by Cancer Site
28
23
13
10
8
7
7
7
6
6
5
4
3
2
2
2
2
2
North of England Cancer Network SEA Report
2
2
2
1
1
1
30
Analysis – Lessons Learned
Key Reflections, and the number of times these issues were raised within the audits, are summarised below
Ensure appropriate safety
netting and follow up
It is important that the
patient understands
their condition
Trust your instinct
1
Patient denial is
real and should be
taken account of
Vigilance
17
5
3
6
Patients leave
important symptoms
until last in
consultation
Referral guidance
does not always
exist
1
Appropriateness, use and
restrictions of NICE
guidance
16
Effective
communication is
vital
8
Continuity of care is
essential 2
2
2
Opportunistic
testing can be
beneficial
Unpredictable
events complicate
matters
1
Don’t assume
follow up in
secondary care
1
Take a broad view of findings –
beware of ‘red herring’
symptoms
26
A normal result does
not automatically
exclude underlying
pathology
12
5
Unexplained weight
loss must always be
investigated
Telephone is fine but
face to face is better
2
Secure a wide
view of the
patient’s
health
1
2
Ensure you
recognise training
and education as
a factor
1
The importance of a full
history
Recognition that specific
clinical findings should mean
specific actions
14
20
Analysis – Changes Made
Number of Audits identifying changes made'
70
Yes
92
No
Categorised 'changes made'
Enhancement of actions carried out in review clinics
Improved communication with secondary care
1
5
Standardisation of the use of guidelines
6
Improved standard of documentation
6
Improved patient education about their condition
6
Protocol - amended, updated or introduced
Administrative practice
7
20
Clinical practice
North of England Cancer Network SEA Report
57
32
Analysis – Changes Made
Number of changes made by Cancer Site
19
19
10
8
6
6
5
5
4
3
3
3
3
3
3
2
2
1
North of England Cancer Network SEA Report
1
1
1
33
Analysis – Perceptions of the Effectiveness of the Audit
107
Number of comments regarding the effectiveness of the SEA
29
11
10
2
1
1
1
1
1
1
Of the 162 audits 143 stated the audit had been effective. Of the 143 audits who stated the audit was effective they cited 165
reasons for effectiveness These reasons have been categorised above and graphed above.
North of England Cancer Network SEA Report
34
Learning, Messages and Reflections
North of England Cancer Network SEA
Report
35
Learning, Messages and Reflections – All Cancer Sites
Presented below are learning, messages and reflections extracted from the audit narratives. These have been summarised so as to support
meaningful representation , whilst adhering to the original script as much as possible. Many are generic in nature and have therefore been
presented under the grouping of ‘all cancer sites’ and presented within the
context of the ‘Health System Model’
Clinical Decisions and Actions – A total of 78 lessons/messages were provided from across all cancer sites
It is important to take a broader view of examination findings in relation to
symptoms - beware 'red herring' symptoms
26
Identification or recognition of very specific clinical actions required when very
specific clinical circumstances occur e.g. Changing the threshold for chest x-ray
in non resolving cough
20
The importance of considering the full history
14
Need for follow up procedures
6
Vigilance
5
Continuity of care is essential - from first presentation to end of life
2
Unexplained weight loss is a 'real' red flag and should always be investigated
2
In the case of rarely presenting patients take the opportunity to secure a wide
view of their general health
1
The audits supported documentation of ‘what
has been learned’ which forms the basis of the
learning within this report. In addition, the audit
asked ‘what has been changed?’ below
represents changes which align to the lessons,
but again, have been summarised and grouped
to present a picture of how the practices
addressed the outcome:
• Changes to clinical practice
• Addressing administrative procedures
• Reviewing how guidelines are used and
looking to standardise use
• A direct revision to existing practice protocols
or the introduction of a new practice protocol
• Specific action to improve the standard of
completed clinical documentation
• In one case the introduction of additional
clinical testing / history to be completed
during long term condition review clinics
North of England Cancer Network SEA Report
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Learning, Messages and Reflections – All Cancer Sites
