Improving Early Diagnosis of Cancer How Can Primary Care Help Save 5000 Lives? Dr Phil Sawyer MVCN Primary Care Lead HVCCG Cancer Lead

content Context Improving early Diagnosis of Ovarian cancer Improving Early Diagnosis of Colorectal cancer Tools to help us in Primary Care Reflective practice –Practice profiles –RCGP audits –Safety-netting

Saving 5000 Lives Cancer Reform Strategy European bench-marking studies NHS outcomes framework –domain 1: Reducing Premature Mortality NAEDI – public, primary care, screening & diagnostics Mike Richards film

Ovarian Cancer Awareness Campaign Film Questions or comments? Resource pack

Colorectal Cancer Awareness Campaign Film Questions or comments? Resource pack

Risk Assessment Tools Evidence base Help inform decision re further investigation or referral Clinical context remains crucial Different models exist –Willie Hamilton’s RATs –Qcancer

Resource packs Colorectal & Ovary… BCOC campaign information –Patient, Clinician, Practice staff Film RATs Referral guidance & proforma Education module MDT information*

Practice Profiles Background, Data sources, Purpose –in public domain Reflective practice not performance management NCIN format MVCN peer-comparison format **** How you might use the information

Introduction Purpose of the report The purpose of this report is to provide a summary of the key diagnosis and referral indicators for practices across Herts Valley CCG. Eight key indicators are reviewed at practice level, highlighting those practices which are above or below the national target, or outside the recommended range. The key indicators are: Percentage of females aged 50–70 screened for breast cancer in last 36 months Percentage of females aged 25–64 attending cervical screening within target period Percentage of persons aged 60–69 screened for bowel cancer in last 30 months Two Week Wait referral ratio Percentage of Two Week Wait referrals with cancer Percentage of new cancer cases treated which are Two Week Wait referrals Number of emergency admissions with cancer per 100,000 population Route of presentation The report also considers the demographic profile of the CCG and how demographics relate to the performance across the eight key practice level indicators. The following demographics have been included: Practice Population aged 65+ Socio-economic deprivation New cancer cases Cancer deaths Prevalent cancer cases Data source: GP Practice Profiles for cancer, Cancer Commissioning Toolkit 2012 Maps contain: Ordnance Survey data © Crown copyright and database right 2012 Royal Mail data © Royal Mail copyright and database right 2012, National Statistics data © Crown copyright and database right 2012.

Cancer indicators: Summary of practice performance Key Number of targets achieved Practices are shaded to show the number of indicators that are above the national target or are within the recommended range 1. Number of cancer indicators above the national target or within the recommended range 63% of practices failed to meet half of the recommended ranges for the eight cancer indicators. Practices within recommended range Indicator 2 Pr.% % Females aged screened for breast cancer in last 36 months 2842% % Females aged screened for cervical cancer in last 42/66 months 1015% % Persons aged screened for bowel cancer in last 30 months 1624% Two-week wait referral ratio3045% % of two-week referrals with cancer 3552% % of new cancer cases treated which are Two Week Wait referrals 3654% Number of emergency admissions with cancer per 100,000 popn 6496% Number of managed referral presentations per 100,000 popn 4669% Recommended ranges achieved No. of indicatorsPr.%  7 to 846%  5 to 62131%  3 to 42943%  1 to 21319% Total practices67100% 1 See appendix (page 48) for targets / recommended ranges 2 See appendix (page 31-40) for full definitions. Maps contain: Ordnance Survey data © Crown copyright and database right 2012, Royal Mail data © Royal Mail copyright and database right 2012, National Statistics data © Crown copyright and database right 2012.

Practice performance ranked within Herts Valleys CCG Cancer indicators: Summary of practice performance ranked Key Quartiles for combined indicator score Practices are shaded to show where they rank within the CCG for their overall performance across the indicators. Combined indicator score The eight indicators reviewed in this report have been combined into a single score 1, as a proxy for overall performance across the indicators. The score is used to rank the practices within the CCG. 1 See appendix (page 30) for methodology. Maps contain: Ordnance Survey data © Crown copyright and database right 2012, Royal Mail data © Royal Mail copyright and database right 2012, National Statistics data © Crown copyright and database right 2012

Percentage of females aged 50–70 screened for breast cancer in last 36 months 3 year coverage (2008/09 – 2010/11) Summary statistics England mean average = 72.5% CCG mean average = 70.4% CCG practice range = 46.5% to 82.9% Best practice: At or above 70% Data source: GP Practice Profiles for cancer, Cancer Commissioning Toolkit Definition: The number of females registered to the practice screened adequately in previous 36 months divided by the number of eligible females on last day of the review period. (See appendix page 31 for full definition) Indicator source(s): Data was extracted from the NHAIS via the Open Exeter system. Data was collected by the NHS Cancer Screening Programme. Aim to be above the national target (70%) Consider actively encouraging patients to participate in screening programmes with letters or opportunistic prompts. GPs can be influential here.

