1. The Single Cancer Pathway

2. Background and Case for Change

3. Case for Change (1)
Broadly patient experience of cancer services in Wales is good: 93% of patients rate their care as 7/10 or better (WPES)
But survival compared to other developed countries is poor (ICBP)

4. The consistency of this finding suggests this is less related to use of treatment but the way the system is working (ICBP, Eurocare, Concorde)
Five year relative survival rate comparisons for Wales
5-year-age-standardised relative survival for adult patients with cancer, diagnosed
De Angelis R, Sant M, Coleman MP, et al. Cancer survival in Europe 1999–2007 by country and age: results of EUROCARE-5
— a population-based study. The Lancet Oncology 2013

5. International Cancer Benchmarking Partnership
Module 1: Inferior survival likely related in part to late stage presentation (1 year survival surrogate for stage at presentation)

6. International Cancer Benchmarking Partnership
Module 3: GPs in Wales less likely to refer and/or investigate for a given set of signs and symptoms
This correlated with worse survival

7. International Cancer Benchmarking Partnership
Module 4: After presentation patients in Wales spend longer in healthcare system before starting treatment than other countries/jurisdictions

8. State of Diagnostic Services in Wales
9-10% increase in CT, MR, Endoscopy year on year
10-50% posts vacant in Wales, all HBs outsourcing
30% of workforce could retire in next 5 years
>50% current workforce >10 (many >12), unable to attract trainees,
<50% primary care timely direct access to NICE recommended diagnostics
7 radiologists per 100, 000 compared to European average 12.7
7 CT scanners per million, compared with 35 in Denmark
Situation similar or worse across primary care and pathology

10. 30 8 14 18 4
Getting patients through to earlier diagnosis and timely access to treatment
Gareth Davies leading an ambitious improvement programme

11. Case of Mr Jones 72 year old previously fit male t0 PS 0 DG 1 72Kg
Noticed food sticking in October 17, saw GP, prescribed PPI
Rapid access OGD Jan, malignant stricture lower oesophagus t90 PS 1 DG2 68Kg
Referred to Upper GI team (nUSC), seen within 2 weeks
CT scan and local MDT 2 weeks
EUS (Carmarthen) and PET 3 weeks
CPEX in further 2 weeks
MDT 10 days after PET, T4N1M0 cancer, refer to oncology
Seen within 2 weeks, unable to swallow, referred for a stent t120 PS 2 DG 3 64Kg

13. USC 62 day performance (%) against target in Wales over last 5 years
nUSC 31 day performance (%) against target in Wales over last 5 years

14. Variation in the System

15. Conversion rates for all cancers by HB in 2017
Detection rates for all cancers by HB in 2017

16. Conversion rates for all UGI cancers by HB in 2017
Detection rates for all UGI cancers by HB in 2017

17. USC conversion rates by cancer site in 2017
Detection rates by cancer site in 2017

18. The Single Cancer Pathway

19. (in Wales but similar to England)
Cancer Waiting Times
(in Wales but similar to England)
62 day pathway for Urgent Suspected Cancer (USC) primary care referrals from receipt of referral
Performance Wales ~ 85-90%
31 day pathway for non USC from point patient agrees treatment plan
Performance Wales ~ 95-98%

20. ~35-45% of cancers diagnosed via USC pathway
USC Pathway – 62 day pathway
Day 0
Day 62
Point of Suspicion (PoS)
Referral
Diagnosis
Date of Decision to Treat
Treatment
Time NOT currently captured by CWT
~35-45% of cancers diagnosed via USC pathway
Time in system NOT currently captured by CWT
~55-65% of cancers identified via
non-USC pathway
- These waits will be exposed under the proposed SCP reporting
Key:
Non-USC Pathway – 31 day pathway

21. Cancer Waiting Times (in Wales but similar to England)
Average 70
Median 65
95th Percentile
114.8
The majority (~55-65%) of cancer patients are diagnosed via the nUSC pathway
Approximately 50% of patients on complex pathways wait > 62 days on nUSC pathway from point of suspicion
This reporting of this CWT
does not reflect patient experience,
does not reflect diagnostic capacity challenges and
does not drive pathway improvement
Waiting times for UGI patients from Point of Suspicion i.e. OGD

22. USC CWT performance by HB & Cancer Site Sept – Dec 17

23. Numbers of Total USC referrals in Wales

24. USC Referrals UGI numbers 2013-17 USC numbers treated UGI within time per quarter Sept – Dec 17

25. USC Referrals numbers 2013-17 UGI & LGI

26. Ministerial and CIG response
Pressure on system to comply with current CWT targets
2015 asked for clinical review of CWT targets
Clinical view
Waiting times important for patients and clinicians
System should work better and 62 days max time
Not in favour of exclusions
2016/17 WG/Network response
Pilot new suspected cancer (SC) pathway starting at PoS (where nec as defined by NG12)
Pilot suggested 20% increased demand in diagnostics but requirement for improved pathways and not including required increase for NG12
Autumn 2017
Cabinet secretary indicated support for move to SCP
Urged NHS Wales to prepare to be compliant with a 62 day SCP target

