1. NI Chemotherapy Service
Safety and Quality in
NI Chemotherapy Service
Regional Review and NCEPOD
29th June 2009
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 ??

2. Aims of presentation
To present initial findings from the Regional Chemotherapy Review baseline assessment and NCEPOD self assessment
To raise awareness of quality issues and major risks in the system and consider necessary leadership responses
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

3. Background Decentralisation of chemo 1998
Safe guards, systems and processes
RPA Loss of organisational memory
Variations in practice
Increasing workload
New therapies and technologies
Patient expectations
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

4. Drivers for change NICaN Chemotherapy Group DHSSPS
Patient and professional feedback and audit
Need for review and reform of services identified
DHSSPS
Cancer Control Programme
DHSSPS Cancer Service Framework Standards
Recent National Reports
NCEPOD (2008)
National Chemotherapy Advisory Group (NCAG)
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

5. 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

6. Regional Chemotherapy Review
The aim is 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

7. 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

8. Mandate & Process
Limited capacity to meet exponential demand – Cancer Reform Strategy
Meet provider and commissioner needs
Project endorsed by NICaN Board
Macmillan funded project manager appointed Jan 09
Steering group established*
Baseline assessment underway
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

9. Baseline assessment process
NCEPOD Self Assessment (complete)
Stakeholder engagement (Until end of July)
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

10. Patient experience feedback
Patient metaphors
Its like being on a conveyor belt
I’m just a number
Its like a cattle market
At end of treatment it feels like the bike stabilisers are removed and you’re pushed off
Going through A/E is a nightmare
Lack of systematic information giving and sign posting to other services
It’s the luck of the draw – find things out from other patients
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

11. Different groups of patients
Patients with chemotherapy complications
Patients who have received chemotherapy but have other apparently unrelated health issues
Patients with cancer who previously had chemotherapy / radiotherapy who have comorbidites
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

12. NI Risk Management Issues
Poorly defined acute oncology arrangements *
Timeliness and location of assessment
Absence of joint protocols
Lack of clarity of roles and responsibilities
Strained relationships between A/E and oncology
Weak system for managing chemotherapy complications
Reported Adverse Incidents – learning?
Neutropenic sepsis – recognition of and delays in AE
Pathways poorly defined – variation in where pt admitted between centre and units during hours and out of hours
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

13. Acute Oncology Defined
Involves clinicians working in AE, acute medicine as well as oncology and related disciplines
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

14. NI Risk Management Issues
Workforce issues
Limited oncology cover
Lack of shared care arrangements
Unit with very limited medical cover
Lack of Knowledge, communication arrangements and feedback loops to oncology
Lack of robust system/ shared care arrangement for patients with cancer and co morbidities
Orphan patients
Patient expectations
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

15. NI Risk Management issues:
Telephone arrangements
During hours and out of hours
Variation in staff knowledge, advice and protocols
Prescriber competencies
Lacks formal process
Audit
Ad hoc and limited
Morbidity and mortality
No formal or systematic mechanism to discuss
Information System inadequate
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

16. Cancer Reform Concerns (Prof. M Richards)
NPSA rapid response alert on oral chemotherapy
3 deaths, 400 incidents over 4 yrs (England)
Cancer Peer Review
Concerns regarding leadership for emergency arrangements and standards of safety
NCEPOD report
Need to get basics right, consent, performance status, investigations, recording of toxicities, prescribing
Need to focus on management of complications
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

17. What needs to be done?
Draw on recommendations contained in NCEPOD and NCAG
Strategic ownership and steer
Trusts understanding and prioritisation of integrated response
Knowledge of and support for work-strands underway
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

18. National Chemo Advisory Group
Focus on safety and quality (aligned with NCEPOD)
Highlights need to improve both elective chemotherapy services and acute oncology services
Involves A&E and acute medicine as well as oncology
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

19. NCAG: Acute Oncology
All hospitals with an A&E should establish an ‘acute oncology service’
Local policies and procedures (agreed with the network)
Training of junior doctors and other staff
24 hour access to specialist oncological advice
Routine audit of emergency admissions with cancer
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

20. NCAG: areas of focus Assessment, decision to treat and consent
Prescribing and dispensing
Delivery (CPORT)
Information, Education, Support and Advice
Helpline 24 and appropriate access to emergency care
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

21. NCAG areas of focus Urgent assessment of chemotherapy complications
Know which hospital to go to
Out of hours arrangements
Clear policies agreed across network
24 advice from oncologist
If admitted to hospital acute oncology team informed within 24hours
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

22. NCAG areas of focus Knowledge and recording of toxicity
End of treatment record
Subsequent care plan drawn up and communicated to relevant health care professionals
Models of service delivery
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

23. Collaboration needed NICaN Chemotherapy Network Work Program
Policies, guidance, telephone standards, clinical management guidelines, training packages
Chemotherapy Service Review Steering Group
Synthesis of issues, capacity planning tool, new models of review, recommendations, inform commissioning
HSCT Trusts
Robust chemotherapy risk management arrangements required
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

24. In particular - Acute Oncology
All hospitals with an A&E should establish an ‘acute oncology service’
Local policies and procedures (agreed with the network)
Training of junior doctors and other staff
24 hour access to specialist oncological advice
Routine audit of emergency admissions with cancer
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

25. Relevance to HSC Trusts
Medical Directors influence within Trusts and strategically
Development of acute oncology teams and protocols
Supportive infrastructure (eg rapid turn around bloods etc)
Audit agenda – challenge of morbidity/mortality
Medical training
Future A&E arrangements / location of assessment
Systems for communication and feedback for patients and professionals
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival