Head & Neck Cancer at Ipswich Hospital Mr H.T. Davies & Miss L.C. Fryer Maxillofacial Surgery Ipswich Hospital Ipswich Hospital

Head and Neck Cancer Treatment of H&N cancer is complex requiring surgery, radiotherapy and chemotherapy or a combination Treatment of H&N cancer is complex requiring surgery, radiotherapy and chemotherapy or a combination The cancer or its treatment can be disfiguring and has a major impact on breathing, eating, swallowing, voice and speech The cancer or its treatment can be disfiguring and has a major impact on breathing, eating, swallowing, voice and speech Efficient and competent treatment requires close collaboration between specialties and effective rehabilitation Efficient and competent treatment requires close collaboration between specialties and effective rehabilitation

Ipswich Hospital Head & Neck Cancer Service Ipswich Hospital Head & Neck Cancer Service MDT (Multidisciplinary Team) well established for > 10 years MDT (Multidisciplinary Team) well established for > 10 years MDT satisfies NICE guidance MDT satisfies NICE guidance Weekly Weekly All cases discussed and reviewed All cases discussed and reviewed 2 week wait target consistently achieved 2 week wait target consistently achieved Peer review Peer review

MDT 4 Surgeons 4 Surgeons 1 Oncologist 1 Oncologist 1 Pathologist 1 Pathologist 1 Radiologist 1 Radiologist 1 Reconstructive Surgeon 1 Reconstructive Surgeon 1 Restorative Consultant 1 Restorative Consultant 2 Speech and Language therapist 2 Speech and Language therapist 1 Head & Neck Dietician 1 Head & Neck Dietician 2 Head & Neck/Oncology Specialist Nurses 2 Head & Neck/Oncology Specialist Nurses 1 Macmillan radiographer 1 Macmillan radiographer 1 Pathway coordinator 1 Pathway coordinator

Professor R Hall 2000 Ipswich is one of the smaller oncology units in the country but must also be one of the best Ipswich is one of the smaller oncology units in the country but must also be one of the best

NICE and IOG NICE guidance contains many benchmark items, which are peer reviewed NICE guidance contains many benchmark items, which are peer reviewed Guidance is not mandatory Guidance is not mandatory Surgery should take place in specialist centres that treat a minimum of 100 new cases each year and serve a population of one million people BAHNO recommend a minimum of 80 new cases a year IOG confirms that this is appropriate in a rural area IOG confirms that this is appropriate in a rural area

NICE and IOG Cancer services should be related to clinical outcomes and survival rates not random numbers Cancer services should be related to clinical outcomes and survival rates not random numbers Audrey Bradford (ACN Director) stated to ACN board that she was humbled as they had no access to outcome and survival figures Audrey Bradford (ACN Director) stated to ACN board that she was humbled as they had no access to outcome and survival figures Carol Taylor–Brown (ACN Chairman and Suffolk PCT Chief Executive) stated that “some policies may work in an urban setting but don’t make sense in a rural county like Suffolk” - Evening Star 22nd Feb 2008 Carol Taylor–Brown (ACN Chairman and Suffolk PCT Chief Executive) stated that “some policies may work in an urban setting but don’t make sense in a rural county like Suffolk” - Evening Star 22nd Feb 2008

Better Outcomes ? The evidence that centralisation is of clinical benefit is poor, as admitted, in the introduction to the NICE guidance. The evidence that centralisation is of clinical benefit is poor, as admitted, in the introduction to the NICE guidance. Page 2 of the forward- “However we have found little specific evidence from studies of head and neck cancer treatment to guide our recommendations. Indeed, the evidence picture overall is thin.” Page 2 of the forward- “However we have found little specific evidence from studies of head and neck cancer treatment to guide our recommendations. Indeed, the evidence picture overall is thin.”

Definition of Head & Neck Cancer The term head and neck cancer covers over 30 different cancers. The term upper aero-digestive tract (UAT) refers to the majority of cancers in this group and includes cancer of the lip, mouth, oral cavity, salivary glands, sinuses, pharynx and larynx. The term head and neck cancer is used to refer to cancers of the upper aero-digestive tract (UAT) and thyroid. In most respects thyroid cancers are unlike UAT cancers, but are included in the term as the services required for patients overlap. (Dr Kanka, appendix.1, consultation paper)

Original H&N figures – Ipswich Hospital Excluded many cases Excluded many cases Used narrow definition of UAT cancer Used narrow definition of UAT cancer In dispute In dispute

Head & Neck Cancer Figures for 2006 and 2007 – Ipswich Hospital SNOMED which is the pathology search engine/system SNOMED which is the pathology search engine/system MDT clinic lists MDT clinic lists Lorenzo Hospital System Lorenzo Hospital System

2007 H&N Cancer cases Total number of new patients through clinic 108 Total number of new patients through clinic 108 Total number of UAT patients in Ipswich 90 Total number of UAT patients in Ipswich 90 Total number of H&N cancers = UAT (90) + thyroid (6) = 96 Total number of H&N cancers = UAT (90) + thyroid (6) = 96 Others = 12 Others = 12 Complex skin cancer Complex skin cancer Metastatic cancer Metastatic cancer

2007 H&N cases Validated by Clinicians Validated by Clinicians Validated by Medical Director and Chief Executive Validated by Medical Director and Chief Executive Recently ACN and Suffolk PCT have also requested external independent validation. This has not been undertaken for any other centre Recently ACN and Suffolk PCT have also requested external independent validation. This has not been undertaken for any other centre

Other H&N Centers Two other designated centres for head and neck cancer in ACN Cambridge Norwich Cambridge serves a population of 1.3 million, carries out 170 cases annually. Norwich serves a population of 940,000 and carries out 125 cases annually. Chelmsford cancer centre for Essex…… ???

