LUNG CANCER SEA L+SC CANCER ALLIANCE July 12th 2018 Dr Chrissie Hunt

SEA/CASE ANALYSIS Standard tool used by GPs in their PD Requirement for Appraisal and Revalidation Evidence demonstrates value for Cancer Improving learning and patient care Significant Event Audit (SEA) is a standard tool used by G.P.s in their personal development and is a requirement for appraisal and revalidation. There is evidence from the Royal College of General Practitioners (RCG.P.s) of the value of SEAs on cancer cases in terms of learning and improving patient care. A SEA allows GPs to reflect on cases considering what went well, what can be learnt from the case and the process. It can make suggestions about actions in the practice, CCGs and hospitals that will lead to improved patient care. This will inform insights into why patients present late, and actions that stakeholders within the system can take to support earlier presentation, therefore reducing the number of cases of cancer being diagnosed via emergency presentation. As part of the national GP re-validation, a GP is expected to undertake a minimum of 1 SEA but there is no

WHAT THE ALLIANCE IS PROPOSING An Alliance Wide Primary Care Lung SEA project Incentivising Practices to:- Select appropriate lung cancer diagnosis Complete a team discussion as a case review or SEA Report the actions and learning back to the Alliance The Audit covers all areas within our Alliance footprint. Lung cancer is the preliminary site of focus, due to the commitment to make all efforts in creating a step change for improvement with performance with this specific cancer. However, the implementation of this process could be replicated across all cohorts, therefore the proposed report would be used as a learning tool for standardising cancer reviews across all of Lancashire South Cumbria and wider. Pilots in Pennine Lancashire have previously undertaken small scale projects on supporting G.P.s to undertake cancer SEA. They have been well received, resulted in shared learning (G.P educational events) and new services developed (G.P.s access to urgent investigations for suspected cancer). This work dovetails into the work that has commenced across the Lancashire & South Cumbria Cancer Alliance regarding implementation of the national lung optimal pathway and one of the reporting streams of this work will be into the Lung NSSG. This audit also links into the work we are planning to ensure compliance with the ‘Faster Diagnosis Standard’ (day 28). It also links into the requirements of ‘secondary care networking’ as the results of this audit will make recommendations on actions required. This project has support from the Cancer Alliance Board.

SEA/Case Study Form/Return form Demographics Gender Age COPD Asbestos exposure Smoking history Route to diagnosis Attendees at the SEA Brief Description What went well? What could have been improved? Each GP Practice within our Alliance is being asked to search on all new cases of lung cancer in the preceding 3 years, 01/04/15 and 31/3/18 using the following components: Malignant neoplasm of trachea, bronchus and lung Read Code B22 A Data Quality facilitator from the Commissioning Support Unit has developed an EMIS search to support the practices. (Virtually all GPs in our Alliance use the EMIS GP system) Practices will be asked to select one or more cases identified by the search on which to undertake an SEA. (The average number of new cases of cancer per 2000 population is 8 each year with 1 case of lung cancer). Therefore as a minimum, a practice with a small list size of <3,000 should see at least 1 case per annum for review. For practices with a list size of more than 3,000 we would be expecting 1 SEA for each 3,000 patients registered with the Practice (eg list size of 12,000 patients would result in 4 significant event audits being completed). The aim is to focus on one tumour type to critically reconsider the patient journey (including prior to diagnosis) and improve services and outcomes. Lung cancer is a common cause of emergency presentations and many lung cancers present as emergencies. Although the project is not exclusively about cases that present as emergencies, it is expected that a high proportion would be. Furthermore we would recommend that the G.P.s select cases that were emergency presentations as there is potentially more to learn and act on by reflecting on these cases.

