1. Regional Chemotherapy
Service Review
Chairman
Welcome
Purpose of our workshop is to review the achievements to date and agree the priorities for the Northern Ireland Cancer Network Development Plan. In light of experience in year 1, consideration will also be given to the arrangements required to support the implementation of the Network priorities.
Attendance
Dr Aine McNeill, GP is attending her first meeting of the NICaN Board
Number of invited guests attending the workshop:
Dr Karen Hamilton, Senor Research Fellow
Dr Glenda Mock, ?
Joining the meeting tomorrow to participate in the discussions
Mr Peter Deazley, Secondary Care Directorate, DHSSPS
Mr Noel McCann, Director of Performance Management, DHSSPS
Apologies:
Dr Paula Kilbane?? – Dr Anne Wilson ??
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

2. Context NICaN Regional Chemotherapy Workshop Policy Direction
identified the need for a regional review of chemotherapy services
Policy Direction
DHSSPS Cancer Control Programme
DHSSPS Cancer Service Framework Standards
Current Service
Capacity & Demand
Single handed practice
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

3. Regional review Endorsed by NICaN Board
Chemotherapy Service Development Manager appointed Jan 09
Two Strands of work
Baseline current chemotherapy services
Service developments
Baseline assessment
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

4. Regional Chemotherapy Review
To develop a safe, clinical and cost effective, patient centred, integrated chemotherapy service in line with regional policy, patient and carer expectations and best practice
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

5. Key elements of review Identifying safety and quality issues
Appropriateness of treatment location
Current activity levels
Workforce review
Capacity planning tool
Accrual to clinical trials
New models of chemotherapy delivery
Cost benefit analysis
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

6. Baseline assessment process
Stakeholder Engagement Methodology
Consideration given to following Documents during the process (triggered questions)
NCEPOD Self Assessment (complete)
NCAG
Commissioning Guidance for Cancer
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

7. Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

8. Process used What is positive about the chemotherapy service?
What concerns do you have about the chemotherapy service?
What are the issues to be addressed?
Any suggestions for action?
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

9. Positive Feedback Received
No delay in accessing initial treatment
Emerging evidence better patient outcomes
Development of telephone helplines
Increased access to Clinical Trials
Development of Infusional Services at BCH
Community PICC care and maintenance
Electronic Diary for Scheduling
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

10. Positive Feedback Received
Excellent Competent Staff
Staff try provide pt centred service and supportive care
Innovative Posts with positive patient impact
Excellent Clinical Pharmacy Service (Altnagelvin)
Nurse Practitioner role in Enniskillen/Omagh
Oncology / Community Liaison posts (Belfast Trust)
Positive patient feedback received
Cancer Units size enable patients to have a sense of belonging
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

11. Positive Feedback Received
Macmillan Information and Support Centre
Starting to introduce new ways of delivering systemic therapy
Lean Project in BCH – identifying potential for moving in patient to out patient chemotherapy
Health Care at Home
NICaN
Improved multiprofessional team working
Brings key stakeholders together
Reduced working in isolation
Standardised chemo practice + regimes
Managed approach to introduction of new therapies (NICaN D&T)
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

12. Concerns expressed Capacity
Excessive Demand with Centre / capacity
Concerns how deliver expanding chemo service
Inadequate rooms / seating
Inappropriate referral patterns
Unit chemo centre
No Capacity Planning tool
Inappropriate use of beds – In pts not on tx/complications
In Patient Chemo could move to OP but no capacity to do so
Lack of available beds neutropenic sepsis
Centre is location of last resort
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

13. Concerns Expressed Waiting times in the centre / units
Bloods / results
Assessment - scheduling
Treatment - 5am-9pm
Oral Chemo – Haematology
PICC insertion – delay in treatment
Scan results
Poorly defined acute oncology arrangements
Strained relationships between A/E and oncology
Timeliness and location of assessment
Absence of joint protocols
Lack of clarity of roles and responsibilities
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

14. Concerns Expressed Weak system for managing chemotherapy complications
Neutropenic sepsis – recognition / delays in AE
Pathways poorly defined – variation in where pt admitted between centre and units during hours and out of hours
Workforce Issues
Limited oncology cover
Cons workload too high
Lack of succession planning to meet Cons retirement
Shared care arrangements
Unit with very limited medical cover
Lack of knowledge, communication arrangements and feedback loops to oncology
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

15. Concerns Expressed
Lack of robust system/ shared care arrangement for pts with cancer and co morbidities
Orphan patients
Patient expectations
Single Handed Practice
Annual leave lack of cover
New Patients – deferred
Patients travelling long distances
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

16. Concerns Expressed Telephone arrangements
During hours and out of hours
Variation in staff knowledge / competency
Inappropriate advice / protocols
COIS not up to date
Inappropriate use
6 week cut off – nowhere for pts
Unrealistic timeframe 20min callback – 45mins
Staff stressed
Communication delay to consultant / unaware
Unfunded
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

17. Concerns Expressed Information System inadequate - COIS
Not fit for purpose
Break down
Delays
Time consuming
Errors – governance issue
Manual entry blood results
‘Nightmare’
‘IT support is a disgrace’
Lack of systematic information giving and sign posting to other services
’only told by fellow pts’
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

18. Concerns Expressed Treatment Intent not always explained/ understood
Major issue
Unclear / Documentation
‘Olive leaf of chemo’
Patient expectations – unrealistic / manage / relatives
Poor palliative / supportive care arrangements
Grey area - palliative/prognosis guarded
How vigorously pursue potent comp of tx V comfortable
Toxicities
Explanation / long term effects
Need better recording
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

19. Concerns Expressed
Fertility not discussed / given serious consideration
Clinics
Excessive nos attending
Inappropriate appointment scheduling
Bank holidays impact
Variation in nurses being in attendance to enable communication / coordination
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

20. Concerns Expressed Inequity End of txreatment Car Parking
Access to services – MISC / Lymphoedema (extrav)
Lack of choice of treatment day
Nursing time given by nurses
Access to Clinical Trials at Units
End of txreatment
Sense of Abandonment
Ambiguity around shared care – Onc / Surg / GP
Go into “Limbo land”
Lack of Support
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

21. Patient experience feedback
Patient metaphors
Its like being on a conveyor belt
I’m just a number
Its like a cattle market
What’s your number again?
If only they’d tell you what was going on
At end of treatment it feels like the stabilisers are taken off your bike
Going through A/E is a nightmare
It’s the luck of the draw – find things out from other patients
it would be great to have a chemo buddy like in breast cancer, no one seems to encourage it. It’s only when you go through it you know what it’s like
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

22. Summary of emerging issues
Capacity
Workforce
Organisation of Service
Acute Oncology Arrangements
Telephone Helpline
Information System
Wider team unclear re intent of treatment
Survivorship issues
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

23. Working Groups
Capacity Planning Working Group (to identify a capacity planning tool and produce a business case in the first instance)
Models of Chemotherapy Delivery Working Group (to explore and make recommendations for new and innovative approaches to chemotherapy services across NI)
Workforce Development Working Group (to identify skill mix initiatives and training implications in support of a new model of chemotherapy delivery)
Acute Oncology Arrangements Working Group (to develop pathways through A/E , integrated team working, and supportive organisational systems)
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival