Transcript Slide 1

NHS Yorkshire & the Humber
Monthly QIPP Resource Pack
September 2010
1
Introduction
This is the ninth QIPP monthly resource pack. The pack has three components:
BETTER FOR LESS EXAMPLES: We have worked with you to develop practical examples of schemes
which have been developed locally and have potential to deliver better quality at lower cost. This
month the ‘better for less’ examples focus on cancer services.
CANCER ‘HOT TOPIC’: Each month we will produce one ‘hot topic’ briefing which provides more
detailed analysis on a subject relevant to QIPP. This month the hot topic is cancer. The analyses
presented here are designed to offer insight and raise questions about variation in performance.
They need to be interpreted in the local context.
QIPP METRICS: We have developed a set of metrics to help understand system health in the tighter
financial climate. We will publish these metrics monthly although some of the indicators will only be
updated quarterly. The purpose is to offer insight and improve understanding of how the system
delivering with lower growth.
The next resource pack will be published week commencing 11th October. The hot topic will be
children’s services. If you have any questions or comments on the pack, please contact Ian Holmes.
([email protected])
2
1) Healthy Ambitions: Better for Less
3
Better for less - New models of care for breast cancer patients
Why new models of care for breast
cancer patients?
There are an estimated 34,000
women in Yorkshire & the Humber
who have survived a breast cancer
diagnosis. Due to improving care and
the ageing population, this number
will increase over time, putting
additional pressure on resources for
follow-up care.
There is currently variation in the
management of follow-up care for
patients.
How can we provide Better for Less?
The provision of a patient-led, selfmanaged follow up programme for
breast cancer survivors empowers
patients through the self management
of their condition.
Better for less – New models of care
Implementing new follow-up models of care for
breast cancer removes variation in the service
across providers, empowers patients and
generates efficiency improvements for the system.
Better for less - New models of care for breast cancer patients
Patient benefits
Where people are well supported
the number who can return to
work is increased, leading to a
positive impact on self-esteem,
finances and contribution to
society.
Reductions in emergency and
unplanned admissions are evident
in areas where care is coordinated and patients are
encouraged to self-manage.
Financial benefits
The average savings to PCTs in
Yorkshire & the Humber over a 5
year time period are estimated to
be around £175,000 per PCT. This
figure only accounts for savings as
a result of reducing outpatient
appointments.
The National Cancer Survivorship
Initiative (NCSI) are further
exploring the evidence (and
potential cost savings) through
reduced unplanned and emergency
admissions as a result of self
management.
Better for less – New models of care
The approach also improves
efficiency in the system and helps
to prevent unnecessary hospital
attendances.
Better for less - New models of care for breast cancer patients
The result is a patient led, selfmanaged follow-up programme where
scheduled follow-up visits were
reduced from anywhere between five
and 12 to just three. Efficiency has
been increased through streamlining
appointments to coincide with
mammographic screening and
endocrine decision-making
appointments.
For further information:
Sheryl Warttig
Cancer Service Improvement Manager,
North Trent Cancer Network
[email protected]
Better for less – New models of care
Case study: North Trent Cancer
Network
Breast teams across North Trent
Cancer Network developed a new
follow up model for their patients;
input from patients, clinicians and
commissioners refined the pathway
with a focus on:
-educating and empowering patients
in their disease management,
- providing adequate and timely
support and,
- preventing unnecessary hospital
attendances.
6
Better for less – Specialist monitoring in the community
Why Specialist monitoring in the
community?
There is currently wide variation in the
monitoring of patients with MGUS, MBL
and early CLL, such variation leads to
differential levels of care. Where routine
monitoring takes place, patients are
typically seen twice annually by
specialist teams in secondary care
clinics.
Monitoring in secondary care can be slow
due to pressure on limited specialist teams;
it is often inconvenient for patients and
costly in comparison to community based
alternatives.
How can we provide better for less?
More patient-centred, systematic
monitoring for patients with
haematological conditions, MGUS and early
CLL can be delivered through a community
based monitoring service.
Better for less – Specialist monitoring
A community based approach to specialist monitoring
can provide a safe and effective means of managing
patients with haematological conditions, MGUS and
early CLL. The scheme offers greater patient choice
and benefits to the local health economy.
Patient benefits
Reduction in hospital visits and
consultations. Test results are returned
promptly to the GP who then
communicates them to the patient and
appropriate action is taken.
Quality benefits
GPs have rapid one to one access to
specialist opinion and advice. Community
monitoring can ensure more appropriate
use is made of specialist opinion and
resources.
Savings per PCT are estimated at just under
£30,000 per year for the patient groups
currently covered. There is potential for the
approach to be applied more widely to
generate further savings. The scheme also
has opportunities for economies of scale.
Case Study: Haematological Malignancy
Diagnosis Service (HMDS)
The specialist monitoring initiative has been
running at Leeds Teaching Hospitals NHS Trust
led by the HMDS in collaboration with the
Yorkshire Cancer Network for 3 years.
Patients who choose the service and are
eligible are monitored twice annually: 2
In 2010/11 the scheme being run at Leeds weeks prior to the follow up date, patients
Teaching Hospitals NHS Trust costs £78 per receive an information pack and
questionnaire, they are also asked to make an
contact, over 30% cheaper than an
appointment with the practice nurse or
appropriate outpatient appointment.
phlebotomist.
Financial benefits
Better for less – Specialist monitoring
Better for less – Specialist monitoring in the community
Patients with no sign of disease
progression receive a report and date for
their next appointment. Those presenting
with a cause for concern are contacted by
the HMDS for further exploration of
symptoms or re-appointed to the
haematology clinic as appropriate.
284 patients were involved in the pilot of
the scheme. 88% of patients using the
community approach said they preferred
the service to clinic attendance.
The scheme has proved to be a safe and
effective approach to disease monitoring.
The robustness of the approach also lends
itself to other patient groups.
Key benefits include:
- Greater patient choice
- High quality monitoring in a local setting
- Benefits to the local health economy
through reduced clinic appointments and
use of patient transport.
Further information:
Andrew Jack
Clinical Director for the Haematological
Malignancy Diagnosis Service
[email protected]
Carol Ferguson
Service Improvement Lead, Yorkshire
Cancer Network
[email protected]
Better for less – Specialist monitoring
Better for less – Specialist monitoring in the community
9
2) Hot topic: Cancer
10
Contents
Overview
Colorectal cancer
Breast cancer
Annexes
Cancer - Contents
Lung cancer
11
Contents
Overview
Colorectal cancer
Breast cancer
Annexes
Cancer - Contents
Lung cancer
12
Overview
This information pack is the ninth in a series ‘hot topics’ that will be
produced by the SHA to support organisations in developing their
understanding of some of the challenges and opportunities presented by
the QIPP agenda.
We would be delighted to receive comments on the contents together with
any ideas for further ‘cancer’ analysis.
Cancer - Overview
While recognising that it may raise more questions than answers, we hope
it will stimulate thought and debate within organisations and health
communities. Clearly the data presented need to be interpreted in the
local context.
