Mid Nottinghamshire CCGs Strategy for delivering Adult Cancer Services
Mid Nottinghamshire Cancer Strategy - March 2015
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Executive Summary
The incidence and prevalence of all cancers across Mid Nottinghamshire continues to increase at
more than 3% per year. Key drivers for this trend include an ageing population, improved earlier
diagnosis and continued improvements and availability in cancer treatments. All cancer prevalence is
expected to double between 2010 and 2030.
The increase in prevalence of all cancers and increased complexity of needs of those living longer
with their cancer, has produced a significant and sustained increase in demand on secondary care
services, which is not sustainable for health services, nor meeting the needs of patients.
While overall, cancer outcomes are improving, for most cancers, outcomes for some cancers across
Mid Nottinghamshire remain worse than the England average and that of the Area Team.
In May 2014, Greater East Midlands Commissioning Support Unit (GEM CSU) presented the findings
of the commissioned ‘Cancer Deep Dive’ to Mid Nottinghamshire Health community. The report and
presentation confirmed that across Mid Nottinghamshire, cancer outcomes and spend when
compared against comparator CCGs, demonstrated potential opportunity to improve cancer
outcomes and release resources. While the report defined particular interventions which could
potentially deliver significant savings and improve outcomes, it also confirmed, with further
discussion during the presentation, the added benefit of commissioning across ‘whole pathways of
care’ with specific focus on primary prevention, early detection, improved cancer treatments,
survivorship pathways and end of life care.
The report defined key tumour site outliers, for outcomes and spends, by CCG, in particular, but not
exclusively, lung, breast, colorectal and Lower Gastro-Intestinal across Mid Nottinghamshire.
Many of the recommendations described in the Deep Dive Packs presented to the CCGs reflected
the recommendations described within the NCSI report ‘Living with and Beyond Cancer – Taking
Action to Improve Outcomes’, published in 2013. The scope of the Deep Dive however, includes
reference and recommendation to Primary and Secondary Prevention of cancer, and the role of
commissioning across health communities to deliver systematic prevention messages and support.
‘Living with and Beyond Cancer – Taking Action to Improve Outcomes’ suggests resources tied up in
secondary care follow-up, are estimated to be £1554 per patient over 5 years (excluding inpatient
costs). For low and medium risk patients, the use of follow up can be reduced, by unlocking of this
resource and redirecting it to support self-management interventions, care planning and
coordinated care. A study in Manchester suggests that once inpatient, outpatient and emergency
costs are considered, it should be possible to unlock savings of £1,000 per patient through a
stratified approach to follow-up, pathway;
Mid Nottinghamshire Cancer Strategy - March 2015
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“Current face-to-face out-patient follow up is not meeting patients’ needs, isn’t good value for
money, and won’t cope with increasing numbers. Routine follow up appointments are not effective in
terms of detection of recurrence. In practice the large majority of recurrences are detected either
by patients themselves or on investigations which can be planned without a patient having to attend
a clinic.” Models of aftercare support for the majority of cancer survivors are generic with other
long-term conditions. In some areas, specialist cancer specific services and programmes are needed.
(NCSI 2013).
Local stakeholder events underpinning the programme of integration of services for LTCs across
Newark and Sherwood during 2012 /131 clearly articulated the case for change; a move towards
integrated patient centred services that proactively support self-management, care coordination
and shared decision making.
NHS England’s NHS Outcomes Framework2 describes the 5 domains of the NHS for people with Long
Term Conditions. The NCSI recommendations and approaches to supporting people to live with and
beyond their cancer diagnosis, aligns with the National Long Term Conditions programme, through
several key recommendations;
1.
2.
3.
4.
5.
6.
Access to Information and Support from the point of Diagnosis
Promoting Recovery
Sustaining Recovery
Managing the Consequences of Treatment
Supporting people with active and advanced disease
Improving Survivorship Intelligence.
The Better Together Programme provides both CCGs with a significant opportunity to address the
issues raised in these reports, in the context of improving patient experience, patient outcomes, and
redesigning cancer services. The intended actions will release capacity within secondary care and
will direct care to the most appropriate service provider, including Primary care, community based
services and the Third Sector, based on evidence collated from the NCSI pilots and increasing
experience across the UK.