Percentage of females aged 25–64 attending cervical screening within target period 3.5 or 5.5 year coverage (2005/06Q3 – 2010/11) Summary statistics England mean average = 75.3% CCG mean average = 76.5% CCG practice range = 59.9% to 85.2% Best practice: At or above 80% Data source: GP Practice Profiles for cancer, Cancer Commissioning Toolkit Definition: The overall cervical screening coverage: the number of women registered at the practice screened adequately in the previous 42 months (if aged 24-49) or 66 months (if aged 50-64) divided by the number of eligible women on last day of review period. (See appendix page 32 for full definition) Indicator source(s): Data was extracted from the NHAIS via the Open Exeter system. Data was collected by the NHS Cancer Screening Programme. Aim to be above the national target (80%) Consider actively encouraging patients to participate in screening programmes with letters or opportunistic prompts. GPs can be influential here.

Percentage of persons aged 60–69 screened for bowel cancer in last 30 months 2.5 year coverage (2008/09Q3 – 2010/11) Summary statistics England mean average = 57.4% CCG mean average = 56.0% CCG practice range = 34.6% to 65.8% Best practice: At or above 60% Data source: GP Practice Profiles for cancer, Cancer Commissioning Toolkit Definition: The number of persons registered to the practice screened adequately in the previous 30 months divided by the number of eligible persons on last day of the review period. (See appendix page 33 for full definition) Indicator source(s): Bowel Cancer Screening System (BCCS) via the Open Exeter system. Data was collected by the NHS Cancer Screening Programme. Aim to be above the national target (60%) Consider actively encouraging patients to participate in screening programmes with letters or opportunistic prompts. GPs can be influential here.

Two Week Wait referrals Indirectly age standardised referral ratio (2010/11) Summary statistics England mean average = 100.0% CCG mean average = n/a CCG practice range = 26.5% to 169.8% Best practice: National average +/- 20% Data source: GP Practice Profiles for cancer, Cancer Commissioning Toolkit Definition: The number of Two Week Wait referrals where cancer is suspected multiplied by 100,000 divided by the list size of the practice in question. (See appendix page 34 for full definition) Indicator source(s): Trent Cancer Registry based on Cancer Waiting Times data for England, 2011/12, held on the DH Cancer Waiting Times Database. Ke y Aim to be referring within 20% of the England average two week wait referral rate. Rates outside this range may indicate over/under use of the two week wait referral route. You may wish to audit your referrals against NICE cancer referral guidance.

Key Left hand axis Right hand axis Percentage of Two Week Wait referrals with cancer Conversion rate: Percentage of all Two Week Waits with cancer (2010/11) Data source: GP Practice Profiles for cancer, Cancer Commissioning Toolkit Definition: The ‘conversion rate’, i.e., the proportion of Two Week Wait referrals that are subsequently diagnosed with cancer: the number of new cancer cases treated in 2011/12 who were referred through the two week wait route divided by the total number of Two Week Wait referrals in 2011/12. (See appendix page 35 for full definition) Indicator source(s): Trent Cancer Registry based on Cancer Waiting Times data for England, 2011/12, held on the DH Cancer Waiting Times Database. Summary statistics England mean average = 10.6% CCG mean average = 9.4% CCG practice range = 0.0% to 20.2% Recommended range = 8% to 14% Aim to have conversion rate between 8-14%. Rates outside this range may indicate over/under use of the two week wait referral route. You may wish to audit your referrals against NICE cancer referral guidance. There is no target number for referral as this depends on practice size and demographics.

Data source: GP Practice Profiles for cancer, Cancer Commissioning Toolkit Definition: The proportion of new cancer cases treated who were referred through the Two Week Wait route. (See appendix page 36 for full definition) Indicator source(s): Trent Cancer Registry based on Cancer Waiting Times data for England, 2011/12, held on the DH Cancer Waiting Times Database. Percentage of new cancer cases treated which are Two Week Wait referrals (2010/11) Summary statistics England mean average = 46.5% CCG mean average = 40.1% CCG practice range = 0.0% to 71.4% Recommended range: > 40% Ke y Aim to be above the line and have more of your cancer cases diagnosed through the two week wait referral route. Consider doing the RCGP cancer diagnosis audit.

Number of emergency admissions with cancer per 100,000 population Number per 100,000 population (2010/11) Summary statistics England mean average = 587 CCG mean average = 446 CCG practice range = 83 to 933 Recommended range: National average (587) Data source: GP Practice Profiles for cancer, Cancer Commissioning Toolkit Definition: The number of persons admitted to hospital as an inpatient or day-case via an emergency admission multiplied by 100,000 divided by the number of persons in the practice list, expressed as a rate per 100,000 persons. (See appendix page 37 for full definition) Indicator source(s): Hospital Episode Statistics (HES) data for 1st March 2011 to 29th February 2012 was taken from the UKACR “Cancer HES” offload originally sourced from the NHS Information Centre for Health and Social Care HES dataset. Ke y Aim to minimize the number of cancer patients requiring emergency admissions. Try to proactively manage cases. Consider using the RCGP Significant Event Audit to reflect on cases.

