Early Awareness and Diagnosis Roy McLachlan, NECN Director May 2011

Structure Awareness and Earlier Diagnosis – the challenge Analysis of Significant Event Audits National and Local Primary Care Audit Using Lean Methodology Kaizen Events –Kaizen events with General Practices –Kaizen event with City Hospitals Sunderland Questions

Improving outcomes: A strategy for Cancer level of ambition Our aspiration is that England should achieve cancer outcomes which are comparable with the best in the world We believe that by 2014/15, 5000 additional lives can be saved each year. It is now for the NHS, working with PHE (Public Health England) to deliver this ambition Note: The additional 5000 lives will require England to match the European average. Approximately 10,000 additional lives would be saved if England was to match survival achieved in Sweden (and Australia and Canada)

From this….

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Analysis of Significant Event Audits for diagnosis of lung cancer & cancers in young people Aim The main aim of this study was to gain insights into the events that surround the diagnosis for these two cancers General Practices from the North East of England were invited to participate, recruited by Local NHS cancer leads The 92 practices involved were invited to record clinical details on the last patient diagnosed with lung cancer(132 SEA returned) and with cancer TYA, aged with 35 SEA Participating practices were provided with electronic templates to record their SEA based on a structure recommended by the National Patient Safety Agency

Significant Event Audit continued Key factors identified by GPs as essential to the process of recognition & referral: –Having systems in place within the practice to deal with abnormal results –Having continuity of care within the practice where possible –Having mechanisms in place to follow up, manage and refer non-resolving symptoms –Considering negative/benign CXRs for the appearance in context, as these do not exclude the possibility of lung cancer –Having an appropriate consulting style that allows young people to feel comfortable enough to explain their symptoms

RCGP/NCAT Cancer Diagnosis Audit in Primary Care The audit tool was developed in response to the Cancer Reform Strategy and with support from the National Cancer Action Team. Those contributing to its development included primary care cancer leads and academic GPs who are researching issues of early diagnosis. The work was done under the aegis of the Royal College of General Practitioners Aims of using the audit tool –To identify any potential groups of patients or tumour types which are particularly vulnerable to delay –To use the findings to plan interventions to improve early diagnosis for cancer patients –Contribute to a national picture of causality of delays

National Cancer Audit in Primary Care NECN aims in participating in the audit were: –To identify any delays in patient pathways –To identify any potential groups of patients or tumour types which are particularly vulnerable to delay –To use the findings to plan interventions to improve early diagnosis for cancer patients across North of England Cancer Network –To ensure that the findings inform commissioning intentions

NECN primary care audit findings Issues Repeat Chest x-ray for suspected lung cancer required further thought and action The 2 week wait referral criteria did not always fit a patient presentation Co morbidity often masked underlying cancer Negative investigation results delayed diagnosis Learning The 2 most important learning themes identified by almost all practices were: GPs are required to be far more vigilant in their suspicions of cancer even when clinical symptoms did not quite fit, the initial investigations were negative and/or the patient had co morbidities that might mask underlying cancer. Communication within the practice is vital. In some cases referral was delayed as a result of a patient seeing several different GPs within a practice over a period of time.

Kaizen Events A Kaizen event is: A rigorous two day event that eliminates waste and improves flow through the redesign of ineffective processes The team members and the home teams are empowered to make the changes that are needed

Kaizen events – 3 x Practices, Sunderland Aim: To reduce the Lead time from GP referral for chest x-ray to GP receipt of x-ray report. To improve communication. To reduce the number of process steps in the process

The Key Findings are summarised below NHS South of Tyne and Wear Key Findings All three practices could identify circumstances where patients got trapped in a loop of consultation, treatment and review – this was usual where the patients presented with vague symptoms or had co morbid problems that masked a potential cancer diagnosis All practices found the presenting signs and symptoms in some patients wide and varied often delaying onward referral All three practices had evidence of initial normal CXR in patients who subsequently were diagnosed as having lung cancer Clinical All three practices cited issues with radiology reporting that caused delays in the patient journey – none of the practices had implemented any fail safe systems to improve this including checks on patient attendance for the CXR All three practices found areas within their current systems and processes that could be improved to reduce the time from initial patient presentation to referral to secondary care All three practices found key issues with protocols or standardised practice within their systems that could potentially slow the patient journey System All three practices found communication between GP and other practitioners to have compromised the speed of the patient journey on one or more occasion Communication All practices found that the better data they had the better decisions they made Information All practices agree this process would be transferable to other areas that required attention within their practice Process

City Hospital Kaizen Background: Kaizens in January/February 2010 Parking lot, including CXR reporting Problems with current pathway and turnaround of radiological tests June 2010 TITO – CXR reporting Highlighted by GP survey, GP audit and current performance

Key changes and impact Remove dual paper and IT systems Single level of referral for CXR Consultant rota and reporting arrangements Removal of backlog Apply to all GP plain films not just CXR Reports available on HISS ICE and paper reports Process and value stream maps

X-ray request to Report Value Stream Map Future State CT VA NV A % VA CT VA NV A % VA CT VA NV A % VA CT VA NV A % VA CT VA NV A % VA CT VA NV A % VA CT VA NV A % VA CT VA NV A % VA GP request (signed) Pt attends for x ray CHS receives paper work Start dictation by Consultant Draft report on HISS) Signed report on HISS Date report printed Lead Time: Report available to GP 11wd10 3 days

EMIS, HISS and ICE Possible use of EMIS referral forms Read coding for analysis and safety netting Regular accessing of HISS Programme to roll out ICE

Summary Solution generated by working together Right people round the table Extension to all plain films Service improvement need not cost Reports available on HISS Methodology applicable across sectors

Whats coming up?… General Practice Profiles on Cancer National support Be Clear on Cancer Campaign Partnership with Macmillan Annual Conference

Be Clear on Cancer – national materials

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