Clinical Decisions and Actions continued
Lack of Education or Training
1
Trust your instinct
1
North of England Cancer Network SEA Report
37
Learning, Messages and Reflections – All Cancer Sites
Communications Issues – 29 lessons identified
Ensure appropriate systems for safety netting and follow up
11
Effective communication is vital and should never be underestimated
8
Patient denial or fear can be very real and should be recognised when
communicating with the patient and deciding on actions
5
Be aware during consultations that patients may leave important
symptoms / issues till the last moment
2
Telephone consultation can be useful but face to face is really important
2
Unpredictable events complicate matters
1
The audits supported documentation of
‘what has been learned’ which forms the
basis of the learning within this report. In
addition, the audit asked ‘what has been
changed?’ below represents changes which
align to the lessons, but again, have been
summarised and grouped to present a picture
of how the practices addressed the outcome:
• Addressing administrative procedures
• Addressing how primary care and
secondary care communicate to improve
the process
• Changes to clinical practice
• Looking at ways of improving patient
education and awareness
• Specific action to improve the standard of
completed clinical documentation
North of England Cancer Network SEA Report
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Learning, Messages and Reflections – All Cancer Sites
Investigations and Reporting – 13 lessons identified
A normal result does not automatically exclude underlying pathology
12
1
Opportunistic testing can be beneficial
The audits supported documentation of
‘what has been learned’ which forms the
basis of the learning within this report. In
addition, the audit asked ‘what has been
changed?’ below represents changes which
align to the lessons, but again, have been
summarised and grouped to present a picture
of how the practices addressed the outcome:
• Addressing how primary care and
secondary care communicate to improve
the process
• Changes to clinical practice
• A direct revision to existing practice
protocols or the introduction of a new
practice protocol
• Addressing administrative procedures
North of England Cancer Network SEA Report
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Learning, Messages and Reflections – All Cancer Sites
Patient Decisions and Actions – 4 lessons identified
It is important that patients are aware of, and understand their condition
Patient denial or fear can be very real and should be recognised when
communicating with the patient and deciding on actions
3
1
The audits supported documentation of
‘what has been learned’ which forms the
basis of the learning within this report. In
addition, the audit asked ‘what has been
changed?’ below represents changes which
align to the lessons, but again, have been
summarised and grouped to present a picture
of how the practices addressed the outcome:
• Addressing administrative procedures
• Changes to clinical practice
• Reviewing how guidelines are used and
looking to standardise use
North of England Cancer Network SEA Report
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Learning, Messages and Reflections – All Cancer Sites
Referral Processes – 22 lessons identified
The use, appropriateness and restrictions of NICE guidance
16
6
Don't assume follow up in secondary care
The audits supported documentation of
‘what has been learned’ which forms the
basis of the learning within this report. In
addition, the audit asked ‘what has been
changed?’ below represents changes which
align to the lessons, but again, have been
summarised and grouped to present a picture
of how the practices addressed the outcome:
• Addressing administrative procedures
• Changes to clinical practice
• Reviewing how guidelines are used and
looking to standardise use
• Looking at ways of improving patient
education and awareness
• Specific action to improve the standard of
completed clinical documentation
North of England Cancer Network SEA Report
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Learning, Messages and Reflections – Lung Cancer Site
The following pages present specific learning, messages and reflections extracted from the ‘Top 4’ cancer site narratives. Each
cancer site is colour coded (as per the graphs) for ease of reading and each audit extraction is numbered