13
Foreword from CEO sponsor
Around 14,000 people die from cancer each year in our region. Y&H spends approximately £505m
annually on cancer services; cancer is our 3rd highest spend programme budget category. Approximately
12% of all cancer spend is currently directed to inpatient care, implementing “Winning Principles” can
deliver major improvements with benefits to patients and the NHS.
There are significant variations across the region in the number of people that have or will get cancer,
the way that services are delivered and resulting health outcomes. Some of this variation reflects
deprivation which is strongly correlated with mortality, and, to a lesser extent with incidence: every
year, approximately 6,000 tumours could be avoided and 8,500 deaths prevented if all areas of Y&H had
the same incidence and mortality rates as the least deprived quintile.
This QIPP pack aims to draw out some of this variation and highlight areas of good practice. The
overview presents a high level analysis of all cancers; the subsequent chapters focus in more detail on
breast, lung and colorectal cancers, which together account for approximately 40% of all cancer cases.
Expertise and resource exists within your local Cancer Network to support you with this challenging
agenda. The key contacts are: [email protected]; [email protected]; [email protected].
Rob Webster, Chair, Yorkshire Cancer Network
Cancer - Overview
We also know that there are examples of excellent practice within our region which, if adopted more
widely can improve care and reduce cost. These include releasing technical efficiencies from inpatient
spend, investment in prevention and earlier diagnosis, reducing inequalities, and redesigning outpatient
follow-up services.
Cancer incidence and prevalence in Yorkshire & the Humber
The number of new cancer cases has been rising
steadily over time: although the standardised
incidence of cancer is predicted to at least level
off in the future, the ageing population is likely
to increase the number of new cases in the
region. Delivering technical efficiencies and
improving care pathways will be essential to
ensure that the needs of our population are met.
The number of people who have been previously
diagnosed with cancer has also increased - there Projections are crude planning tools only: projections based
on predicted population changes and previous incidence rates
are now over 130,000 people in Y&H who have
but do not account for changing lifestyle factors.
survived a cancer diagnosis. This increase is
mainly due to improved survival and the ageing
With an increase in prevalence in years to
population.
There is increasing evidence that ‘survivors’ with
no active cancer have significant long term
health problems and health needs.
come, new models of long-term follow up
need to be developed, see “Better for Less”.
Cancer - Overview
Higher levels of deprivation and smoking in Y&H
are increasing the gap in the age standardised
rate of cases between Yorkshire & the Humber
and England.
Cancer incidence and deprivation
Cancer accounts for 21% of the inequalities gap
in life expectancy - largely due to the effects of
smoking (also alcohol, obesity and diet).
Tobacco control remains the most important
factor in cancer prevention.
Age standardised incidence rates of all cancers (excl. nmsc) in Yorkshire
and Humber by deprivation quintile (IMD 2007) Patients diagnosed 2005-07
ASIR per 100,000
Cancer incidence is generally positively
correlated with deprivation (exceptions include
breast, ovary, melanoma and kidney cancers).
500
450
400
350
300
250
200
150
100
50
0
1 (least
deprived)
Almost 6,000 cancer cases in Y&H would be
prevented annually if incidence rates
reflected those of the least deprived
quintile (2005-07 rates).
Persons
ASR per 100,000 population
PCT variation in standardised incidence rates
reflect variation in deprivation & lifestyle
choices across the region.
2
3
4
Males
5 (most
deprived)
Females
Age standardised incidence rates: all cancers (exc nmsc),
patients diagnosed 2005-2007
600.00
500.00
400.00
300.00
200.00
100.00
-
Commissioners must work with Public
Health colleagues to reduce preventable
inequalities in the incidence of cancer.
Persons
Male
Females
Cancer - Overview
Inequalities in outcomes are also caused by
variations in: awareness and the timeliness &
uptake of intervention and treatment.
Cancer referrals – by priority type
250
200
Volume of referrals
There is variation across the region
regarding the type of referral used for
suspected cancer patients and the
conversion rate of referrals into
diagnoses.
All cancer referral rate by priority type: per 100,000 population
(2009)
150
100
There is no right or wrong level of
urgent referral but PCTs and
practices are encouraged to review
referral patterns at individual
practice level and determine
appropriate use of alternative
referral routes.
50
0
2 Week Wait
Urgent
Routine
Null
SHA
Cancer - Overview
Across the country, GPs make an
average of 160 urgent referrals per
10,000 population annually. There is
wide variation in the uptake of the two
week wait (TWW) referral route
between PCTs.
Cancer referrals resulting in diagnosis
The proportion of patients referred
through the TWW/ urgent route who were
subsequently found to have cancer varies
across the region and is likely to vary
significantly at practice level.
80%
70%
60%
50%
40%
30%
20%
10%
0%
%TWW
• A low referral rate plus a high
conversion rate may indicate underuse
of the TWW route – the threshold of
referral should be lowered to allow
earlier diagnosis.
%Urgent
SHA
% patients referred as 2 week wait or urgent diagnosed with any
cancer (2009)
25%
20%
15%
10%
• A combination of low referral rate and
low conversion rate may mean both
underuse and poor selection of patients
for referral.
5%
0%
TWW
Urgent
SHA
Trent Cancer Registry
Cancer - Overview
Nationally, the average rate of patients
diagnosed that were referred through the
TWW pathway is 12%; this value ranges
from less than 10% in Rotherham and
Barnsley to over 15% in Calderdale.
% patients diagnosed with any cancer referred as 2 week wait
or urgent (2009)
Overview – non-elective admissions for all cancers
Admissions reductions will require close
partnership working with Adult Social
Care and the primary & community
sector, and must lead to a closure of
inpatient beds once safe community
alternatives are established.
78
85
89
Bradford & Airedale
N Lincs
90
Kirklees
89
92
Leeds
NYY
92
Calderale
108
Hull
93
109
Doncaster
Wakefield
112
EROY
137
Rotherham
100
80
60
40
20
NE Lincs
Barnsley
ALL
Y&H
0
Dr Foster
Intelligence
Standardised admission ratio: Number of observed admissions
relative to expected values determined using national rates.
Analysis is based on all non-elective admissions with a
diagnosis of cancer.
19
Cancer - Overview
Using the NHS Improvement Cancer
‘Winning Principles’ (see slides below),
acute oncology services and other
admissions prevention initiatives will
reduce unnecessary non-elective
admissions and will improve patients’
experiences. Ensuring adequate
palliative care provision is also key.
120
102
140
126
141
160
Sheffield
Standardised admission ratio: non-elective admissions, all
cancers (2009/10)
Ratio value
Whilst the average standardised
admission ratio for Yorkshire & the
Humber is slightly higher than
expected compared to national rates,
there is two-fold variation in the ratio
across PCTs.
Cancer – expenditure & mortality for all cancers
For many cancers, mortality is correlated
with deprivation – this relationship is
recognisable when considering all cancers
together: only the more affluent PCTs of
NYY and East Riding have outcomes above
the line for the England average.
Programme budgeting tool 1.3 (2008/09)
Cancer - Overview
The relationship between spend and
outcome is complicated. Ideally, the more
we spend, we hope the better the
outcome. Despite higher spending,
outcomes are generally worse than the
England average (PCTs outside the largest
pink rectangle are statistically
significantly different.
