Transcript Cancer Reform Strategy

Sustainable solutions for
improved patient outcomes
Ian Mackenzie
Consultant in Public Health, Peninsula Cancer Network
Tracey Sweet
Director of Communications and Corporate Governance, NHS
Cornwall & Isles of Scilly
13th South West Residential School – 20 and 21 October 2009
Upper gastro-intestinal cancer
UGI
Service reconfiguration – the clinical
case for change
Improving Outcomes Guidance
UGI cancer
• Published in 2001
• Surgery to be carried out by specialist teams
at a designated location
• Specialist teams likely to cover a population of
1-2million
• Minimum of 100 resections a year
Where is your oesophagus?
What is a resection?
Peninsula Cancer Network
Cancer Reform Strategy
Box 13: Specialist surgery for oesophageal cancer
Oesophagectomies (an operation to remove the ‘food pipe’) and
oesophagogastrectomies (to remove both the food pipe and the
stomach) are two examples of cancer surgery that are increasingly
done by specialists.
In 1997/98, 309 surgeons in 147 Trusts carried out these operations.
By 2004/05, they were concentrated in the hands of only 188
surgeons in 96 trusts.
The impact of this has been significant – the number of patients that
died in hospital following one of these operations almost halved in
this period (from 9.4% to 4.9%)
Although there will be a number of factors that contributed to this,
one is specialisation by surgeons and their teams.
Surgical intervention reducing
Difficult decisions take longer
• Jan 2001 IOG published and considered by Network
site specific group
• 2002-2003 3 site option proposed, followed by 2 site
option (not agreed) – stalemate
• 2005 Independent review commissioned – go to 2
sites by Dec 2007 and single centre by 2010
• Sept 2008 – Independent review RCHT
• Dec 2008 – Independent review extended
to PHT and RD&E
Oesophageal cancer 2004-2008
Small numbers are dangerous!
Royal Cornwall
Hospitals Trust
Plymouth NHS
Hospital Trust
Royal Devon&
Exeter Foundation
NHS Trust
New cases
287
603
490
Resections
46
163
124
The number of cases operated on each year in individual trusts is
small. This means that the confidence intervals are wide when
considering the small numbers of deaths that occur and comparisons
of performance on mortality rates between individual trusts is not
appropriate.
Anticipated patient flows per year for all UGI
cancers - if Plymouth chosen as centre
Total
From RD&E UGI Unit
From Cornwall UGI Unit
55
20
Diagnosis carried out locally
Specialist surgery to be carried out at designated
specialist centre
Local treatment with chemotherapy and
radiotherapy
What sort of people are affected?
• Oesophageal and gastric cancer show a social
gradient in men (commoner in more deprived)
• Mainly older people – often retired
Group Work - Force Field Analysis
What are the forces for and against the centralisation of UGI specialist
surgery?
Real Involvement
• Law was strengthened in November 2008 - clearer about
when NHS must involve people in planning, developing and
delivering health services
• PCTs have a duty to report on consultations they have
undertaken that relate to commissioning decisions
• Duty covers a range of activities from providing information
to large public consultation
• Duty to involve applies irrespective of whether OSC is
consulted
• New duty to report on consultation
• Real Involvement (working with people to improve services)
is statutory guidance published by the Department of Health
in October 2008
Principles of local accountability and
effective involvement
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Clear, accessible and transparent
Open
Inclusive
Responsive
Sustainable
Proactive
Focused on improvement
Issues for consideration in relation to
centralisation of cancer surgery
• The context (IOGs, World Class Commissioning, Our NHS, Our
Future, NHS Constitution, Patient Choice)
• The givens and what people can influence
• Who to involve
• The emotional dimension
• The political dimension
• The local context
• Level of support – clinical and organisational
• Co-ordinating engagement – PCTs, as members of SCGs, retain
responsibility for statutory functions
Group Work
• How would you approach public and
patient involvement across the
Peninsula?
How we approached engagement – a local
perspective (1)
• Phase One (May – July 2008):
• Publication of public information pack, including scoping paper
for health impact assessment
• Presentation to the OSC meeting by PCN Medical Director
setting out clinical case for change
• Three independently chaired Select Committee style hearings
• Three public Question Time events, chaired by Regional
Director of Public Health, and involving leading Upper GI
Surgeons
• Invitation to write/e-mail directly to the PCT
• Less than 100 people involved (although many thousands
signed a petition)
How we approached engagement – a local
perspective (2)
• Commissioning of Independent Clinical Review (September
2008)
• Phase Two (April 2009)
• PCT organised focus group with LINk to develop local events
focussing on patients and their families/carers
• Four events planned across county
• Other opportunities to share views by telephone, email and
letter
• With LINKs input, two letters were forwarded by hospital staff
to patients and their family members/carers.
• 20 patients/carers attended. In addition 1 letter, 3 emails and
3 telephone calls
Independent evaluation across the
Peninsula
• To seek the views of the general public on
specialist services for treatment of less
common cancers as well as patients and carers
• Procurement of an independent research
organisation
• Involvement of PCTs and lay members in the
procurement process
MORI - Qualitative Methodology
• Deliberative events – in five venues with
recruited members of the public (100 people
in total)
Deliberative events
Case for change video
• Making the case for change
Qualitative Methodology
• Deliberative events – in five venues with
recruited members of the public (100 people
in total)
• In-depth interviews
– hard to reach audiences (11 interviews)
– Cancer patients (15 interviews)
– Carers of cancer patients (5 interviews)
Quantitative Methodology
• Telephone survey of 1003 people aged 16 and
over comprising a representative sample of
the Peninsula population and each PCT
– Initial views and understanding
– Reaction to the case for change
– Exploring concerns and how the public would like these to
be mitigated
Reflecting on experiences
• Importance of starting with strong and aligned
clinical and organisational support (role of
independent clinical review)
• Role of OSCs and timing of proposals
• Importance of mitigating measures
• Preparing for impact on individuals involved
• Taking a social marketing approach – understanding
the perspective of patients
• Balancing duties in relation to clinical governance
and involvement
• Impact of the media/ perceptions of proposals
Issues and concerns video
• Issues and concerns video
MORI Findings
• Despite media attention only 29% aware and most
of those knew little
• Many misconceptions
– Stronger negative feelings expressed in Cornwall
• Principle – travelling further for better outcomes –
supported by >70% (across all PCTs
• Concerns over travel and accommodation, costs and
communication
Key Issues Raised During Engagement
•Travel
•Accommodation
•Continuity of care
Group Work
•What mitigating measures could be put in
place to assist with successful
implementation?
Mitigating Measures Proposed – travel,
accommodation and continuity of care
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Capping charges at £20 each way travelled
Appointing a further Cancer Nurse Specialist
Developing a joint Patient Held Record
Case by Case review process
Negotiation of discounted weekly rates for
accommodation for visitors
Local Video Links
Flexible Admission and Visiting Times
Continuity of Consultant
Patient information DVD