1
2
th
Newark and Sherwood Integrated Care for Long Term Conditions Stakeholder Workshop May 9 2012
http://www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/
*including implementation of all recommendations of recovery package
2
http://www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/
*including implementation of all recommendations of recovery package
Mid Nottinghamshire Cancer Strategy - March 2015
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Content
Page
1. Cancer Incidence, prevalence, survival and mortality rates.
2. Routes to Diagnosis
3. Deep Dive Summary
4. Deep Dive Recommendations
5. Cancer Waiting Times
6. Cancer Prevention
7. Earlier Diagnosis
8. Acute Oncology
9. Cancer Survivorship (Living with and Beyond Cancer)
10. Current position of cancer services across Mid Nottinghamshire
11. Patient Experience
12. Summary
Commissioning Intentions for Mid Nottinghamshire
1. Primary Prevention
2. Earlier Diagnosis
3. Commissioning the Recovery Package
4. Proactive Management of Cancer as a Long Term Condition
5. Risk stratification
6. Programme Delivery Enablers
7. Summary
8. Generic Redesigned Cancer Pathway
9. Distribution of needs of cancer patients
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1. Cancer Incidence, prevalence, survival and mortality rates.
Nationally, and across Mid-Nottinghamshire, the incidence and prevalence of cancer is increasing
and anticipated to double by 2030.
Over the last ten years in Great Britain (between 2000-2002 and 2009-2011), the Age Standardised
incidence rates increased by 3% in males and 7% in females3.
Table 1. Local Cancer Intelligence (NCIN4 and Macmillan Cancer Support September 2014)
CCG
CCG Pop
All
Anticipate All Cancer All cancer DASR
One
5 year
Sept 14
Cancer
d cancer
Incidence
Incidence
Cancer
year
Survival
Prevale prevalence DASR
Per local
Mortality Surviv
nce (est by 2030
/100,000
CCG
/100,000 al
2014)
(2010)
population
(3.2%
(est 2014) (2012)
growth
pa)
Mansfie 187,599
6,204
10,300
633
1390
344*
67%
48%
ld and
Ashfield
Newark 130,090
4,097
6,800
620
942
273**
71%
48%
and
Sherwo
od
Mid
317,689
10,300
17,100
2332
Notts
total
England
UK
UK
599
> 331,000
290
LAT
LAT
/ LAT
2million. 4million
68%
48%
Growth
>3.2%
Engla England
all
nd*** 54.3%
cancers
70.5%
*Direct Age standardised rates for cancer mortality in the top 4 tumour types in Mansfield and Ashfield are all higher than
the England average. The four combined account for 54% of all cancers. (CRUK 2014).**The Direct Age Standardised rates
for cancer mortality in breast and prostate for Newark and Sherwood are in the bottom quintile of the comparator group.
(GEM 2014) and significantly higher than the England average (NCIN 2014). *** England data from CRUK DASR all cancers
excluding non-melanoma skin cancer.
Due to the lower numbers at CCG level, 1 year survival rates by tumour site and CCG are not
available.
3
4
Cancer Research UK 2014
National Cancer Intelligence Network
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2. Routes to Diagnosis
The four tumour sites identified in the table below account for more than 54% of all cancers5.
2.1. ‘Managed Routes’ include patients who are referred by 2 week wait, or referred to a
specialist by GP for signs and symptoms which are of concern, or who may be managed by
their GP as ‘watchful waiting’
2.2. Screening programmes are aimed at age specific groups of patients who are asymptomatic.
Currently, screening programmes exist for Bowel, cervical and breast cancer, and pick up
rates vary for all three programmes across the two CCGs. Bowel screening pick up is less
than 60% locally and nationally. As more than 40% of patients offered screening are not
participating in the programme this presents a challenge to the CCGs in improving outcomes
for bowel cancer. Breast screening and cervical screening pick up rates are significantly
higher, although they have dropped in recent months. Prostate cancer screening is not
currently available in the UK. However the Prostate Cancer Risk Management Programme is
available on request, following information and risk awareness between GP and patient,
2.3. Patients who present as an Emergency exhibit poorer outcomes than those through
managed routes, as the presentation is often as a result of symptoms created by the primary
or metastatic tumour, e.g bowel obstruction, retention of urine or difficulty breathing.
Table 2 Routes to Diagnosis (2006-2010) (NCIN 2014)
Table 2. (F)= female only
DASR by route per 100,000
Screen
detected
Managed
Mansfield and Ashfield
Breast (F) 35.8
68.2
Colorectal 3.7
30.2
Lung
32.8
Prostate
78.4
Newark and Sherwood
Breast (F) 45.0
70.3
Colorectal 2.9
32.2
Lung
Prostate
England
Breast (F)
Colorectal
Lung
Prostate
5
Percentage by route
Emergency
present.