Spend (£)
Nationally, spend on cancers and tumours
is the 3rd largest programme budget
category. Yorkshire & the Humber has the
fourth highest spend in England on cancer
care.
Expenditure on all cancers per head of population(2008/09)
160.00
140.00
120.00
100.00
80.00
60.00
40.00
20.00
-
Cancer mortality – all cancers
The NHS Yorkshire & the Humber has a
mortality rate of 182.9 (per 100,000
population) although there is wide variation
between the lowest rate in North Yorkshire &
York and highest in Hull PCT.
Age standardised mortality rate, under 75s: all cancers,
2005-2007
Hull Teaching PCT
Barnsley PCT
Wakefield District PCT
Doncaster PCT
N E Lincs Care Trust Plus
Rotherham PCT
Kirklees PCT
Sheffield PCT
Leeds PCT
North Lincolnshire PCT
Bradford & Airedale Teaching PCT
Calderdale PCT
East Riding of Yorkshire PCT
North Yorkshire and York PCT
Y&H is on track to meet the 2010 target of a
20% reduction since 1995/7 baseline.
For PCT level data see the following link:
http://www.nycris.nhs.uk/uploads/doc/vid_4513_Y&H
%20SHA%20PCT%20mortality%20pack%20060509.pdf
NHS Yorkshire & The Humber
England
0.0
20.0
40.0
60.0
80.0 100.0 120.0 140.0 160.0
Y&H SHA, all cancers (excl nmsc) mortality, under 75 yrs
Cancer - Overview
Mortality in under 75s mortality has fallen
over time due to improvements in screening
and treatment: for females the decline
appears to be slowing, probably due to a rise
in female smoking in recent decades. The
changing casemix of cancers also accounts for
some of the reduction (relative decline in
lung cancer and increase in breast cancer
improves the overall mortality picture).
21
Cancer mortality and deprivation – all cancers
People die more from cancer in deprived
areas. Almost 8,500 deaths would be
prevented in Y&H annually if incidence
rates for the region reflected those of
the least deprived quintile (2006-08
rates).
Persons
Male
Female
Y&H Average
Y&H Average
Y&H Average
300
250
200
150
100
50
0
Least
Deprivation Quintile
Most
Income Domain Deprivation Quintiles for 2007 downloaded from ukacr
website (http://www.ukacr.org)
Commissioners must ensure that
opportunities are utilised to significantly
reduce inequalities in outcome for cancer
patients.
Cancer - Overview
This variation is partly explained by
cancer incidence, other factors may be:
• the timeliness of detection of cancer
• the care that is received
• worse underlying health
Age-standardised Mortality Rate for All Cancers (excl. nmsc) 2006-2008
per Income Domain Deprivation Quintile : Yorkshire & Humber SHA
Rate per 100 000
Generally, there is a strong relationship
between population deprivation and
cancer mortality: the 20% most deprived
population in the region have around 60%
higher mortality rates than the 20% least
deprived. This relationship is stronger
than that between deprivation and
incidence.
22
Improving cancer care: early diagnosis
It is estimated that increasing awareness of cancer in the population and increasing early
detection of cancer should save approximately 500-1,000 lives per year in Yorkshire and the
Humber, 66 for an average PCT (Department of Health).
This approach is most likely to be effective for breast, bowel and lung cancers (which account for
approx 40% of all cancer cases). The evidence base is still emerging but it is likely that early
diagnosis can be increased by a combination of:
- social marketing and increasing awareness in the population (push)
- improved diagnosis in primary care, screening (excl lung) and through direct access (pull)
Health Economics for Early Diagnosis :
Analysis of interventions for cancer
Cancer type
Breast
Colorectal
Lung
Cost per year
of life saved
£5,079
£2,345
£2,071
1 year
survival rate* 72% → 80% 93.8% → 97.1% 28% → 44.3%
Source: Department of Health
*From current rate to target rate after some years and
substantial improvement in awareness and screening
23
Cancer - Overview
Investment in early diagnosis (mainly
attributed to the increase in total cost
of diagnostic tests and outpatient
appointments) for the four main
cancers (breast, lung, colorectal and
prostate), fares favourably with other
interventions in terms of costs per life
year saved. Commissioners should take
this into account in prioritisation
processes.
Early diagnosis: the approach taken in Doncaster
Recognising a number of problems in the existing system, Doncaster introduced an early
intervention programme for lung cancer. Problems of the existing system included: late
presentation, low use of Chest X Rays in primary care, barriers along the clinical pathway: low
awareness of symptoms, fearful and fatalistic, smoking stigma, irrelevance, limited empowerment.
• Creative led targeted media
campaign
• Face to face events in the
community
• Co-production in target
communities
Customer
Push-through
Service Pullthrough
• Targeted practice based brief
intervention training for frontline
health and social care staff
• Commissioning of extra CXRs
• Capacity review of hospital
services
Cancer - Overview
Results 2008:
Public attitudes and behaviours: Percentage who would go to their GP and ask for a chest X-ray
increased from 64% to 76%
Practitioner behaviours: Target practices increased chest X-ray referrals 3-fold
Lung cancer diagnoses and staging: 20 additional cases diagnosed during the campaign; Stage I&II
increased from 11% to 19%
More info at http://info.cancerresearchuk.org/spotcancerearly/naedi/local-activity/socialmarketing/index.htm [email protected]
24
Improving cancer care - transforming inpatient care
Cancer inpatient costs account for 12% of all acute
inpatient care costs in England; emergency
admissions for cancer account for 2/3 of the
national cancer bed days.
Cancer - Overview
One of the major commitments in the Cancer
Reform Strategy (2007) is to shift care from an
inpatient to an ambulatory care setting as per the
‘Winning Principles’ transforming inpatient care
programme led by NHS Improvement. Implementing
these four principles could save the NHS a million
bed days per year and improve quality of care for
patients.
Pilot schemes have shown that there is considerable
potential to avoid unnecessary emergency
admissions and to reduce lengths of stay, both for
elective and emergency admissions. Making this
happen will be a major task for Cancer Networks,
PCTs / GP commissioners and acute trusts.
For more information:
http://www.improvement.nhs.uk/cancer/Wi
nningPrinciples/tabid/88/Default.aspx
25
Improving cancer care – reducing emergency admissions
The PEAKS alert system in Doncaster and Bassetlaw Hospitals is aimed at improving communication &
quality of service, and reducing avoidable emergency admissions for known cancer patients.
The alert activates via email or a text message to a cancer key worker if a patient with an active cancer
diagnosis presents as an emergency at a local hospital. Once aware that a patient has attended as an
emergency they can be supported throughout their admission or supported through their care if an
alternative service is more appropriate.
The system was initially run as a pilot, the
following benefits were identified:
Cancer – Overview
• Preventing inappropriate admissions/ treatments
• Reduced Length of Stay
• Improved direct admission to the appropriate
area
• Increased communications for the Team
• Improved quality of care for patients & carers
The system has been rolled out to include all
tumour groups. Opportunities have been
identified to extend the scheme to patients with
LTCs and hospital associated infections as well as
to reduce inpatient stays and improve links with
community teams.