Safety Netting Communicate to Patients Action for GP’s Action for Practices Part 2 - Safety netting   In column 1 please tick the issue(s) relevant to your case In column 2 please tick what issue(s) you are going to work on in practice. Column 1 Column 2 COMMUNICATE TO PATIENTS Likely time course of current symptoms When to come back if symptoms do not resolve in expected time course Specific warning/ red flag symptoms or changes to look out for Who should make Part 2 - Safety netting Who should make a follow up appointment with the GP, if needed The reasons for tests or referrals If a diagnosis is uncertain ACTIONS FOR G.P.s Detail any safety netting advice in the medical notes Consider referral after repeated consultations for the same symptom where the diagnosis is uncertain (e.g. three strikes and you are in) Ensure the patient understands the safety netting advice (take into account language/literacy barriers) Code all symptoms and urgent referrals If symptoms do not resolve, carry out further investigations even if previous tests are negative ACTIONS FOR PRACTICES Ensure that you have current contact details for patients undergoing tests or referrals Ensure patients know how to obtain their results Have a system for communicating abnormal test results to patients Have a system for contacting patients with abnormal test results who fail to attend for follow up Put in place systems to document that all results have been viewed, and acted upon appropriately Have policies in place to ensure that tests/ investigations ordered by locums are followed up Have systems that can highlight repeat consultations for unexplained recurrent symptoms/ signs Make sure practice staff involved in logging results are aware of reasons for urgent tests and referrals under the two week wait Conduct significant event analyses for patients diagnosed as a result of an emergency admission Conduct an annual audit of new cancer diagnoses Abridged from: Safety netting to improve early cancer diagnosis in primary care: development of consensus guidelines. Final report.4th May 2011. Clare Bankhead et al. a follow up appointment with the GP, if needed Consider referral after repeated consultations for the same symptom where the diagnosis is uncertain (e.g. three strikes and you are in) Make sure practice staff involved in logging results are aware of reasons for urgent tests and referrals under the two week wait

LEARNING AND RECOMMENDATIONS 3 LEARNING POINTS 3 RECOMMENDATIONS/ACTIONS FOR PRACTICES 3 RECOMMNEDATIONS/ACTIONS FOR CCG’S 3 RECOMMENDATIONS/ACTIONS FOR THE HOSPITAL

WHICH CCG’S ALREADY INVOLVED CONTENT OF CCG CANCER BUNDLES Preston Chorley and South Ribble Yes? MBCCG Yes? Blackpool Fylde and Wyre Yes? Blackburn and East Lancs Yes Preston - Undertake a case review of confirmed lung cancer diagnosis that is not a HSC205 (2ww) referral using a specified template. Demonstrate implementation of any learning either through peer group minutes or internal practice meeting minutes and feedback any learning to the CCG upon request MBCCG - Significant Event Analyses on cancer diagnosis in the calendar year (Jan – Dec) One of the SEA’s - Lung Cancer if possible, if not the SEA could be a Cancer diagnosed through an Emergency Route. i)Tiered Approach to the number of SEA’s per practice based on practice population. 2 SEA’s for up to 10,000 patients, 3 SEA’s for 10 to 20,000 patients, 4 SEA’s for 20 to 30,000 patients and increasing by one SEA for every 10,000 practice population thereafter. Submission to the CCG by 07.01.2019. ii) Practice to send at least one clinician to a SEA Learning event with the Lung CA or Emergency Route diagnoses of CA to CCG Organised Learning event in Autumn 2018. (Date Tbc) Blackpool - Undertake an SEA with learning of 1 cancer diagnosis per GP per year, ideally in cases where the cancer presented late or as an emergency (not via the 2 week rule). Blackburn 3. Significant Event Audit – Lung cancer diagnosis- SEAs (1/3000) patient diagnosed with lung cancer within the last 3 years. Reflect on learning and opportunities to improve safety netting. Recommendations brought to locality group for actions to be implemented at CCG and LSC Cancer Alliance level.

Improve patient care WHAT ARE WE HOPING TO ACHIEVE? Collation of demographic and clinical data – lung cancer Encourage the use of SEA/Case reviews in clinical practice Identify learning needs Make recommendation at practice CCG and hospital levels Support development of services Inform commissioning intentions Improve patient care The aims of the SEA project is:  To collate demographic and clinical data on patients with lung cancer.  To encourage practices to discuss clinical cases sharing what went well and what could be improved. Make recommendations for the practice, its CCG and local hospital

THANKYOU DR CHRISSIE HUNT STRATEGIC LEAD GP CRUK/L+SC CANCER ALLIANCE