Transcript Aligning research with clinical service delivery

Aligning Research
with
Clinical Service Delivery
Dr Tom Crosby
Medical Director
Wales Cancer Network
November 2016
Will cover....

Cancer Services in Wales

Cancer Delivery Plan and Conference Highlights

Benefits of research and service working together

Research priorities for the Network research community
The Good
Peer review and National Audit as
service quality review systems
Radiotherapy developments
The Bad (Patchy progress)
Acute oncology
Primary care ‘oncology’
Cancer Pathway Improvement work
Equitable treatment access
The Ugly
Cancer information systems
Regional cancer services planning
and commissioning
Outcome Indicators and Measures
100%
Patient
experience
50%
58
31
8
3
1
Good
Fair
Poor
0
Excellent Very Good
Cancer Survival
Health Equality for Wales
UK Cancer incidence projections
to 2035
Smittenaar et
al, BJC 2016
How Do We Get Better?
Better treatments?
Better systems?
Cancer Priorities 2014/15

Simplify organisational structure
–

Primary Care Oncology
–
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SEA, Prehab, Pathway, Awareness campaign, Access to surgery
Patient Centred Care
–

Established Framework for Cancer
Lung Cancer Initiative
–

Single Cancer ‘Network’
Key worker, HNA, Care plans
Single Suspected Cancer Pathway
–
Hidden waits, single pathway, pathway improvement
Organisational Structures
WG
NHS
Wales
Cancer Implementation
Group
Wales
Cancer
Network
Wales Cancer
Research
Community
Local and
Specialist
Commissioning
(eg WHSSC)
(inc 1000 lives)
Framework
for Cancer
F4C
CSGs
Lung
breast etc
COSC
SACT
LHBs
DoPs
DoFs
CIG Priorities 2015/16

Cancer Diagnostics
–
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Primary Care Oncology
–

SEA, Prehab, Pathway, Awareness campaign, Access surgery
Patient Centred Care
–

Established Framework for Cancer
Lung Cancer Initiative
–

Diagnostic Centres, Direct primary care access
Key worker, HNA, Care plans
Single Suspected Cancer Pathway
–
Hidden waits, single pathway, pathway improvement
Refreshed 2016-2020
Key Elements
•Early Diagnosis Initiative
•Patient Centred Centre Programme
•Cancer Information Framework
•Cancer Performance Framework
•Cancer Research Strategy for Wales
Detecting Cancer Earlier
Detecting Cancer Early
Bowel Screening
Home FOB test
kit every two
years for adults
aged 60-74 in
England & Wales
Adapted technologies
may be offered in
future
70%
60%
50%
40%
30%
20%
10%
0%
Q1 - least
deprived
Q2
Q3
Q4
Q5 - most
deprived
Bowel screening uptake by deprivation quintile and gender, 2010-11
Cancer awareness and delay
Patient delay
in the
Symptom awareness
in the
UK UK
100
% anticipating >2 weeks before help-seeking
% correctly recognise symptom
90
100
90
80
70
60
80
70
60
50 50
40 40
30
20
30
20
10
10
0
0
Persistent cough
Persistent cough
Unexplained bleeding
Rectal bleeding
Unexplained lump
Breast changes
Quaife S, Forbes L, Ramirez A, Brain KE, Donnelly C, Simon AE, Wardle J. Recognition of cancer warning signs and
anticipated delay in help-seeking in a population sample of adults in the UK. Brit J Cancer 2014; 110: 12-8.
Opportunities
 Significant Event Audit

BMJ Education

Advice and Referral
support systems
Evidence I: countries where GPs are
more willing to test have better cancer
outcomes
Evidence I: countries where GPs are
more willing to test have better cancer
outcomes
PRIFYSGOL BANGOR / BANGOR UNIVERSITY
WICKED
(Wales Interventions and
Cancer Knowledge about
Early Diagnosis)
Develop and evaluate an
intervention for GPs and their
teams to achieve:
•
•
•
prompter referral of
suspected cancer
earlier and cost-effective
diagnosis of symptomatic
cancer
improved survival
The Danish 3-Legged Model
Silkeborg Diagnostic Centre
Increase in 1-year relative survival
Our Learning
Gatekeeper system and downgrading
•
•
Vested et al suggest from their research that there is
a correlation between relative one-year survival and
the existence of a gatekeeper system.
Encourage referrals and low conversion rate
Clinical Responsibility and onward referral
•
Role of Co-ordinator is key for patient pathway
management and for point of contact for patient
Our Learning (continued…)
Use Radiologist to their full potential
–
In Aarhus, Radiologists are encouraged to act as
diagnosticians and refer onwards to the next pathway
step as per their clinical judgement
The Welsh infrastructure requires investment
–
Diagnostic workforce and equipment
Evidence V: cancer doesn’t stop growing
once it produces symptoms