For further details contact:
[email protected]
26
Improving cancer care - enhanced recovery
Enhanced recovery has been
successfully implemented for
cancer surgery:
Enhanced recovery is designed to ensure that:
– The patient is in the best possible condition for surgery
– The patient has the best possible management during
and after his/her operation
– The patient experiences the best post-operative
rehabilitation
• Guy’s and St. Thomas’ NHS FT:
average length of stay significantly
reduced from 14 to 9 days for
patients having major colorectal
surgery.
Outcomes:
improved clinical outcomes
faster patient recovery
reduced length of stay in hospital.
To implement enhanced recovery with predictable patient
pathways it is essential that a local pathway is agreed and
standardised between the surgeons, anaesthetists and pain
team in a way that reflects local skills and practicalities.
• Queen Mary’s Sidcup NHS Trust:
a retrospective audit identified a
50% reduction in length of stay
following surgery when compared
to baseline data.
See http://www.library.nhs.uk/qipp/ViewResource.aspx?resID=330552&tabID=289 for more information
27
Cancer - Overview
Enhanced recovery is an evidence-based approach to
improving the patients pathway of treatment involving a
selected number of interventions which, when implemented
as a group, demonstrate a greater impact on outcomes than
when implemented as individual interventions.
Enhanced recovery in Yorkshire and the Humber?
Total bed days per 100,000 weighted population (2009/10)
Around 12% of all inpatient bed days are
for cancer, at an estimated cost to
Yorkshire & the Humber of £58.5m; the
three main cancers account for 30% of
these costs. Across the region there is
50% variation in the median length of
stay for cancer patients.
9,000
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
-
Y&H
average
Dr Foster; unified weighted populations
(Department of Health)
6.5
6.4
NE Lincs
Kirklees
6
5.6
6.6
Barnsley
6.2
6.7
Bradford & Airedale
NYY
6.8
Rotherham
6.4
6.8
Leeds
Wakefield
6.8
Calderale
7.3
8.2
Sheffield
7.7
8.4
5
4
3
2
1
N Lincs
Doncaster
0
EROY
Commissioners and providers should
consider enhanced recovery & other
approaches to reduce length of stay.
7
Y&H
ALL
Reducing length of stay and consequently
bed days appropriately can improve
patient experience and value for money.
Length of stay
8
6.9
9
Hull
Median length of stay, all cancers (2009/10)
Commissioners should ensure adequate
non-hospital based end of life care.
Dr Foster
28
Cancer - Overview
High bed days are associated with long
lengths of stay and may reflect poor
hospice provision.
Radiotherapy – a cost effective, underused resource?
Radiotherapy has many advantages over other forms of treatment and is effective in
terms of Cost/QALY. Anecdotal evidence suggests that there is variation in use across the
region with patients in rural areas choosing chemotherapy due to ease of access.
Radiotherapy cures cancer and sufficient resource and workforce are needed to deliver it:
•Radiotherapy is a significant component of the treatment of 40% of patients who are cured of their cancer.
•Timely access to radiotherapy should improve cancer outcome and survival.
Radiotherapy is more targeted than chemotherapy and less invasive than surgery:
•It is a more directed form of treatment than chemotherapy there are fewer side effects on the rest of the body;
•Radiotherapy is a highly effective local treatment which can spare patients from radical surgery.
Source: National Radiotherapy Awareness Initiative, NCAT (2010)
North Trent Cancer Network are co-ordinating the process of planning future radiotherapy
developments across Y&H, working with Cancer Networks and SCG.
Commissioners should commission productive radiotherapy units and also ensure
patients have adequate access to radiotherapy as part of informed decision making
about treatment options.
Cancer - Overview
Radiotherapy is the most cost effective way of treating cancer:
•Radiotherapy is extremely cost effective in comparison to other curative cancer treatments;
•New faster and more precise technologies reduce the need for long term treatment for common side effects.
29
Contents
Overview
Colorectal
Colorectalcancer
cancer
Breast cancer
Annexes
Cancer - Contents
Lung cancer
30
Colorectal cancer - overview
Colorectal cancer is the third leading cause of cancer after breast and lung
cancers. The average annual number of cases will continue to increase over time
as the population ages, most cases (approx 84%) occur after age 60.
The new bowel cancer screening programme is now live across the region and
should help with earlier case finding and improved outcomes. The prevalent
round has identified a higher than expected level of benign and malignant polyps.
Commissioners should work with Public Health colleagues to ensure bowel cancer
is prevented through diet, obesity, alcohol and smoking initiatives.
Cancer – Colorectal cancer
Caught at an early stage, colorectal cancer can be curable. Collection of data on
staging is a vital aspect of improving outcomes. Surgery is the primary
intervention for colorectal cancer, the difference between the percentage of
patients receiving surgery appears significant across the region.
Colorectal cancer – incidence rates: future trends
Age is a key risk factor for colorectal
cancer. As such, the number of new
cases will increase over time as the
population ages. Additional significant
risk factors are diet, obesity, alcohol
and smoking.
Projections are crude planning tools only:
projections based on predicted population
changes and previous incidence rates but do not
account for changing lifestyle factors.
Cancer – Colorectal cancer
The standardised incidence of colon
cancer is predicted to continue
declining over time, however the rate
for rectal cancer is predicted to
increase. Since 2002, the standardised
incidence of colon cancer in Y&H has
moved above the national average,
the gap between the regional and
national level for rectal cancer is
expected to remain.
Colorectal cancer – incidence rates
Average spend on colorectal cancer
in Yorkshire & the Humber is
greater than the national average.
This is expected given that
incidence rates are also currently
higher than national values.
50
40
30
20
10
0
Males
Females
Commissioners should work with Public
Health colleagues to ensure bowel cancer is
prevented through diet, obesity, alcohol and
smoking initiatives.
Cancer – Colorectal cancer
Incidence varies by PCT, rates are
likely to reflect variations in
behaviour in (descending order in):
• diet
• obesity
• alcohol
• smoking and,
• increasingly, the uptake of
screening (revealing better
prognosis polyps).
Colorectal cancer: Mean annual age standardised incidence
rate (ASR) 2005-2007
60
Colorectal cancer – stage at diagnosis
Colorectal cancer can be curable
when caught at early stages, cure
becomes less likely as the disease
develops.
Colorectal cancer: stage at diagnosis.
Patients diagnosed 2005-2007
100%
90%
80%
70%
60%
Recording of stage remains
variable. Commissioners should
ensure that staging data is
collected though electronic dataset
submissions.
Screening and early diagnosis
initiatives will help improve the
stage at diagnosis and the longer
term outcomes for patients.
50%
40%
30%
20%
10%
0%
See annex A for note on data
Cancer – Colorectal cancer
Of all colorectal cancers with a stage
at diagnosis (excluding all unknown
stage), 44.4% are stage I or stage II
(early), and 55.6% are stage III or
stage IV (late).
Colorectal cancer – non elective admissions
61
80
63
66
80
Wakefield
77
81
Calderale
87
NYY
108
Barnsley
87
109
Doncaster
Leeds
114
EROY
100
91
119
Sheffield
120
Hull
123
Rotherham
140
91
The standardised ratio for nonelective admissions varies across
the region, being generally worse
in South Yorkshire.