Route of presentation Percentage of presentations by route (2008) Data source: GP Practice Profiles for cancer, Cancer Commissioning Toolkit Definition: Proportion of persons diagnosed via an emergency, managed referral or other route. (See appendix page for full definition) Indicator source(s): Routes to Diagnosis project database. 1 Routes to Diagnosis methodology, available online at: Emergency presentations Other presentations Managed ref. presentations England mean average23.7%27.1%49.2% CCG mean average22.1%27.9%50.0% CCG practice range0% to 66.7%0% to 58.1%0% to 100% Summary statistics Aim to have as few emergency presentations of cancer and more of the cases detected through managed referral routes. Consider using the RCGP significant Event Audit to reflect on cases and using Risk Assessment Tools to help guide investigation and referral. Ke y England CCG Emergency presentations Managed referral presentations Other presentations

Population aged 65+ % of practice population aged 65+ Data source: GP Practice Profiles for cancer, Cancer Commissioning Toolkit 2010/11 Definition: The number of persons registered at the practice aged 65+, April (See appendix page 42 for full definition) Indicator source(s): Attribution Dataset, South East Public Health Observatory. Ke y The height of the bars show the demographic value. Practices are highlighted in green or red depending on whether they are ranked within the top or bottom 25% for their overall performance across the indicators (see appendix page 30 for further information).

RCGP Audits Cancer Diagnosis audit –6 month retrospective brief case analysis –Excluding screen detection & NMSC –Route to diagnosis –Diagnostic delays Cancer Significant Event Analysis – –Detailed reflective case analysis –Identified learning & action –RCGP Peer reviewed process –Good & bad examples…

Recommended safety netting information to communicate to the patient High Priority Cancer Safety Netting Advice (Include in patient communication) The likely time course (time to resolution of self-limiting condition) of current symptoms (e.g. cough, bowel symptoms, pain) Specific information about when and how to re-consult if symptoms do not resolve in the expected time course Specific warning symptoms and signs of serious disease (e.g. cancer) Who should make a follow up appointment with the GP, if needed (usually requesting the patient make the appointment, sometimes the doctor) Intermediate Priority (Consider including in patient communication) If a diagnosis is uncertain, give a clear explanation for the reasons for tests or investigations (e.g. to exclude the possibility of serious disease or cancer) If a diagnosis is uncertain, that uncertainty should be communicated to the patient

Recommended safety netting actions that GPs should take during or shortly after the consultation High Priority Cancer Safety Netting Advice (Include in consultations) Safety net advice should be documented in the medical notes GPs should consider referral after repeated consultations for the same symptom where the diagnosis is uncertain (e.g. three strikes and you are in). The GP should ensure that the patient understands the safety netting advice GPs should take additional measures to ensure that safety netting advice is understood in patients with language and literacy barriers GPs should keep up to date on current guidelines for urgent referral for suspected cancer Intermediate Priority (Consider including in consultations) If symptoms do not resolve, further investigations should be conducted even if previous tests are negative Safety netting advice should be given verbally

Recommended safety netting actions for Practices High Priority Safety Netting advice (Ensure patient communication procedures are in place) procedures in place to ensure that patients are aware of how to obtain results of investigations ensure that current contact details are available for patients undergoing tests/investigations or referrals a system for communicating abnormal test results to patients a system for contacting patients with abnormal test results who fail to attend for follow up High Priority (Ensure reliable practice systems are in place) Practice systems should be in place to document that all results have been viewed, and acted upon appropriately Practices should have policies in place to ensure that tests/investigations ordered by locums are followed up Practices should conduct significant event analysis for delayed diagnoses of cancer (focusing on symptoms, signs, diagnostic procedures, continuity of care and reasons for delay) Intermediate Priority (Consider using reliable practice systems) Practice systems should be able to highlight repeat consultations for unexplained recurrent symptoms/signs Practices should conduct an annual audit of new cancer diagnoses Practices should participate in cancer awareness campaigns Practice staff involved in processing /logging of results should be aware of reasons for urgent referral under the 2 week wait

Other resources Macmillan **** NICE referral guidelines MVCN websitewebsite Learning modules on BMJ site, RCGP, doctors.net, Univardis

and don’t forget… Acute Oncology –Malignant spinal cord compression –Neutropenic sepsis –Hypercalcaemia –Side effects of treatment (mucositis, vomiting) Late Effects of treatments Relapse and Recurrence Survivorship Palliative Care Prevention

Questions/comments Thank you!