Other
Screen
detected
Managed
Emergency
present.
Other
6.4
12.5
20.8
12.8
2.6
1.1
1.0
1.3
27%
7%
-
63%
62%
58%
84%
5%
28%
40%
15%
5%
2%
2%
1%
4.0
11.1
6.0
1.8
33%
6%
58%
67%
4%
24%
5%
4%
-
26.9
83.7
15.5
10.2
0.7
5.2
-
60%
84%
30%
11%
2%
5%
38.4
2..5
-
71.2
29.3
27.5
88.7
3.9
10.2
16.6
8.9
6.0
1.9
1.6
5.7
28%
5%
-
62%
66%
58%
85%
5%
25%
38%
9%
5%
4%
4%
5%
Cancer Research UK 2014
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3. Deep Dive Summary (caution advised by authors).
The authors of the Deep dive advised caution in considering the potential savings at CCG level:
“Further investigation is required to understand this variation…”6
The deep dive data focussed on the CCG achieving the group mean against a number of indicators,
including;




Prescribing
Practice benchmarking
Cancer expenditure on elective and non-elective admissions.
Cancer controls.
Mansfield and Ashfield CCG
a.
b.
c.
d.
In the highest quintile in the benchmark group and England for all secondary cancer care spend
In the highest quintile in the benchmark group and England for inpatient cancer spend including
Lung, Upper GI and Lower GI.
In the highest quintile in the benchmark group and England for emergency cancer spend
including Upper GI.
If the CCG were to move to the benchmark group average, the following improvements would
be seen:
£1.7m reduction on all secondary care cancer spend, including:
 £562K on emergency cancer spend
 225K on inpatient lung cancer spend
 117K on lower GI inpatient spend
e.
f.
Higher cancer-spend may be linked to higher prevalence.
Mortality and Survival indicators suggest that there are opportunities for improving cancer
control of breast, prostate and colorectal cancers. This is confirmed by NCIN data (2014)7.
Newark and Sherwood CCG
a. Average recorded prevalence of all cancer compared with comparator CCGs in group.
b. Significantly higher spend and admission rates for all secondary care, inpatient/day-case elective
care and non-elective care
c. Significantly higher spend on cancer prescribing
d. Significantly higher emergency bed days
e. Significantly higher rate of GP urgent cancer referrals
f. Significantly higher premature mortality from breast cancer
6
7
GEM CVS Cancer Deep Dive Mansfield and Ashfield May 2014 Power point presentation.
National Cancer Intelligence Network 2014.
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g. Significantly higher premature mortality from prostate cancer
h. If the CCG were to move to the benchmark group average, the following improvements would
be seen:
£ 503,199 reduction on secondary care spending including;



Cancer secondary care spend (all cancers) per 1000 population £446529
Lung cancer inpatient spend per 1000 population £44126
Lung cancer day-patient spend per 1000 population £12544
NCIN (2014) confirms that Breast and Prostate Mortality is significantly higher in Newark and
Sherwood than the England average.
4. Deep Dive recommendations (Mansfield and Ashfield and Newark and Sherwood)
The potential benefits described within the Deep Dive pack focused on;
a.
b.
c.
d.
e.
f.
Primary Prevention
Early detection (screening programmes)
Earlier diagnosis and prompt treatment
Better treatment by cancer type
Better survivorship
Better end of life care
The Deep Dive recommended a range of interventions, including (not limited to)
a. Better Cancer control, with particular reference to Breast and prostate (N+S) and all cancers
(M+A)
b. Prescribing audit
c. Development of information sharing across Primary and Secondary Care
d. Recording of Staging and Grading data
e. Review of day case activity
f. Implementation of enhanced recovery (if not in place)
g. Ambulatory breast surgery
h. Investigation into late diagnosis using NAEDI tool in Primary care
i. Further investigation of quality of breast and prostate specialist services using the Breast
and Prostate Audit tool.
5. Cancer Waiting times.
Cancer waiting times across both CCGs are reported monthly across 11 standards and are reported
by provider and CCG including 2 week waits (referral to specialist) 31 days, Decision to treat to
treatment starts, and 62 days, referral to treatment
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To date, NUH and SFHFT have received a year on year increase in 2 week wait referrals. Throughout
2014 both providers have breached several of the waiting time targets citing the following causes;
a.
b.
c.
d.