Standardised admission ratio: non-elective admissions,
cancer of the colon (2009/10)
60
40
N Lincs
NE Lincs
Bradford & Airedale
Kirklees
Y&H
ALL
0
Dr Foster 2009/10
119
115
111
Hull
Leeds
N Lincs
NE Lincs
Wakefield
Calderale
Doncaster
42
69
93
119
Bradford & Airedale
NYY
122
Kirklees
98
128
Rotherham
EROY
135
Barnsley
98
138
Sheffield
179
113
ALL
200
180
160
140
120
100
80
60
40
20
0
Standardised admission ratio, non-elective admissions,
cancer of the rectum (2009/10)
Y&H
New developments such as acute
oncology and patient alert systems
(eg PEAKS) will help to ensure only
patients who really need to be
admitted are.
20
Cancer – Colorectal cancer
Implementing the ‘Winning
Principles’ will help reduce
unnecessary emergency admissions
and improve patient care. Ensuring
adequate palliative care provision
is also key.
Dr Foster 2009/10
35
Colorectal cancer – surgery rates
There is a statistically significant
difference across PCTs in terms of the
percentage of colorectal cancer
patients receiving any surgery, and also
left hemicolectomy (not shown).
Whilst some differences in surgery
are expected due to differing
incidence rates & differing stage of
diagnosis, PCTs should consider
variation in surgical practice &
outcomes for patients in determining
appropriate surgery levels for their
locality.
70%
60%
50%
40%
30%
20%
10%
0%
Chart represents total number of surgical procedures for:
excision of colon, right hemicolectomy, right hemicolectomy,
excision of rectum
Cancer – Colorectal cancer
Surgery is the primary treatment for
colorectal cancer. 1896 patients
diagnosed in 2007 underwent a surgical
procedure for colorectal tumour whose
data was collected by the Registries
(this is likely to be a significant
underestimate).
% of 2007-diagnosed colorectal tumours receiving surgery
Colorectal cancer - referrals
• A low referral rate plus a high
conversion rate may indicate
under-use of the TWW route – the
threshold of referral should be
lowered to allow earlier
diagnosis.
• A combination of low referral
rate and low conversion rate may
mean both underuse and poor
selection of patients for referral.
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
%TWW
%Urgent
SHA
% patients referred as 2 week wait or urgent diagnosed with any
cancer (2009)
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
TWW
Urgent
SHA
Cancer – Colorectal cancer
There is variation across the
region in the proportion of
patients referred through the
TWW/ urgent route who were
subsequently found to have
cancer. Variation is likely to be
wider still at practice level.
% patients diagnosed with any cancer referred as 2 week wait
or urgent (2009)
Colorectal cancer – length of stay
17.1
18
14
12
12.6 12.5
10.7
11.8 11.7
10
10.7 10.4
9.8
9.3
9.2
Rotherham
16
Calderale
Approximately half of all cancer costs
relate to admissions (Department of
Health), for colorectal cancer, the daily
cost of an inpatient stay totals £7.6m for
the region.
Median length of stay: cancer of the colon (2009/10)
9.2
9
8.5
8.4
8
6
4
Kirklees
N Lincs
Leeds
Wakefield
NYY
Doncaster
NE Lincs
Barnsley
Sheffield
EROY
Bradford & Airedale
Dr Foster 2009/10
Median length of stay: cancer of the rectum (2009/10)
16
13.9
14
12
13.3
11.5 11.2
10.4
10.6 10.5 10.3 10.1
9.9
10
9.8
9.7
9.4
9.4
7.5
8
6
4
2
N Lincs
Leeds
Kirklees
Wakefield
Calderale
NYY
EROY
NE Lincs
Doncaster
Bradford & Airedale
Sheffield
Rotherham
Barnsley
0
Hull
Implementing ‘Winning Principles’ and
commissioning Enhanced Recovery
Pathways will help reduce length of stay
and improve patient care. Commissioners
should also ensure adequate non-hospital
based end of life care.
Hull
ALL
Y&H
0
Y&H
ALL
Commissioning enhanced recovery pathways
may help reduce Length of stay.
2
Dr Foster 2009/10
Cancer – Colorectal cancer
For colon cancer, variation between the
PCTs with highest and lowest lengths of stay
is more than two fold. Such variation likely
reflects more than casemix.
38
Colorectal cancer – survival rates
North Yorkshire and York
Kirklees
NAEDI
consensus
target
Bradford and Airedale
England
Sheffield
Y&H SHA
79
Leeds
East Riding of Yorkshire
Calderdale
Wakefield
North East Lincolnshire
North Lincolnshire
Rotherham
Doncaster
There is a strong association between
deprivation and 1 and 5 year survival. This
reflects inequalities in stage of presentation
and possibly in methods and choices of
treatment.
There is no association between deprivation
and the incidence of colorectal cancer,
however there is a significant trend towards
poorer survival with increasing deprivation.
Hull Teaching
Barnsley
0
10
20
30
40
50
relative survival (%)
Data source: NCIS
NAEDI consensus target
60
70
80
90
Cancer – Colorectal cancer
1 year survival is a measure of how early
cancer is diagnosed and treated. England has
poor outcomes for colorectal cancer in
comparison with international best practice
(NAEDI consensus target). The Y&H survival
rate is marginally worse than the England
average, however the regional average masks
wide variation.
1 year survival rate: patients diagnosed 2002-2006
Colorectal cancer – spend and mortality
Higher than average spend is not
consistently associated with
reduced mortality rates.
It is expected that spend will
continue to increase with
incidence.Given the increasing
demands on budgets, PCTs need
to adhere to best practice to
contain spend whilst improving
outcomes.
Cancer – Colorectal cancer
Does this outcome reflect the
relative incidence across PCTs?
Can spend and mortality be
better aligned through more
efficient use of resources?
Colorectal cancer – age standardised mortality rates
Across the region, the average
mortality rate for colorectal
cancer is 17.7 per 100,000
population.
N E Lincs Care Trust Plus
Wakefield District PCT
Bradford & Airedale Teaching PCT
Kirklees PCT
East Riding of Yorkshire PCT
Doncaster PCT
Sheffield PCT
North Yorkshire and York PCT
North Lincolnshire PCT
Barnsley PCT
Hull Teaching PCT
Leeds PCT
Rotherham PCT
Calderdale PCT
North East Lincolnshire also has
relatively low incidence rates
across Y&H however the mortality
rate is the highest in the region,
this may reflect the low proportion
of patients with a 1 or 2 diagnosis.
Y&H has met the 2010 target for
colorectal cancer mortality.
NHS Yorkshire & The Humber
England
0.0
2.0
4.0
6.0
8.0
10.0 12.0 14.0 16.0 18.0
Cancer – Colorectal cancer
Calderdale has both the lowest
mortality and incidence rates in
the region for colorectal cancer.
