1. Workforce Development Regional Chemotherapy Service Review
29th September 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. Background Increasing demand, scarce resource, service pressure
Baseline Assessment April - Aug 2009
Stakeholder interviews n=430
Positive, concerns, issues
4 working groups established
New Models of Chemo Delivery
Workforce Development*
Capacity Planning
Acute Oncology Services
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

3. Issues of relevance to this group
Baseline Assessment
Issues of relevance to this group
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 ??

4. Components of chemo service
Service configuration
Workforce configuration
Leadership arrangement
Governance arrangements
Data and information technology
Effective communication systems & processes
Commissioning arrangement
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

5. Current Organisational Model
Hub and spoke model
Centre based site specific oncologists visit units weekly
Registrars travel out to units to support clinics
Variation in staff grade support at units
Resident hematologists at centre and units
Common cancers treated at units
Centre acts as unit for local catchment area plus regional service for complex cancers
Appointments governed by cancer centre
Notes leave CC and immediately returned
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

6. ? 5 locations: Chemo assessment clinics Chemotherapy administration
Review clinics
Chemotherapy preparation and dispensing suite (pharmacy)
Chemo Comp Nurses
5 locations: ?
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

7. Workforce Medical Nursing Pharmacy
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

8. Consultant Workforce Clinical Onc (wte) Medical Onc (wte) 17.5 5.9
Cons Workforce
17.5
5.9
Population per WTE Cons
100,000
305,000
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

9. Population per WTE Cons
Consultant Workforce
NI – 2009
Population per WTE Cons
Scotland – 2008
Clinical Oncologist
100 78
Medical Oncologist
305
155
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

10. Single Handed Practice
‘Where one Consultant is timetabled to attend a particular clinic in the Cancer Unit or where one Consultant has sole expertise in the treatment of a particular tumour site in the Cancer Centre.’
Not sustainable for individuals
Poor attendance at MDMs
Delays in assessment and treatment
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

11. New Patient Attendances
Northern
Southern
S. Eastern
Western
Belfast
05 / 06
549
578
438
502
1663
06 / 07
488
592
391
516
1929
07 / 08
543
676
435
545
1782
Growth in 12mths
11.3%
14.2%
5.6%
-7.6%
New patient attendances increasing across all 4 Units with largest increase in Southern Trust
Decrease in new patient attendances in Cancer Centre consistent with no change in number of chemotherapy day case treatments
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

12. Review Attendances
Northern
Southern
S. Eastern
Western
Belfast
05 / 06
5443
4892
4095
4537
9789
06 / 07
5558
5017
4550
4787
11050
07 / 08
5825
5640
4711
5116
11726
Growth in 12mths
4.8%
12.4%
3.5%
6.9%
6.1%
New : Rev Ratio
1:11
1:8
1:9
1:7
Review numbers increasing across all 4 Units with the largest increase again in the Southern Trust
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

13. Chemotherapy Day Cases
Northern
Southern
S. Eastern
Western
Belfast
05 / 06
1346
1918
2105
1674
6704
06 / 07
1484
2001
1940
1890
6972
07 / 08
1510
2089
2412
2123
7003
Growth in 12mths
1.7%
4.4%
24.3%
12.3%
0.4%
Increases across all 4 Units with the largest increase in S EHST
Minimal increase at the Cancer Centre
In 2007/08 the Health Board of residence of patients attending the Cancer Centre were:
EHSSB – 63%, NHSSB – 20%, SHSSB – 12% and WHSSB – 5%
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

14. Oncology Unplanned Admissions
Northern
Southern
S. Eastern
Western
Belfast
05 / 06 54
No data
166
06 / 07 36
No date 47
253
07 / 08 23 60
410
Growth in 12mths
-36%
28%
62%
Unit data re unplanned admissions is acknowledged to be incomplete
Large increases with the exception of the Northern Trust
Downturn in Northern Trust inconsistent with increases in new/review patient numbers. Is there any link with higher than expected % of unplanned admissions from NHSSB to the Cancer Centre?
2007/08 Health Board of residence of unplanned admissions to Belfast:
EHSSB – 70%, NHSSB – 24%, SHSSB – 5.5% and WHSSB – 0.5%
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

15. Onc Unplanned Admissions
Activity Changes : 2006/07 – 2007/08
Northern
Southern
S. Eastern
Western
Belfast
New Attendances
+11.3%
+14.2%
+5.6%
-7.6%
Reviews
+4.8%
+12.4%
+3.5%
+6.9%
+6.1%
Chemo DC
+1.7%
+4.4%
+24.3%
+12.3%
+0.4%
Onc Unplanned Admissions
-36.1%
No Data
+28%
+62%
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