Examine what what happens between the
diagnostic scan and the staging scan in
treatment of ENT cancer.
In a SR of 44 studies, the increase in local
recurrence was 14% (CI 9-21%) per month gap
between scans.
So treatment delays can worsen prognosis –
and quite quickly.
Current performance
Jun-13
USC
Sep-13
NUSC
75%
USC
Dec-13
NUSC
USC
Mar-14
NUSC
USC
Jun-14
NUSC
USC
NUSC
100%
100%
100%
100%
100%
100%
100%
96%
100%
100%
95%
95%
95%
98%
99%
99%
99%
99%
93%
99%
85%
99%
87%
100%
87%
100%
77%
98%
80%
96%
80%
100%
80%
100%
81%
100%
82%
100%
79%
100%
64%
84%
74%
97%
92%
99%
90%
93%
80%
97%
66%
96%
71%
99%
84%
98%
81%
97%
73%
98%
78%
99%
87%
99%
90%
99%
88%
98%
89%
99%
94%
80%
100%
100%
100%
60%
100%
97%
99%
96%
99%
98%
100%
97%
99%
97%
100%
99%
73%
97%
79%
98%
80%
99%
91%
98%
84%
99%
77%
95%
85%
95%
94%
96%
91%
96%
85%
96%
Total number who started treatment
(USC Pathway)
Area
Sep 13
Dec 13
Mar 14
Jun 14
Wales
89
86
97
92
Abertawe Bro Morgannwg
27
29
27
29
Aneurin Bevan
6
5
5
7
Betsi Cadwaladr
28
28
28
22
Cardiff and Vale
12
8
22
17
Cwm Taf
8
7
10
11
Hywel Dda
8
9
5
6
Improving Patient Waiting Times through Velindre
Improvement Programme (VIP)
Before
After
Improvement
Median
wait
26 days
14.5 days
79%
Average
wait
24.5 days
15.4 days
59%
EXAMPLE
Lung Cancer Pathway
14
15
CT
Bronchoscopy
1
18
17
2
33
14
Agreed Pathway
(Days )
Patient No
14
: Last patients
1OPA /RACC
3
15
31
62
Refer to
treating Trust
Therapist
Clinic DTT
1 st Treatment
Treatment
type
24
24
37
37
Chemo
32
41
42
56
68
Teletherapy
28
27
35
35
49
46
Teletherapy
60
60
81
91
Teletherapy
50
51
69
76
Chemo
27
28
42
49
Chemo
35
64
74
76
Teletherapy
CT Guided
biopsy
21
PET
23
MDT
Discussion
31
Post MDT
Clinic
4
S
5
21
18
5
S
13
15
14
6
5
13
18
7
13
38
37
8
2
11
8
17
43
63
72
Chemo
9
14
15
14
21
32
33
41
Chemo
10
6
22
14
23
24
33
38
Chemo
Colorectal Cancer 62 Day
Pathway Webex
42
54
59
EXAMPLE
Lung Cancer Pathway
14
15
CT
Bronchoscopy
1
12
14
2
13
25
13
13
Agreed Pathway
(Days )
Patient No
14
: Last patients
1OPA /RACC
3
15
31
62
Refer to
treating Trust
Therapist
Clinic DTT
1 st Treatment
Treatment
type
16
18
26
42
Chemo
30
35
55
65
Teletherapy
20
22
25
30
48
Teletherapy
18
28
30
55
Teletherapy
30
50
55
68
Chemo
21
30
38
50
Chemo
20
24
34
55
Teletherapy
CT Guided
biopsy
21
PET
27
23
MDT
Discussion
31
Post MDT
Clinic
4
S
6
8
14
5
S
12
16
19
6
5
13
18
7
12
13
15
8
5
11
14
17
41
53
63
Chemo
9
13
16
18
21
31
34
48
Chemo
10
6
12
14
18
22
30
39
Chemo
Colorectal Cancer 62 Day
Pathway Webex
19
15
25
Lung Results
4 key questions for
patients




What are my options?
What are the benefits and harms?
Do I really need this?
What can I do myself?
Wales first Six
1. Scans and X-rays aren’t usually needed for straightforward
back pain.
2. In advanced incurable cancer, the risks and benefits of
chemotherapy need to be considered carefully.
3. For most people with reflux and indigestion, long-term use of
Proton Pump Inhibitor (PPI – stomach acid suppressants )
medicines (omeprazole & lansoprazole) is best avoided.
4. In the very frail and the terminally ill, there should be very
careful consideration of whether long-term medicines need to
be continued.
5. In iron-deficiency anaemia, blood transfusions are usually not
needed unless the Haemoglobin level is below 70g/l.
6. Daily blood glucose monitoring is usually not needed for most
cases of Type 2 Diabetes.
Working Together
Benefits of Research-Service
Collaboration



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
Service and outcomes better in research rich
environment
Raise standards of care
Introduce service developments earlier and
better through detailed protocols and high
quality assurance systems
Support costs of access to high quality care
Supports concept of precision medicine
Study of Chemoradiotherapy in Oesophageal Cancer
with PET and dose Escalation
A randomised Phase II/III trial to study radiotherapy dose escalation in
patients with oesophageal cancer treated with definitive chemoradiation with an embedded Phase II trial for patients with a poor
early response using positron emission tomography (PET)
All cancer trials information in one
place?
http://www.cancerresearchuk.org/about-cancer/find-a-clinical-trial
Refreshed 2016-2020
Key Elements Research
•Cancer research strategy for Wales
•Increased number and availability of
commercial and non commercial studies
•Recruitment irrespective of
organisational boundaries
•Improve participation in research across
disciplines through dedicated time
•Support targeted consenting of patients
tissue for WCB
Thank you!
Diolch!
[email protected]