Age standardised mortality rate, under 75s: colorectal cancer
(persons) 2005-2007
Contents
Overview
Colorectal cancer
Breast cancer
Annexes
Cancer - Contents
Lung
Lungcancer
cancer
42
Lung cancer - overview
Lung cancer is the second most common cancer in the UK with more than
38,000 people diagnosed each year, smoking is the main cause in most cases.
Prevention of lung cancer through eliminating tobacco smoking is highly
cost effective. The expanding gap in standardised incidence rates between
Yorkshire & the Humber and the national average reflects increased smoking
prevalence across our region.
Applying lean methodology to the lung cancer pathway (such as the YCN
project) leads to QIPP opportunities and can be replicated in other cancer
(and non-cancer) pathway areas. For further information about the YCN Lean
project contact Carol Ferguson: [email protected];
Cancer – Lung cancer
Outcomes in Yorkshire & the Humber are worse than the national average. A
key factor in survival and mortality is the stage of the disease at diagnosis:
across the region, too many patients are diagnosed with later stages of the
disease. Tobacco control, smoking cessation, and early diagnosis of lung
cancer are all priorities for the region.
Lung cancer – incidence rates
Due to the ageing population, the number
of new cases of lung cancer is predicted to
rise sharply in the coming decade, even
though the overall standardised rate is
falling.
There is two-fold variation in male
incidence rates of lung cancer across the
region, an apparent reflection of current
and historical smoking prevalence.
Prevention and early diagnosis of
lung cancer are key to improving
cancer outcomes and reducing
cancer inequalities in Y&H.
Lung cancer: Mean annual age standardised incidence rate
(ASR) 2005-2007
120.0
100.0
80.0
60.0
40.0
20.0
0.0
Projections are crude planning tools only: projections
based on predicted population changes and previous
incidence rates but do not account for changing
lifestyle factors.
Males
Females
Cancer – Lung cancer
The gap between incidence rates for Y&H
and England is rising due to the prevalence
of smoking in the region.
Lung cancer – stage at diagnosis
Of all lung cancers with a stage at
diagnosis (excluding all unknown
stage), 20.3% are stage I or stage II
(early), and 79.7% are stage III or stage
IV (late).
Cancer – Lung cancer
Recording of stage remains poor
with just over half of all cases
coded. Commissioners should ensure
that staging data is collected though
electronic dataset submissions.
As a consequence of late stage
diagnoses, poor survival and
mortality rates occur in Yorkshire &
the Humber. Early diagnosis of
lung cancer is a priority for the
region.
See Annex A for note on data
Lung cancer – non elective admissions
73
90
Wakefield
89
92
N Lincs
95
111
Leeds
Bradford & Airedale
114
Kirklees
97
119
Calderale
Doncaster
120
Barnsley
128
136
100
80
60
40
20
NE Lincs
NYY
EROY
Rotherham
Sheffield
Hull
0
Dr Foster 2009/10
Cancer – Lung cancer
subjective breathlessness is a common
cause of lung cancer admissions.
Cognitive behavioural approaches can
help reduce anxiety-related
breathlessness in such cases and avoid
preventable admissions as well as
promoting self care.
120
112
160
147
180
140
Whilst ratios may reflect case mix,
implementing ‘Winning Principles’ is
an opportunity to prevent unnecessary
admissions. Ensuring adequate
palliative care provision is also key.
163
Lung Cancer standardised admission ratio: non elective
admissions (2009/10)
ALL
Y&H
Hull and Sheffield have the highest
standardised non-elective admission
ratios.
Lung cancer – surgery rates
323 patients recorded by the
Registries diagnosed in 2007
underwent lung excision (this is likely
to be a significant underestimate).
There is no significant difference
between PCTs statistically.
Percentage of 2007-diagnosed tumours receiving excision of lung
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
For further information:
[email protected]
Earlier diagnosis of lung cancer
allows for higher rates of surgical
intervention which may be
curative.
Cancer – Lung cancer
Using Lean tools the YCN has seen a
reduction in surgical pathways steps
and the time between prognosis &
treatment has been slashed.
Lung cancer - referrals
The proportion of patients referred through
the TWW/ urgent route who were
subsequently found to have cancer varies
across the region. Variation at practice level
is also likely to be significant.
• A low referral rate plus a high conversion
rate may indicate under-use of the TWW
route - the threshold of referral should be
lowered to allow earlier diagnosis.
• A combination of low referral rate and low
conversion rate may mean both underuse and
poor selection of patients for referral.
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
%TWW
%Urgent
SHA
% patients diagnosed with lung cancer referred as TWW or
urgent in 2009
40%
35%
30%
25%
20%
15%
10%
5%
0%
TWW
Urgent
SHA
Cancer – Lung cancer
Hull and Sheffield have the lowest
percentage of patients referred through TWW
and urgent routes diagnosed with lung cancer,
their relatively high non-elective admissions
ratios may reflect this referrals practice.
% patients referred as TWW or urgent in 2009 diagnosed
with lung cancer
Lung cancer – inpatient stays
1,200
1,000
800
600
400
200
-
7.9
7.6
7.6
7.9
NE Lincs
N Lincs
NYY
Rotherham
9
8.1
Leeds
10.3
7.8
Kirklees
10.8
9.2
Doncaster
Hull
9.3
7.4
Bradford & Airedale
Calderale
7.3
8
Barnsley
10
6
4
2
Wakefield
Sheffield
0
Y&H
ALL
Implementing ‘Winning Principles’ and
commissioning Enhanced Recovery
Pathways will help reduce inpatient bed
days & improve patient care.
Commissioners should also ensure
adequate non-hospital based end of life
care.
8.7
12
10.9
Lung cancer: Median length of stay (2009/10)
Cancer – Lung cancer
The relationship between bed days per
head of population and the median
length of stay implies that PCTs with
higher bed days are keeping those that
they do treat in longer.
EROY
Lung cancer accounted for a total of
36,774 bed days in Yorkshire & the
Humber in 2009/10 at an estimated
cost of £5.9m. Variation in total bed
days per head of population is more
than 2-fold across the region.
Lung cancer bed days per 100,000 weighted population (2009/10)
49
Lung cancer – survival rates
There is an association between deprivation
and 1 year survival in YH. This reflects
inequalities in stage of presentation and
possibly in methods and choices of
treatment. The difference at 5 years is not
significant (probably reflecting the fact that
very few people survive 5 years with lung
cancer at present).
North Yorkshire and York
Sheffield
Bradford and Airedale
Leeds
37
Hull Teaching
England
Y&H SHA
North Lincolnshire
Doncaster
Wakefield
Calderdale
Kirklees
North East Lincolnshire
Rotherham
Barnsley
0
5
10
15
20
25
relative survival (%)
Data source: NCIS
NAEDI consensus target
30
35
40
Cancer – Lung cancer
1 year survival is a measure of how early
cancer is diagnosed and treated. England
has very poor outcomes for lung cancer in
comparison with international best practice
(NAEDI consensus target) and YH is similar
to the England average, with only 27% of
patients surviving to 1 year. Within the
region, there is considerable variation in
survival, reflecting stage of presentation,
coding and possibly local practice. Earlier
diagnosis of lung cancer through public
awareness, primary care initiatives, and
novel approaches such as open access
diagnostics, will help improve 1 year
outcomes and is a priority for the region.