16. Chemotherapy Care Pathway
Access & referral
Delivery & treatment environment
Pt / carer information, education
Assessment decision to treat, pt consent
Prescribing, dispensing
Urgent assessment, management of complications
End of treatment record and care plan

17. Positive feedback
Staff highly praised, committed, skilled, knowledgeable, professional, friendly
No delay in starting chemotherapy
Cancer Units size enables patients to have a sense of belonging
Insertion of CVAD in centre and units and maintenance support in community
Helplines are valued
Clinical trials network developing
NICaN has enabled MDT, standardisation etc
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

18. Positive Feedback Where available Clinical Pharmacy at chemo unit
Nurses providing support and continuity by being present with patients during clinics
Healthcare at Home very highly praised
Hospital community liaison posts
Oncology nurse practitioner review
Macmillan Support and Information Centre
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

19. Chemotherapy Care Pathway
Access & referral
Delivery & treatment environment
Pt / carer information, education
Assessment decision to treat, pt consent
Prescribing, dispensing
Urgent assessment, management of complications
End of treatment record and care plan

20. Chemotherapy Care Pathway
Access & referral
Delivery & treatment environment
Pt / carer information, education
Assessment decision to treat, pt consent
Prescribing, dispensing
Urgent assessment, management of complications
End of treatment record and care plan
Assessment process inadequate (issues skimmed over eg fertility)
Variation in assessment process (pre assessment bloods, some nurse led, some telephone assessment)
Variation in assessing performance status
Lack standardized toxicity grading tool
Who can assess?
How can the assessment be more holistic?

21. Chemotherapy Care Pathway
Access & referral
Delivery & treatment environment
Pt / carer information, education
Assessment decision to treat, pt consent
Prescribing, dispensing
Urgent assessment, management of complications
End of treatment record and care plan
Patients waiting around IV chemo to come out from pharmacy
Patients waiting long times for oral chemotherapy and scripts
What needs to happen to enable pharmacy to maintain their high quality service but be more responsive to the needs of patients?
What roles could pharmacy staff potentially fulfil to meet service and patient need?

22. Chemotherapy Care Pathway
Access & referral
Delivery & treatment environment
Pt / carer information, education
Assessment decision to treat, pt consent
Prescribing, dispensing
Urgent assessment, management of complications
End of treatment record and care plan
Visiting Consultants, difficult to contact, no continuity, single handed practice, no cover for AL. Inability to see patients in wards – delayed discharges, reduces availability of clinical trials. Arriving late for clinics
Overcrowded Clinics, inadequate medical cover, poor pre planning during some, Poor scheduling , peaks and troughs, not utilizing the week
Inadequate capacity – patients see the pressure
Medical cover: Lack of robust system during chemo administration
Patient Experience: Excessive travel for patients, long delays awaiting treatment, Feel like a number, conveyor belt, dehumanising, gold fish bowl, Pre assessment bloods rarely done at cancer centre, poor continuity, repetitious for patients, difficult developing relationships
Environment poor in some units – cold, limited chairs, uncomfortable seating, too many relatives, Lack rooms/space for assessing and treating, Limited facilities Privacy / finances / social workers / bad news/ Tea
Continued……

23. Chemotherapy Care Pathway
Access & referral
Delivery & treatment environment
Pt / carer information, education
Assessment decision to treat, pt consent
Prescribing, dispensing
Urgent assessment, management of complications
End of treatment record and care plan
Inappropriate treatment location – historical referral patterns
Knock on effect of lack of beds means day unit staff held back from chemo administration: Ill patients in inappropriate environments
Inequities exist: HCAH and confusion re their role
Inequitable issues re PICC service – different competence levels of nurse inserted (ie learners)
Inadequate Hickman service both for insertion and removal
What type of service model needs to be developed to make best use of the multiprofessional workforce and to improve the patient experience?
How can we make more effective use of scarce resources?