Patient choice
Capacity
Patient illness
Hospital cancellation
Both providers have received a significant increase in cancer referrals and increased numbers of
patients receiving treatment.
While patient choice is often cited as a reason, with particular reference to 2ww, as demand
increases there is less flexibility for patients to choose an appointment that will meet their needs,
leading to later appointments being offered which breach the waiting time targets.
Breaches of the waiting times targets particularly at 62 days include late tertiary referral and
complex diagnostics.
The challenge facing secondary care to meet the targets will increase as incidence of cancer
increases.
Currently, Newark and Sherwood CCG cancer waits are of significant concern across 2ww, 61 days,
breast symptomatic 2ww and 31 day subsequent treatments. In Mansfield and Ashfield, targets for
2ww breast symptomatic and 62 days are in breach.
6. Cancer Prevention
Primary Prevention of cancer in Mid Nottinghamshire is led by Public Health. Key public Health
Programmes include;
a.
b.
c.
d.
e.
f.
Smoking cessation programmes
Alcohol awareness programmes
Exercise referral schemes
Weight management programmes
Sexual Health Programmes including HPV vaccination
Cancer awareness programmes (‘ Be Clear on Cancer’)
The Deep Dive recognised low-spend by CCG on Primary prevention which was linked to poorer
outcomes. Recommendations include increasing focus on primary prevention, building on the
existing public health programmes, and considering a system wide approach to health education and
interventions. Recommendations nationally include:



Earlier referral (Revised NICE Guidelines currently under consultation)
Direct access to investigations – positive impact on 5 year survival and survivorship
pathways. (Improvements seen in Australia, Canada and Europe)
References to follow
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Secondary prevention measures include;
a.
b.
c.
d.
Increasing uptake of screening programmes
Reporting and recording of grading and staging data
Performance status – age, co-morbidity, cancer associated morbidity
Utilization and effectiveness of healthcare services
7. Earlier Diagnosis
The Cancer Deep Dive made recommendation for practices to use cancer decision support toolkits to
assist in the referral process and ensure that referral guidelines are central to referral decisions.
Many practices across the CCGs currently use one of many available electronic or table top reference
guides to support referrals processes.
Currently, PHE delivers several key cancer awareness programmes throughout the year, with
support from the regional Strategic Clinical Networks, which are reflected locally through local
media, pharmacies and practices. Current programmes include Lung Cancer ‘Cough Campaign’ and
Urological ‘Blood in Pee’. Regional pilots are in place for Ovarian and Breast Cancer. Locally, during
and after the national campaigns, services have seen an increase in presentation to Health services
for the cancer types, while activity over the succeeding weeks has returned to pre-campaign levels
of presentation and activity.
8. Acute Oncology
Following the publications of the National Cancer Action Team NCAG Report in 2009, Acute
Oncology Services have been established at both NUH and SFHFT. These un-commissioned services
aim to ensure that patients with a diagnosis of cancer who attend hospital as an emergency as a
consequence of their cancer or its treatment, are seen by a cancer specialist.
Patients seen by the AOS present with a range of needs including
•
•
•
•
Oncological Emergency including Neutropaenic Sepsis or Malignant Spinal Cord
Compression
Recurrence or exacerbation of existing cancer or metastasis presenting as an emergency
Presentation with Cancer of Unknown Primary – often near to End of Life
Side effects or consequences of treatment
Many patients attending ED and seen by the AOS service, are actively undergoing treatment, and
seek intervention for symptoms and side effects. Early indications show that some of these patients
would benefit from proactive care planning, and closer management in primary care and reduce the
need for emergency admission. More detail is needed to understand the scale of patients who
potentially can be cared for closer to home. As the implementation of the Recovery Package is
embedded, proactive care planning will enable this to be more clearly understood.
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9. Cancer Survivorship
As more people are diagnosed earlier and treatments develop, more people are living longer with
cancer. Over the past 30 years however, models of aftercare and support for this group of patients
remains largely unchanged. Most follow-up and monitoring continues to be delivered within
secondary care settings.
Recognising the significant and increasing financial challenges, existing unmet needs of people at the
end of treatment, consequences of treatment and the need to improve outcomes for people with
cancer, the NCSI8 in 2013 published its recommendations to address these challenges.
Key issues identified included the need for;





8
Coordinated care for people living with cancer across the whole pathway, through and after
treatment, survivorship and towards end of life.