One-year lung cancer survival for patients diagnosed 2002-06
East Riding of Yorkshire
Lung cancer – spend and mortality
In Yorkshire & the Humber, three PCTs
have spending (statistically)
significantly higher than the England
average. The majority of our PCTs are
in the quadrant of the chart
representing higher spend and worse
outcomes than the England average.
Relatively high spending may be
attributable to higher incidence rates.
Spending on preventative measures
relating to tobacco is highly cost
effective at reducing the incidence of
lung cancer.
Cancer – Lung cancer
Only East Riding & North Yorkshire
have outcomes above the national
average, North Yorkshire has achieved
this with below average expenditure.
This is likely to reflect lower levels of
deprivation and tobacco smoking.
Lung Cancer - Sheffield Multi-Criteria Decision Analysis
For lung cancer ‘health promotion’ (2, ie smoking cessation), offers the greatest value for
money - between 10 and 20 times higher than for other interventions.
40% of lung cancer spend in Sheffield is on palliative care – investing in more cost effective
interventions will, in the longer term reduce the need for inpatient and palliative care costs
as there will be fewer new cases. However, such investment requires the release of
technical efficiency savings from the treatment end of the pathway.
52
Cancer – Lung cancer
NHS Sheffield has performed analysis to understand return on investment within programme
budget lines to determine prioritisation. The lung cancer pathway is presented above.
Lung cancer - mortality
Age standardised mortality rate, under 75s: lung cancer
(persons) 2005-2007
The Yorkshire and Humber SHA
Hull Teaching PCT
shows a mortality rate for lung
Wakefield District PCT
Barnsley PCT
cancer of 45.8 per 100 000
Rotherham PCT
Leeds PCT
population, significantly above the Bradford & Airedale Teaching
PCT
Sheffield PCT
England average.
Doncaster PCT
Whilst Yorkshire & the Humber
has met the 2010 target for 20%
lung cancer mortality reduction,
outcomes remain worse than the
national average.
NHS Yorkshire and the Humber
England
0.0
10.0
20.0
30.0
40.0
50.0
Cancer – Lung cancer
North Yorkshire and York and East
Riding of Yorkshire have
significantly lower mortality rates
than the regional average, these
PCTs also have the lowest
incidence rates. Hull has a
mortality rate significantly above
the regional average.
Calderdale PCT
N E Lincs Care Trust Plus
North Lincolnshire PCT
Kirklees PCT
East Riding of Yorkshire PCT
North Yorkshire and York PCT
Contents
Overview
Colorectal cancer
Breast
Breastcancer
cancer
Annexes
Cancer - Contents
Lung cancer
54
Breast cancer - overview
Breast cancer outcomes are improving over time:
• Mortality has reduced because of screening, tamoxifen and adjuvant
chemotherapy.
• Earlier diagnosis through public awareness, primary care initiatives, and
screening, will help improve 1 year outcomes.
There are an estimated over 34,000 women in Yorkshire & the Humber who
have survived breast cancer. There is a need for new models of follow-up for
breast cancer survivors to enhance quality of care and deliver efficiency
savings, see the enclosed ‘better for less’ briefing.
Cancer – Breast cancer
Although the incidence of breast cancer is lower in more deprived
populations, the mortality is higher. This is a consequence of inequalities in
delayed diagnosis, and methods and choice of treatment.
Breast cancer – incidence rates
Whilst the age standardised rate is
likely to level off, the number of
new cases of breast cancer is
projected to continue to increase
over the next 10 years due to
population aging.
The incidence of breast cancer
varies little across the region.
Unlike colorectal and lung cancers,
differences in incidence do not
reflect deprivation.
Projections are crude planning tools only: projections
based on predicted population changes and previous
incidence rates but do not account for changing
lifestyle factors.
Breast cancer: Mean annual age standardised incidence rates
2005-2007
120
100
80
60
40
20
0
Cancer – Breast cancer
Commissioners will need to be
prepared for increasing numbers of
new cases and survivors.
Breast cancer – stage at diagnosis
Breast cancer: Stage at diagnosis. Patients diagnosed 2005-2007
10%
This is encouraging and is
primarily related to cancer
screening programmes.
0%
Recording of stage remains
variable. Commissioners should
ensure that staging data is
collected though electronic
dataset submissions.
See annex A for more information on data.
Cancer – Breast cancer
Of all women with a stage at
100%
diagnosis for breast cancer
90%
80%
(excluding all unknown stage),
86.4% are diagnosed at stage I or 70%
60%
stage II (early), and 13.6% are
50%
diagnosed at stage III or stage IV 40%
30%
(late).
20%
Breast cancer – non-elective admissions
Unscheduled (emergency) patients
should be assessed prior to the
decision to admit and community
services developed to support
people at home, including palliative
care provision.
256
65
66
66
79
100
88
95
96
105
112
113
122
110
150
118
186
200
NE Lincs
NYY
Leeds
Kirklees
Calderale
N Lincs
Doncaster
EROY
Barnsley
Hull
Wakefield
Rotherham
0
Sheffield
50
Bradford & Airedale
Commissioners should implement the
‘Winning Principles’.
250
Cancer – Breast cancer
North East Lincs, North Yorkshire &
York and Leeds have the lowest nonelective admissions ratios, these PCTs
also have a high proportion of
patients with early stage diagnoses.
300
ALL
Y&H
Emergency admissions for breast
cancer vary across the region. These
may relate to side effects of
chemotherapy or readmissions
following breast surgery, for
example.
Indirectly standardised Non-elective admission ratios
2008/09
Breast cancer - surgery rates
2,711 patients diagnosed in
2007 were recorded by the
Registries as having undergone
a surgical procedure for breast
cancer (this is likely to be a
significant underestimate).
This may be a combination of
real surgical practice, stage of
presentation, and coding
differences/practice between
trusts.
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Cancer – Breast cancer
There are significant
differences between PCTs for
most types of surgery.
Percentage 2007-diagnosed breast tumours receiving surgery, by type
Breast cancer - referrals
The proportion of patients referred through the
100%
TWW/ urgent route who were subsequently
90%
found to have cancer varies across the region
80%
70%
and is likely to vary significantly at practice
60%
50%
level.
• A low referral rate plus a high conversion rate
may indicate under-use of the TWW route – the
threshold of referral should be lowered to
allow earlier diagnosis.
• A combination of low referral rate and low
conversion rate may mean both underuse and
poor selection of patients for referral.
40%
30%
20%
10%
0%
TWW
Urgent
SHA
% patients diagnosed with breast cancer referred as TWW
or urgent in 2009
25%
20%
15%
10%
5%
0%
TWW
Urgent
SHA
Cancer – Breast cancer
The rate of patients diagnosed with cancer
referred through the TWW pathway ranges
from 7% to 15%, variation in urgent referrals is
more significant.
% patients referred as TWW or urgent in 2009 diagnosed
with breast cancer
Breast cancer – inpatient stays
Breast cancer accounted for a
total of 19,177 bed days and a
cost of £31.m in Yorkshire & the
Humber in 2009/10.
