1. Mission (Almost) Impossible: Review of Breast Care Services in North Wales Rob Atenstaedt (Local Public Health Director, Conwy & Denbighshire LHBs) – lead Julia Williams (Associate Local Public Health Director, Conwy & Denbighshire LHBs) – support Andrew Jones, Regional Director of Public Health

2. Background
Breast disease is major public health problem as signif cause of ill-health/death
Holcombe & Raynor Report (2007)
Burns Report (2007)
20th March 2008 – Letter from the Minister: “the current breast care service should remain at Llandudno for the foreseeable future whilst further work and advice is provided on a model of breast care services in North Wales”

3. Overall Project
NW Cancer Network requested by Conwy LHB to lead project to develop model for breast care
NPHS asked to provide public health support and to lead on Phases 1 and 2a of project

4. Description
By Whom
By when
Phase 1: Prepare outline paper identifying current workload and anticipated need for breast care services, current services, clinical pathway and potential issues that require analysis
Public health
Cancer Network officers/ Network Board
August 08
Phase 2a: Develop earlier paper to describe model of service in line with the agreed parameters and evidence based best clinical practice
Public health working with cancer network team in liaison with Breast DON which includes patient and public representatives. Members of Conwy CHC will also attend this event.
End of September 08
Phase 2b: Share outcome of phase 1 and 2a with key stakeholders, in particular, Conwy CHC and the Llandudno Hospital Action Group.
Chair & Director of the Cancer Network supported by public health staff.
October 08
Phase 3: Recognising the content of the agreed model prepare a paper that provides options for the service at Llandudno which will include the potential financial implications of the options identified.
Cancer network supported by input from NHS finance and service planners and Public Health.
Nov 08

5. Your mission is:
As a public health consultant to review the current breast care service provided to North Wales residents and identify the option(s) for optimal configuration of breast care services to ensure that patients have the opportunity to access high quality breast care services.
You only have 10 days to do it (one day a week HSCQ time)…
You are a LPHD…
It’s the middle of the summer…
You cannot give to a trainee….

6. DON’T PANIC!

7. What did we do?
1/Pull together a core project team

8. Core Team Small regional core team consisting - Rob Atenstaedt (Lead)
- Julia Williams (Support)
- Andrew Jones (QA)
no central HSCQ domain support available except for QA purposes

9. What did we do?
2/ Pull in external team support from the wider NPHS and beyond

10. Other NPHS Teams involved
LKMS for literature review
HIAT for NHS activity data

11. Wider NHS Involvement WCISU for cancer data
NWCN for current service profiling

12. What did we do?
3/ Set clear objectives

13. Objectives
1/ To determine burden of breast disease in N Wales & need for breast care services
2/ Review current service provided
3/ To determine elements a high quality breast care service should provide & any gaps in current service
4/ To describe options for new service model to facilitate NWCN to address delivery of preferred clinical model

14. What did we do?
4/ Use a clear methodology

15. Methodology
Methodology used was the NPHS methodology for performing service reviews/service modelling available on HSCQ domain website

16. NPHS Methodology Definition and scope of the service review/design
- Purpose of document
- How and why service needs to be reviewed/redesigned
- If concerns about quality or capacity of service, what evidence is there regarding the extent of the issue
Needs assessment
- State whose needs are being addressed
- Outline size i.e. numbers in the population / client group. Include trends and projections
- Outline extent of problems i.e. the “burden of disease”
- Provide comparative data
- Describe gaps in data
- Describe any caveats with data

17. NPHS Methodology Service profile - Structure of service
- Present activity
- Staffing complement and vacancies
Service model/option appraisal
- Describe recommended provision or “best practice”
- Describe shortfall in provision
- Describe implications of any gaps in the provision
- Describe option(s) for a new service model
Conclusion and summary
Recommendations where applicable

18. What did we do?
5/ Be clear on project limitations

19. Limitations Pragmatic approach
Rapid review building on data presented in the previous report into breast surgery
Data limited to 2006
Not possible to carry out a rigorous systematic review or to review all literature in relation to key areas.
For healthcare needs assessment, only epidemiological, rather than corporate and comparative methods, utilised.

20. What did we do?
6/ Be clear on specific roles/responsibilities within project

21. Core Team: Roles/Responsibilities
Rob: needs assessment of breast disease in North Wales and literature review of what constitutes high quality breast care services
Julia: review of current breast care service in North Wales
Rob/Julia: identify gaps in current service
Rob: options for a new breast care service for North Wales residents
Rob: pull report together/ prepare powerpoint
Andrew: QA and exec summary

22. LKMS support Developing a search strategy
Defining and scoping the search questions
Undertaking a series of searches with a high level of specificity
Screening and filtering of results
Providing document delivery of selected articles
Writing up the search methodology
Assisting with citations
Compiling reference list for the final report

23. Questions looked at in the literature review included
What is epidemiology of breast disease (breast cancer and benign breast conditions) ? [1996-]
What are elements of high quality breast care services? [1996-]
What breast care models are currently in operation in the UK/ Europe/ Developed World? [1996-]
To locate general review papers on aetiology, prevention and management of breast diseases [1994-]
Is there evidence that surgery for breast cancer can be done as a day case procedure? [1996-]
Is there any guidance on how the following services should be organised: [1996-]
Oncoplastic breast surgery
Localisation biopsy/guide wire breast excision A

24. HIAT Support Admission rates Rates of bed use Average length of stay
Benign and malignant breast conditions

25. WCISU Support Incidence data Mortality data Survival data
Breast Cancer predictions
Maps and tables

26. North Wales Cancer Network
Help with data gathering and checking of key messages

27. What did we do?
7/ Have a robust QA process

28. QA Process
Consultant/regional director QA – Peter Stevenson/ Andrew Jones
HCW QA – Hugo Van Woerden
Academic QA – Iain Robbé
Comms Team QA – Chris Lines

29. How long did it take?
Rob: needs assessment of breast disease & lit. review of what constitutes high quality breast care services: 30
Julia: review of current breast care service: 10
Rob/Julia: identify gaps in current service: 2
Rob: options for new breast care service: 2
Rob: pulling report together and preparing powerpoint: 5
Andrew: QA and exec summary: 8
LKMS: 16 sessions
HIAT: 2.5 sessions (estimate)
WCISU: 4 sessions
External QA: 5.5 sessions
Meetings: 5 sessions
TOTAL = 90 (conservative estimate)

30. What went well/not so well?
- Project deadline met (just!)
- good response so far to review from stakeholders
- good communication with Breast DON
Not So Well:
-Communication issue with NWCN

31. What are next Steps? Presented findings at: - North Wales Breast DON
- Conwy CHC meeting
Presentation at Llandudno Hospital Action Group 27 October
Continued NPHS support for Phase 3 of overall project

32. What were our recommendations?
1/ Detailed option appraisal for delivery of breast care services based on findings & options identified. Should have regard to appropriate criteria (including specific needs of national breast screening programme delivered by BTW) & wider consideration of general health care services across N Wales. Criteria could include:
- Accessibility
- GP Practice Opinion
- User opinion
- Ease of staffing
- Ease of management
- Capacity
- Quality of environment
- Time to implement

33. What were our recommendations?
2/ As part of process, existing gaps in service provision should be considered including:
a) need for introduction of on-site breast reconstruction / oncoplastic service in N Wales.
b) introduction of ambulatory breast surgery
3/ N Wales health community, with its partners, should seek to:
a) maximise appropriate uptake of screening
b) actively promote prevention of breast cancer by working in collaboration to address lifestyle/ risk behaviour, and tackle inequalities in N Wales