Extracts from the audit narratives relating to Lung Cancer Site
Refers to child’s rare lung cancer
It is important to auscultate the chest in any ill
and pyrexial child, even in the absence of overt
respiratory symptoms
Also to be alert to follow up unusual
complaints from parents (fremitus)
The patient was high risk for ischaemic heart
disease and initially the chest pain was labelled
‘cardiac’
Cardiac investigations were negative but they
was high inflammatory markers which should
have raised suspicion
Do not always assume that chest pain
relates to cardiac problems
A smoker with significant risk of lung cancer
presented with inexplicable back pain, lasting
several weeks
There was absence of cough or shortness of
breath and the clinical picture did not indicate
lung cancer as a likely cause of the back pain. The
GP ordered a chest x-ray but only attributed this
action to experience rather than clinical
indicators
On reflection all GP agreed to lower
the threshold for diagnostic imaging,
specifically chest x-ray
Abnormal weight loss was a classic “red flag”
symptom . The reassurance provided by a normal
diagnostic test could have caused a delay had the
GP not also instigated a chest x-ray
The importance of having a low threshold for
chest x-ray was discussed and it was agreed that
this represented something of a change of
mindset for many GPs who had been taught to be
aware of exposing patients to too much lifetime
radiation
The use of smoking “pack years”
when considering smoking history
was agreed as a good way of
assessing smoking risk. All GPs were
reminded how to access and use the
computerized tool to calculate pack
years
1
2
3
4
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Learning, Messages and Reflections – Lung Cancer Site
Extracts from the audit narratives relating to Lung Cancer Site
Presentation of a three week
unexplained cough, in a known smoker.
Patient also complained of changes to
general well being and chest pain
Look at the patient, not the x-ray – look
at the clinical picture in front of you
Continuity of clinician is important in an
evolving picture
5
Consider pain more thoroughly as an ‘alarm bell’.
There remains a dilemma as to whether to do a
chest x-ray on every exacerbation of a known
condition – the time to so a chest x-ray is when
improvement is not a quick as expected.
Use our new waiting room TV screens to promote
the benefits of giving up smoking, even for
children’s clinic to show the dangers of STARTING
smoking or being a parent and smoking
Distressed patient with mental health
problems
6
7
8
Investigations in a distressed patient
can be very difficult.
Sometimes with a numbers of
complaints and consultations it can be
difficult to see the wood from the trees
In response the COPD annual review protocol has
been changed to include questions on possible
symptoms of lung cancer – abnormal weight loss,
coughing up blood and increasing frequency of
COPD exacerbations.
The indications for chest x-ray requests are also to
be highlighted within the practice team
Remember shoulder pain may represent
lung/mediastinum pathology
Be sensitive to patients’ concerns and
not stick as rigidly to
investigation/referral guidelines
GP started a survey where each cancer
diagnosis made was examined.
The results serve as learning points
informing the practice of any cancers
missed and the accuracy and
appropriateness of referrals
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Learning, Messages and Reflections – Lung Cancer Site
Extracts from the audit narratives relating to Lung Cancer Site
9
Consider performing a chest x-ray in
prolonged shoulder pains
10
Do not accept hospital
treatment/diagnosis management plans
if the most likely diagnosis has not been
excluded
Be prepared to phone up, listen to
patient concerns and to set up a
dialogue with hospital colleagues
NICE/cancer 2WW referral is not the only means of
getting an appropriate end result
Patient presented with a 3-4 week
cough, with no other worrying symptoms
or signs.
On second consultation (7-8 weeks) still
with persistent cough. Chest x-ray
requested.
Chest x-ray showed likely chest
infection, antibiotics prescribed and
further chest x-ray in 4 weeks.
Anyone with a persistent or unexplained cough for
more than 3 weeks (even at first presentation, with
no other accompanying symptoms or signs) would
merit a chest x-ray in the first instance.
11
Second chest x-ray showed no change
and the advice was to continue with
antibiotics.
Always give patients adequate safe netting on when
to return if symptoms (respiratory) persist
Patient developed haemoptysis and
was referred under the 2WW
12
13
There was concern in retrospect that
backache may have been a presenting
feature of metastatic cancer missed in
medical and physiotherapy assessments
Features of non mechanical back pain
and red flags, together with ill health
meaning an absence from work of over
6 weeks were felt to be indicative of
under lying pathology
Where there are no obvious respiratory
symptoms and a non specific
presentation, a chest x-ray will be
routinely included in investigations
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Learning, Messages and Reflections – Colorectal Cancer Site
Extracts from the audit narratives relating to Colorectal Cancer Site
1
Avoid complacency slipping into
consultations - re-examination can be
important
2
Negative symptoms could have been
documented clearer in the notes - such
as weight loss and change in bowel habit
3
If pain is not settling as expected the
diagnosis should be reviewed even when
it is an apparent recurrence of previous
problems
4
5
It is important not to accept clinical
findings of previous examinations if
history changes or symptoms are
unresolved
Any persistent rectal bleeding should be
referred, even if NICE cancer guidance
referral criteria is not met
Clinicians should trust their instinct
about the need for investigation
urgently, even when NICE two week
rule criteria are not met
Some false reassurance from an earlier
ultra sound scan
Possibly some false reassurance from
detecting H Pylori as a possible cause
6
When patients are discharged from
secondary care follow-up and you feel
the outcome is unsatisfactory it is
important to phone the hospital and
speak to one of the team members
7
Other risk assessment tools are being
considered e.g. Willie Hamilton’s .
NICE guidance will now be available on desk tops
and not as paper copy – so easier to update and
bring to mind
It is important to get second opinion from
colleagues if patients are returning repeatedly with
unexplained symptoms
This may mean more patients fall
within a 2WW referral pathway
North of England Cancer Network SEA Report
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Learning, Messages and Reflections – Colorectal Cancer Site
Extracts from the audit narratives relating to Colorectal Cancer Site
8
It is better to refer to an NHS site if there
is a high chance of cancer as
investigations carried out on a non NHS
site will still require an onward referral
from the GP to an NHS site
9
Is it important to take a detailed family
history in anybody presenting with rectal
bleeding
10
Passing blood mixed with the motion at
any age needs investigation and
definitive diagnosis
Irritable Bowel Syndrome is not a firm
diagnosis but one to be made when
others have been excluded
It is our responsibility to ensure patient
being referred under 2WW are getting
timely investigation
The patient should know what to
expect from a 2WW referral. They
should be clear that they are expected
to be seen within 2 weeks and that
investigations should be completed
within 31 days and be able to receive
treatment within 62 days
All patients are to be given a 2WW leaflet with clear
instructions when to call if there is an apparent
delay.
Be proactive to speak to the hospital and be persist
with the request.
If a timely response is not achieved, be prepared to
go further. Practices should have a tracking system
to follow the referral.
ESRs are carried out as part of a battery
of tests when diagnoses are uncertain.
They can lead us to further investigations
if raised and can be useful but do not
have a high specificity for cancers
In patients with a persist raise ESR and
where other tests are negative the
possibility of requesting a CT scan of
chest and abdomen was considered.
We could think of two other cases
where this would have speeded up
cancer diagnosis.
In patients over 50 with a single episode of painless
rectal bleeding a referral for investigation should be
made, although this would be outside the 2WW rule
guideline.
11
12
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Learning, Messages and Reflections – Ovarian Cancer Site
Extracts from the audit narratives relating to Ovarian Cancer Site
1
When prescribing HRT it is important to
share the risks in easy understandable
terms with the patient
2
Unexplained anaemia ,even if it is only
mild, always warrants prompt further
investigations to rule out underlying
malignancy
3
Beware of urinary symptoms in the
absence of a UTI in female patient
4
Beware atypical presentation of urinary
symptoms in women
5
6
7
When requesting investigations it is
important to understand the results
and what subsequent action is required
There should be consistency across practice in
sharing risks with patients and what tools can be
used e.g. the national prescribing centre tool
Consider a gynaecology reason for
abdominal urinary symptoms
Use the CA125 test in line with NICE guidelines
There is a known association between
ovarian cancer and dyspepsia
The CA125 test will be used more
frequently in appropriate
circumstances
Can be very difficult to pick up symptoms
early in patients who have addictions to
alcohol or drugs
Be vigilant about other physical
illnesses in these patients .