27. Summary THE RIGHT THING TO DO
Patients have relatively poor survival in Wales with stage at diagnosis a key factor in this
Patients are waiting too long in the healthcare system before receiving treatment
The current system of CWT reports contains hidden waits, does not reflect patient experience, does not report inadequate diagnostic and treatment capacity and does not drive improvement
CEOs, Chairs, CIG, CSG, WCN, HB/Trusts agree:
A single suspected cancer pathway that reports waiting times for all patients from the point of suspicion is…..
THE RIGHT THING TO DO
The benefits should lead to better patient outcomes (survival, experience), better patient support and less costly treatment
No one underestimates the challenge but we must work together, share best practice and be open to change

28. Achievements to Date Briefing document for Cab Sec and CEOs
Suite of best practice
Peer review of HB SCP Plans
8 site specific optimum pathways
Received and reviewed HB Implementation Plans
Worked with NWIS to define PoS, impact assessment for DSCN
Worked with DU to determine capacity and demand model
Worked with 1000 lines re improvement approach and 5 workshops
Meetings with Cab Sec and WG

29. Plans Meeting with CEOs, Chairs and Cab Sec Oct 22nd
Submit advice re requirement for increased funding for diagnostics and national SCP Programme
HB to use C&D to inform IMTPs (meet current gap and forecast demand) Q4 2018
Implement new Tracker 7 and embed in HB PAS systems by May 2019
Likely to publish SCP performance from April/May 2019
Continuous improvement work in 2019 ?95% compliance by April 2020

30. SCP Performance

31. SCP Upper GI overall monthly average Apr 17-Dec 17 by HB
70%

32. SCP Lower GI overall monthly average Apr 17-Dec 17 by HB
69%
65%
58%
59%
55%
54%

33. SCP Urology overall monthly average Apr 17-Dec 17 - by HB

34. SCP Lung overall monthly average Apr 17-Dec 17 by HB
75%
74%
70%
71%
71%
59%

35. SCP Gynaecology overall monthly average Apr 17- Dec 17 by HB
70%
57%
54%
50%
50%
24%

36. SCP Head & Neck overall monthly average Apr 17-Dec 17 by HB
76%
63%
57%
57%
54%
45%

37. SCP Breast overall monthly average Apr 17-Dec 17
96%
94%
87%
86%
72%

38. New rules…..

39. How do we do this ? Best Practice Principles
Implementing enabling systems and infrastructure
Point of suspicion
Tracking
Information and Intelligence
Capacity and Demand
Pathway Improvement
Standardising and improving the whole patient pathway
Referral/Primary Care
PoS to Last Diagnostic <28days
DDT to Treatment < 21 days
Clinical Engagement
Patient Centred Care

40. Work streams Information and Intelligence Capacity & Demand
Diagnostic Pathway
Capacity & Demand
Communication
Primary Care
CSG’s and Clinical Engagement
Treatment Pathway
Improvement
Patient Centred Care

41. Priorities
To understand the additional capacity required for the NHS to be able to treat all patients from the PoS within 62 days
or 95% of patients to be diagnosed and staged < 28 days and treated < 21 days from decision to treat
To understand where capacity required eg OPA, imaging, endoscopy, treatment
Understand whether increased capacity due to rising referrals, improved USC performance or accelerated nUSC pathway
To standardise pathways across Wales consistently using best practice principles such as use of NG12 and entry points into system eg straight to test

42. Priorities
To establish informatics systems to link with HB PAS systems that can receive e-referrals, can be easily started on clinical suspicion of cancer, can make system aware patient on accelerated pathway, track patient and record component and total waiting times
To understand better where support systems should be introduced eg patient information, prehabilitation, holistic needs support and research
To undertake a set of improvement workshops within HBs and across boundaries in Cancer Site Groups to reduce delays due to decision making in MDTs or weekly clinics or introduce accelerated steps such as ‘same day/next day to CT’ from endoscopy or CXR

43. Priorities
To establish a set of local and National reports that highlight variation between HBs and Cancer Sites and specific pathway steps, to understand the causes of this variation and share best practice across Wales
To compare and contrast HB SCP Delivery Plans to help a local and National understanding of what required to achieve compliance with an SCP (assuming 95% compliance with 62 day target)

46. Summary THE RIGHT THING TO DO!
Patients have relatively poor survival in Wales with stage at diagnosis a key factor in this
Patients are waiting too long in the healthcare system before receiving treatment
The current system of CWT reports contains hidden waits, does not reflect patient experience, does not report inadequate diagnostic and treatment capacity and does not drive improvement
CEOs, Chairs, CIG, CSG, WCN, HB/Trusts agree:
A single suspected cancer pathway that reports waiting times for all patients from the point of suspicion is…..
THE RIGHT THING TO DO!

47. Summary
The benefits should lead to better patient outcomes (survival, experience), better patient support and less costly treatment
Benefits beyond accelerated pathway, more structured and standardised pathways allow for better information and holistic support, access to research and capacity/demand modelling
No one underestimates the challenge but NHS Wales, WG, 3rd sector and cancer services stakeholders are working together, sharing best practice and are open to change