Options from ACN Option 1: Retain MDT and surgery at Ipswich Hospital. Option 2: Joint MDT between Ipswich and Norwich with surgery on both sites. Clinicians preferred option rejected by ACN Option 3: Joint MDT between Ipswich and Norwich with all surgery in Norwich Preferred option by ACN

Summary analysis OptionDescriptionMeets national requirements Access 1 Provide Specialist head and neck surgery at Ipswich ?√ 2 Split head and neck specialist cancer surgery between NNUH and Ipswich √√ 3 Transfer head and neck cancer surgery to NNUH √X

Confidential Report on Upper GI Cancer Service Mid Essex Hospital Services (RCS England) Increasing pressure from the SHA to locate to one site within 9 months lead to major difficulties Increasing pressure from the SHA to locate to one site within 9 months lead to major difficulties The concept of the operating surgeon not being involved in post operative care was fundamentally wrong The concept of the operating surgeon not being involved in post operative care was fundamentally wrong Operating surgeon needs to look after the patients following surgery Operating surgeon needs to look after the patients following surgery There were an excess number of deaths There were an excess number of deaths

Patients Patients Head and Neck cancer patients are poorly placed to travel Head and Neck cancer patients are poorly placed to travel Transfer of surgery to Norwich is against the wishes of the majority of patients and their families Transfer of surgery to Norwich is against the wishes of the majority of patients and their families Ideally diagnosis, management and subsequent support should be provided locally Ideally diagnosis, management and subsequent support should be provided locally Continuity of care Continuity of care Surgeon providing surgery must follow the patient up Surgeon providing surgery must follow the patient up Who will deal with the inevitable surgical complications and where ? Who will deal with the inevitable surgical complications and where ?

Consultation Is about involving patients and the public in the development of new plans and policies and is a constituent part of the development of a patient led NHS Is about involving patients and the public in the development of new plans and policies and is a constituent part of the development of a patient led NHS EOE (East of England) website states patients will have a real choice about where and how to access treatment EOE (East of England) website states patients will have a real choice about where and how to access treatment

Suffolk Population 700,000 and increasing 700,000 and increasing Increasing age of population Increasing age of population Doesn’t include Patients from South Norfolk and North Essex Doesn’t include Patients from South Norfolk and North Essex Maxillofacial Surgery covers Ipswich, The West Suffolk Hospital and North Essex Maxillofacial Surgery covers Ipswich, The West Suffolk Hospital and North Essex

What about H&N Surgeons ? Intention of ACN is that surgeons from Ipswich go to Norwich to operate. How will this improve care? Need to balance with the maintenance of trauma and emergency care at Ipswich. You cannot separate trauma from cancer

Financial Savings ? Financial advantage of centralisation transfers cost to patients and relatives Financial advantage of centralisation transfers cost to patients and relatives It is to date an assumption that there will be an advantage for patients and better outcomes It is to date an assumption that there will be an advantage for patients and better outcomes “many of these patients are poorly placed to travel. Ideally, diagnosis, management and subsequent support should be provided locally (IOG) “many of these patients are poorly placed to travel. Ideally, diagnosis, management and subsequent support should be provided locally (IOG)

Implications for the OMFS service Inability to provide consultant led trauma service. Inability to provide consultant led trauma service cases a year in Ipswich cases a year in Ipswich. Loss of surgical skills will affect complicated trauma cases Loss of surgical skills will affect complicated trauma cases Loss of consultants and will be impossible to recruit Loss of consultants and will be impossible to recruit Loss of accreditation for H & N training from SAC/PMETB for Specialist Registrars Loss of accreditation for H & N training from SAC/PMETB for Specialist Registrars Downgrading of unit and Loss of staff Downgrading of unit and Loss of staff

Implications for other services Speech and Language therapy Speech and Language therapy Pathology Pathology Dieticians Dieticians Head and Neck nurses Head and Neck nurses

Other options ? Option 2: Establish a joint MDT between Ipswich and Norwich with surgery on both sites

Option 2 - Examples Option 2 - Examples Nottingham and Lincoln dual site operating allowed because of numbers and rurality Nottingham and Lincoln dual site operating allowed because of numbers and rurality 80 new cases in Lincoln 80 new cases in Lincoln Lincoln rural Lincoln rural reason for rejection by ACN but the Countryside Commission defines Suffolk as rural and remote. Lack of sufficient rurality in Suffolk reason for rejection by ACN but the Countryside Commission defines Suffolk as rural and remote. Many other examples of dual site operating Many other examples of dual site operating Exeter and Taunton Exeter and Taunton Exeter and Torquay Exeter and Torquay Northampton and Leicestershire Northampton and Leicestershire Suffolk is rural & IHT provides an excellent service. Suffolk is rural & IHT provides an excellent service.

“ If it is right for the patient it is right for the clinician” Prof. Mike Richards, Government Cancer Czar Network development programme March 2006

Lord Darzi – Our NHS Our Future Specialist services would be moved into larger regional centres only where there was evidence to prove that doing this would provide better care Specialist services would be moved into larger regional centres only where there was evidence to prove that doing this would provide better care Patients would be involved in decisions Patients would be involved in decisions Changes must benefit patients and will be decided by local doctors and managers Changes must benefit patients and will be decided by local doctors and managers