Acute ascites is not a very common
presentation in primary care.
Picking up the phone is a useful way of
getting an out patient appointment and
an urgent scan - we don’t always have
to depend just on the form
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Learning, Messages and Reflections – Ovarian Cancer Site
Extracts from the audit narratives relating to Ovarian Cancer Site
8
For patients with learning disabilities an
annual health check can pick up their
medical problems
9
All females over 50 years old with
bloating and vague abdominal symptoms
should have a CA125 according to new
NICE guidance
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Learning, Messages and Reflections – Prostate Cancer Site
Extracts from the audit narratives relating to Prostate Cancer Site
1
Consider checking alpha foetal protein
and HCG tumour markets for patients
with hydrocele.
Check PSA in older men with urinary
symptoms.
IPSS may be helpful in assessing urinary symptoms
in older men
2
When thinking about making a urological
referral a DRE is appropriate to ensure
that all possible problems can be
considered
3
Practices should have a recall system in
place for appropriate PSA monitoring
every 6 months.
If stable NICE guidance suggests a
watch and wait system 6 – 12 months
The practice has instigated a system for recall.
Should an abnormal test result be received the GP
will enter recall dates onto the practice system.
4
There should be a standard series of
blood tests requested in all cases of
vertebral collapse, even if the x-ray
suggests it is not suspicious
The blood tests suggested are FBC,
ESR, CRP, bone biochemistry, myeloma
screen, vitamin D and PSA
5
There should be prompt referral to
urology of any PSA > 2.5 in over 50s and
> 4.0 in over 60s as stated in local
guidelines
The decision to measure PSA in the
absence of symptoms is still
controversial
6
All men presenting with lower urinary
tract systems have a PR and are
investigated in line with NICE guidance
North of England Cancer Network SEA Report
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Recommendations
North of England Cancer Network SEA
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Recommendations
1
This report should be read in
conjunction with ‘Improving
Diagnosis of Cancer – A Toolkit
for General Practice’ Mitchell
et al - 2012, which provides a
synthesis of the data from 2
rounds of the National Cancer
SEAs.
This can be found on the
National Cancer Action Team
website:
http://www.ncat.nhs.uk/sites/
default/files/workdocs/Improving%20Diagnosis
%20Toolkit%20for%20GPs.pdf
2
The North of England Cancer
Network and the GP Cancer
Leads should encourage
participation in the National
Audit of Cancer Diagnosis in
Primary Care and Cancer
Significant Audit (SEA).
This RCGP pilot will offer
anonymised external peer
assessment of your significant
event analysis of cancer
diagnosis.
3
4
Many of the audits in this
project were of a very high
standard. The GP Cancer
Leads may wish to consider
how these could be used as
‘case studies’ or examples
when reporting to or
encouraging other practices to
participate
Although audit is an integral
part of General Practice some
practices may benefit from
support in setting up a regular
audit programme. This should
include ‘tips’ on how to
facilitate the team discussion
and creating an open and
inclusive environment –
elements that are crucial to
any quality improvement
process as it is only when this
is achieved that team learning
and change can occur
The North of England Cancer
Network is a participating
network and this provides an
opportunity to receive
feedback on your SEA audits
which can go towards your
personal appraisal portfolio.
Further information is
available from the Network
North of England Cancer Network SEA Report
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Acknowledgements
North of England Cancer Network SEA Report
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Acknowledgements
Name
Organisation
The Cancer in Community Group
NECN
GP Cancer Leads
NECN and MacMillan
Suzanne Thompson
NECN Cancer Modernisation Manager
Joanne Preston
NECN Service Improvement Facilitator
Dr Nari Pindolia
NECN
All Participating GPs and their Practices
North of England Cancer Network SEA Report
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North of England Cancer Network SEA
Report
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