Total bed days per 100,000 weighted population (2009/10)
600
500
400
300
200
100
2.6
NYY
2.9
3.2
Rotherham
Wakefield
3.2
Kirklees
3.3
N Lincs
3.5
Doncaster
3.3
3.6
Calderale
Bradford & Airedale
4
NE Lincs
4.1
Leeds
4
4.1
Barnsley
Hull
4.2
EROY
4.7
Median length of stay, breast cancer 2009/10
3.6
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Sheffield
also ensure adequate non-hospital
based end of life care.
Dr Foster 2009/10, unified weighted
population: Department of Health
ALL
Implementing ‘Winning Principles’
and commissioning Enhanced
Recovery Pathways will help reduce
inpatient bed days and improve
patient care. Commissioners should
-
Dr Foster 2009/10
Cancer – Breast cancer
There is considerable variation in
both total bed days and the
median length of stay for breast
cancer across the region. These
appear to reflect more than case
mix.
Breast cancer - 1 year survival rates
1 year survival is a measure of how
early cancer is diagnosed and
treated. England has poor outcomes
for breast cancer in comparison with
international best practice (NAEDI
consensus target). The YH survival is
similar to the England average.
One year breast cancer survival for patients diagnosed 2002-06 in Y&H SHA, with national
comparator and NAEDI consensus target
97
North Lincolnshire
North Yorkshire and York
East Riding of Yorkshire
Kirklees
Hull Teaching
Bradford and Airedale
Wakefield
North East Lincolnshire
Leeds
Y&H SHA
England
Calderdale
Sheffield
Barnsley
Rotherham
0
10
20
30
40
50
60
70
80
90
100
relative survival (%)
Data source: NCIS
NAEDI consensus target
62
Cancer – Breast cancer
Breast cancer is generally associated
with affluence not deprivation yet
there is a strong association between
higher levels of deprivation and
poorer 1 and 5 year survival. This
reflects inequalities in stage of
presentation and possibly in methods
and choices of treatment: even
though more affluent women develop
breast cancer, women in more
deprived circumstances are likely to
die.
Doncaster
Breast cancer – spend and mortality
Cancer – Breast cancer
Spend on Breast cancer services
appears to be higher than the
English average. Breast cancer
outcomes are inversely correlated
with deprivation, and this is seen
in Yorkshire, apart from the
anomalous results in Hull and
North Lincolnshire. Lower
incidence rates may be
overcompensated for by higher
fatality.
Breast cancer - age-standardised mortality rates
Age standardised mortality rate, under 75s: breast cancer
(females) 2005-2007
0.0
The age standardised mortality rate
from breast cancer has been falling
due to improvements in screening,
diagnosis and treatment.
Y&H has met the 2010 PSA target for
breast cancer mortality reduction.
5.0
10.0
15.0
20.0
25.0
30.0
35.0
Cancer – Breast cancer
The Yorkshire and Humber SHA shows
Hull Teaching PCT
a mortality rate for female breast
North Lincolnshire PCT
Leeds PCT
cancer of 26.5 (per 100 000 female
East Riding of Yorkshire PCT
Doncaster PCT
population). The PCTs with lowest
Kirklees PCT
North Yorkshire and York PCT
mortality rate are: Bradford and
Sheffield PCT
Wakefield District PCT
Airedale Teaching, Wakefield District,
Barnsley PCT
N E Lincs Care Trust Plus
North East Lincolnshire, Barnsley,
Calderdale PCT
Rotherham PCT
Calderdale and Rotherham. The
Bradford & Airedale Teaching PCT
highest mortality rates are for: Hull
NHS Yorkshire and the Humber
England
Teaching and North Lincolnshire PCTs.
Contents
Overview
Colorectal cancer
Breast cancer
Annexes
Annexes
Cancer - Contents
Lung cancer
65
Annex A: note re stage at diagnosis for lung cancer
Note Lung cancer: LUCADA is an incomplete dataset and therefore does not cover all lung cancer
patients in Yorkshire and the Humber SHA.
Scarborough and NE Yorkshire Healthcare NHS Trust did not participate in the NLCA 2007, although
there may still be data on patients first seen at this trust by virtue of data being submitted by treating
trust.
By Cancer Network:
Yorkshire Cancer Network: 88.6% of expected cases were submitted. Stage is 46.0% complete. Humber
and Yorkshire Coast Cancer Network: 51.1% of expected cases were submitted. Stage is 73.5%
complete. North Trent Cancer Network: 87.8% of expected cases were submitted. Stage is 74.9%
complete.
By Trust:
Proportion of expected cases ranges from 0.0% (Scarborough and NE Yorkshire Healthcare NHS trust) to
113.6% (Doncaster and Bassetlaw Hospitals NHS Foundation Trust). Completeness of stage ranges from
ranges from 0.0% (Scarborough and NE Yorkshire Healthcare NHS trust) to 93.0% (Bradford Teaching
Hospitals NHS Foundation Trust)
Note: Breast Cancer: A small number are ‘unknown’ stage, this includes pre-treated tumours. This is for
the NYCRIS PCTs only (ie excluding 4 South Yorkshire), and it means that the unknown stage category is inflated.
Patients with pre-treated tumours will not have a stage at diagnosis.
Annex A
Note Colorectal cancer: Unknown stage includes pre-treated tumours for the NYCRIS PCTs only (ie
excluding 4 South Yorkshire), and it means that the unknown stage category is inflated. Patients with
pre-treated tumours in S Yorks will not have a stage at diagnosis.
Key contacts
Carol Ferguson – Yorkshire Cancer Network
[email protected]
Kim Fell – North Trent Cancer Network
[email protected]
Julie Taylor-Clark – Humber & Yorkshire Coast Cancer Network
[email protected]
Ian Holmes – Associate Director, Economics and System Management, NHS Y&H
([email protected])
Helen Mercer – Economist, Strategy and System Reform Directorate, NHS Y&H
([email protected])
Key Contacts
Fiona Day, Consultant in Public Health Medicine, NHS Y&H
([email protected])
67
Acknowledgements
Fiona Day, Consultant in Public Health Medicine, NHS Y&H
Sarah Cuthbertson, NYRCIS, YHPHO and The Yorkshire Cancer Network
Caroline Brook, Nicola Easey at NYCRIS
Jason Poole, Carolynn Gildea, Marta Emmett , Ros Hancock at Trent Cancer Registry
North Trent, Yorkshire, and Humber and Yorkshire Coast Cancer Networks
Acknowledgements
Ian Holmes, Forrest Frankovitch, Andy Tookey, Colin Pollock, Sue Baughan, Helen
Mercer at Y&H Quality Observatory
Jon Fear, Deputy Director of Public Health, NHS Leeds
Prof Mark Baker, Lead Cancer Clinician LTHT and Lead Clinician, National Peer Review
Programme
Jackie Simpkin, Cancer Waits Lead, NHS Y&H
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3) QIPP metrics
69
QIPP metrics (1)
QIPP metrics (2)
QIPP metrics (3)
QIPP metrics (4)
QIPP metrics (5)
QIPP metrics (6)
QIPP metrics – definitions and sources