24. Chemotherapy Care Pathway
Access & referral
Delivery & treatment environment
Pt / carer information, education
Assessment decision to treat, pt consent
Prescribing, dispensing
Urgent assessment, management of complications
End of treatment record and care plan
Information
Not volunteered patient have to seek v overloaded with information, sometimes given with no explanation, no time to assimilate at 1st treatment
No information re PICC being available
Not kept informed re process / delays / able to leave unit
Given information re treatment, but not re support available: finance, support groups, social worker etc
Staff too busy, maybe 40 patients waiting, hinders asking questions
Telephone helpline, variation in competence particularly out of hours, stressful, inappropriate advice use of SHO instead of reg, inappropriate use by patients, slow feedback process to consultant

25. Chemotherapy Care Pathway
Access & referral
Delivery & treatment environment
Pt / carer information, education
Assessment decision to treat, pt consent
Prescribing, dispensing
Urgent assessment, management of complications
End of treatment record and care plan
Relatives: Accompanying relative not invited into consultation; Limited inclusion of patients relatives to participate in supporting care at home
Oral chemo: Older people living alone given tablets – no thought given to social conditions / suitability
No appreciation of the need for a chemo buddy
Limited ability to exercise choice – scalp cooling, where to get treatment
Inequitable system re car parking exemption (free in units) Complicated system in BCH
Inequitable access to complimentary therapy services – its reactive rather than proactive
Limited accessibility to specialist palliative care services
How can the workforce be configured and developed to best meet patient information need?

26. Chemotherapy Care Pathway
Access & referral
Delivery & treatment environment
Pt / carer information, education
Assessment decision to treat, pt consent
Prescribing, dispensing
Urgent assessment, management of complications
End of treatment record and care plan
Patients sent to AE, not right, but where to send them? Inappropriate environment, waiting hours beside drunks
A/E staff not expert in oncology issues – inappropriately investigated or treated – no updates or information sharing
Cancer centre only for treatment – where should others go – orphan patients - Nobody wants to “own” cancer patients who go through A/E (AE can’t close its doors)
Admitted to wards with infections, junior staff with no oncology expertise
Strained professional relationships, AE only get negative feedback and complaints. All patients through AE are priorities not just oncology,
Poor communication – helpline raise expectations
Lack of agreed coherent pathways, team work, systems
NCAG Recommendation: Commissioners and providers should work together to develop acute oncology teams and services in all hospitals with A&E departments Acute Oncology Services Group

27. Chemotherapy Care Pathway
Access & referral
Delivery & treatment environment
Pt / carer information, education
Assessment decision to treat, pt consent
Prescribing, dispensing
Urgent assessment, management of complications
End of treatment record and care plan
“Post treatment drop off”:
Left on own, don’t hear about survivors, all these people then nobody
The after is the hardest, didn’t realize the mental state I would be in
Difficult to know who is in charge of long term – surgeon or oncologist? Post chemo conflicting information, who owns me. Feel in limbo – very scary time, No mention of support services, post chemo support mechanism is nil
Oncologist gives you the impression they want you alive in 10 years but forget about the side effects in 15
End of treatment, I fell of the end of the conveyor belt – when do I go back to work etc
Chemo review – why bother, “your bloods are ok – its not an assessment of me” Saw SHO he didn’t know me, prefer to see breast care nurse
What needs to happen at the end of treatment and what models of review would best support patients?

28. Chemotherapy Care Pathway
Access & referral
Delivery & treatment environment
Pt / carer information, education
Assessment decision to treat, pt consent
Prescribing, dispensing
Urgent assessment, management of complications
End of treatment record and care plan
Infrastructure
Workforce & training
Leadership & teamwork
Clinical Governance
Data, IT, information flows
Effective Commissioning

29. Workforce and Training
Little interaction between onc / haem and GPs
Lack of understanding round scope of roles
Staff frustration as unable to utilise skills
Staff feel under pressure and unable to deliver quality care
Still need to implement guidelines re post treatment complications (GP)
GPs don’t have enough knowledge /experience to help (Pt)
Dr was young and experienced, told me different to consultant
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

30. Workforce and Training
Inadequate supervision while training
Telephone helpline - triage nurse part of chemo team / OOHs telephone helpline competency
Review patients - duplication of roles / ? most appropriate person assessing
Gaps in specialist roles
Need more PICC training
Unpredictability of clinics
No structured method of booking concurrent chemo/xrt
Differences in Onc/Haem – adhoc practice creates difficulties for pharmacy in prioritising treatments
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

31. Chemotherapy Care Pathway
Assessment
decision to
treat consent
Prescribing
and dispensing
Delivery and
Treatment
Environment
Urgent assess
Management
complications
End of Treatment
record care
plan
Pt carer information
What are the needs of patients across the pathway?
What are the knowledge skills and competencies required across the chemotherapy pathway?
What should the workforce profile be like in line with modernisation agenda?
Medical
Nursing
Pharmacy
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

32. Commissioners will want to be assured that:
Patients who might benefit from chemo are able to access quality services
Treatments which are delivered are appropriate to a patients condition
Services are delivered safely
Services are convenient for patients
Patient experience is good
Services represent good value for money
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival