1. Pan-Birmingham Cancer Network NCAT Commissioning Exemplar Breast Cancer Surgery 4 th November 2010

2. Approach Initial scoping was cross-referenced to established guidelines (NICE, NSSG, Map of Medicine) Taken the PbR datasets that are already readily available to NHS Commissioners Analysed and tested outputs with clinicians in the know Refined the data and information and retested with clinicians – Key Issues emerged Production of a Commissioner’s Guidance Note Aim is to inform the discussions between commissioners and hospital providers

3. Project Phases Phase 1 - Project Scoping (Established guidelines and listening to clinicians) Phase 2 – Data Crunch 1 & Clinical Networking to Identify the Issues Phase 3 – Data Crunch 2 & Addressing the Issues Phase 4 – Expanding the Scope – The Wider Clinical Pathway Phase 5 – Bringing it all Together

4. ICD-10 Diagnosis Codes C50 – Breast Neoplasms D05 – Ductal Carcinoma in Situ (DCIS) 2008/09 Dataset Apr 08Apr 09 2009/10 Dataset Apr 10 Dec 09 9 mths Mastectomy / BCS casesFurther Ops in next12 mths The PbR Data-Set 849 ~ £2m214 ~ £430k An extended dataset for the 21-month period April 2008 to December 2009 was used to identify 849 patients who had either a mastectomy or breast conserving surgery in the 9-month period April to December 2008. It was then possible to undertake a detailed analysis of the 214 follow-up operations needed by the cohort during the course of the following year.

5. Key Issues that Emerged Ratio of Mastectomies.v. BCS Rate of Sentinal Node Biopsy Conversion of SNB to Full Axillary Clearance The need for further surgery after BCS Cases planned and achieved as 23hr/daycase Reconstruction Consultant Caseload

6. Presenting a Data Summary Dashboard Created

7. A Separate Dashboard for each of the main pan-Birmingham Hospitals

8. Proportion of patients requiring only a single operation Conserving the Axillary Lymph Node Tissue Ratio of Mastectomies to Breast Conserving Surgery The Need for Additional SurgerySimultaneous Reconstruction Payment by Results Tariff Details ££ Conserving Breast Tissue Number of Initial BCS & Mastectomies

9. Delving Deeper into the Data to Address the Key Issues

13. Can anything be done to reduce the number of second operations

14. Sentinel Node Biopsy Breast Conserving Surgery + Sentinel Node Biopsy HRG JA07 a,b or c PbR £2,053 to £2,764 Axillary Clearance HRG JA06 PbR £2,760 Histology Breast Conserving Surgery + Sentinel Node Biopsy Histology in Theatre and proceed to Axillary Clearance if needed HRG JA06 / JA07 a,b or c PbR £2,053 to £2,764 £4,813 to £5,524£2,053 to 2,764 List planning / Theatre Time / Equipment £400/case extra

15. Sentinel Node Biopsy Total Ops Apr'08 to Dec'08 Partial Mastectomy Axilla NILSampleSNBClearance Ops% % % % 124HEFT2520%22%6653%3125% 160 SWBH 3824%43% 98 67%2013% 109UHB2725%11%5447%2725% 70Walsall1014%4361%1521%23% 23Other Hospitals417%4 1048%522% 486All Hospitals10421%5411%24349%8517% £ PbRExpenditure Axilla NILSampleSNBClearance £ total £ average£ total £ average£ total £ average£ total £ average £223,772HEFT£42,611£1,686£3,512£1,756 £122,00 5 £1,848£55,644£1,798 £291,416SWBH£65,870£1,733£6,794£1,699 £179,94 0£1,836£38,812£1,941 £201,971UHB£50,522£1,829£1,907 £100,77 1£1,866£48,771£1,824 £123,708Walsall£15,034£1,503£78,377£1,823£26,634£1,776£3,663£1,857 £43,665Other Hospitals£7,024£1,781£9,999£2,500£17,862£1,489£8,780£1,463 £884,532All Hospitals £181,06 1£1,725 £100,58 9£1,863 £447,21 2£1,825 £155,67 0£1,818 Using the Data to Quantify the Key Issues

16. SNB to Full Ax Clearance Total Ax Clearances % of snb SNB converting to Axillary Clearance at Time of Further Mastectomy NonePartialFull Ops% % % 46%HEFT 250%2 17 17% SWBH 9 53% 3 18% 5 29% 611%UHB350%3 17%Walsall 1100% 330%Other Hospitals133% 267% 3113%All Hospitals1342%826%1032% £Expenditure at Time of Further Mastectomy NonePartialFull £ total £ average£ total £ average£ total £ average £10,330HEFT £4,456£2,228£5,874£2,937 £42,920SWBH£22,364£2,485£7,081£2,360£13,473£2,695 £15,037UHB£7,647£2,549£7,390£2,463 £2,937Walsall £2,937 £9,903Other Hospitals£2,549 £7,354£3,677 £81,127All Hospitals£32,560£2,505£18,927£2,366£29,638£2,964

17. Sentinel Node Biopsy Breast Conserving Surgery + Sentinel Node Biopsy HRG JA07 a, b or c PbR £2,053 to £2,764 Axillary Clearance HRG JA06 PbR £2,760 Histology Breast Conserving Surgery + Sentinel Node Biopsy Histology in Theatre and proceed to Axillary Clearance if needed HRG JA06 PbR £2,760 £4,813 to £5,524£2,760 List plannning £400/case extra City Hosp x £400 = £39,200 City Hosp x £2,760 = £46,920 98 17

18. Sentinel Node Biopsy Breast Conserving Surgery + Sentinel Node Biopsy HRG JA07 a, b or c PbR £2,053 to £2,764 Axillary Clearance HRG JA06 PbR £2,760 Histology Breast Conserving Surgery + Sentinel Node Biopsy Histology in Theatre and proceed to Axillary Clearance if needed HRG JA06 PbR £2,760 £4,813 to £5,524£2,760 List plannning £400/case extra City Hosp 98 x £400 = £39,200 City Hosp 17 x £2,760 = £46,920 Invest £39,200 to Save £46,920 Only 1 operation for patient instead of 2 Should we be petitioning for Best Practice Tariff ? CQUIN ? Commissioners and Providers now have something to talk about that is evidence based Leverage for Better Care