Proactive care planning and access to information and support to enable people to selfmanage where clinically appropriate
Stronger role for Primary care and information sharing processes across Primary and
Secondary care – Delivered through the commissioning of the ‘Recovery Package’ – a series
of holistic needs assessments and care planning across Secondary and Primary care, and
Health and Wellbeing events to share information and education for groups of people with
cancer and their carers.
Risk stratification of cancer pathways to enable tailor made follow-up arrangements based
on patient needs.
Cultural shift towards shared decision making and support to self-manage.
National Cancer Survivorship Initiative
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The recommendations suggest that implementation of the systematic interventions will free up
resources across the pathway, particularly through the reduction in Follow-ups. Implementation of
national guidelines and regionally agreed clinical pathways for key tumour types including colorectal,
breast and prostate have been demonstrated to reduce follow ups by between 40 – 50% for
colorectal, and in excess of 50% for breast9.
10. Current Position of Cancer Services across Nottinghamshire.
a. SFHFT Cancer Unit.
Kings Mill Hospital is the Cancer Unit providing a range of diagnostics and treatments for some
cancers, including (bit not exclusively) Upper and Lower Gastroenterology, Breast, Lung,
Gynaecology, Head and Neck. SFHFT has no resident oncologist, and therefore Oncology services are
provided from NUH on sessional basis. Haematology services are provided at SFHFT. Newark
Hospital provides some diagnostics, including endoscopy services and out patients, including
outreach Urology clinics from NUH.
Currently, Breast surgery at Kings Mill is provided by a single practitioner, which is unsustainable and
is under priority review.
Patients requiring specialist oncology services are referred to NUH Specialist Cancer Centre. As such,
NUH receives tertiary referrals mainly from SFHFT and ULHT. Patients referred to SFHFT are often
referred onwards to NUH for specialist diagnostics, treatment including radiotherapy, and follow up.
Consequently, patient pathways are often complicated and involve several consultants, teams and
travel across multiple sites.
SFHFT Cancer Lead Dr Shafiq Gill is newly appointed and currently developing the cancer strategy for
SFHFT. Clinical Nursing leadership is provided 1 day per week by Carolyn Bennett.
SFHFT recognises the challenges placed on cancer services and welcome the aspiration to review
end to end cancer pathways.
Currently, the colorectal team are piloting the regionally agreed ‘Curative Intent Risk Stratified
Pathway’ for colorectal patients attending follow-up clinics at Kings Mill. Patients within the pathway
cohort have been identified as at low risk of cancer recurrence at the end of treatment and are
provided with a shortened course of follow-up and information giving, before being referred back to
the GP. Patients are advised of how to rapidly re-access services if they have concerns regarding a
recurrence of their cancer.
NUH and SFHFT are developing closer working relationships and the cancer leads are working to
align cancer strategies where possible. Clinical leads from both Trusts attend the site specific
pathway meetings.
9
‘Living with and Beyond Cancer: Taking Action to Improve Outcomes’ NCSI 2013
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b. NUH
As Cancer Centre, NUH provides all specialist Cancer diagnostics and treatments across
Nottinghamshire and jointly for some tumour types for Lincolnshire. Cancer services are provided at
both City Campus and QMC.
The regional Radiotherapy Centre is located on City Campus and provides a wide range of specialist
radiotherapy services.
NUH is actively engaged in a range of improvement programmes for Cancer including;
•
•
•
•
•
A comprehensive pathway redesign programme, with a key focus on diagnostics and direct
to test, and survivorship. NUH has developed an ambitious cancer plan to redesign and
streamline all cancer pathways. The programme for 2014/15 is focusing on Breast, Lower
Gastrointestinal and Urology pathways, with emerging plans to extend the programme
from 2015/16 onwards.
Head and Neck Pathway redesign, seeking to improve capacity, patient experience and
outcomes.
Radiotherapy Late Effects Programme for people who have had pelvic radiotherapy in
Notts. The team of 3 Macmillan Information Radiographers and Oncologists are developing
late effects pathways, liaising with GPs across the county and preparing information for
patients and carers who have received radiotherapy, to ensure that patients who develop
late effects, understand what to look out for, who to contact and when, and what they can
do to help themselves. This is a new development and is unique in the country. The project
will run for 3 years.
Piloting the electronic Holistic Needs Assessment – one element of the Recovery package10
SCOPES Programme, aimed at improving access to cancer treatment in the over 75s,
through the implementation of the Common Geriatric Assessment, and improving the
performance status of this group of patients.
c. East Midlands Strategic Clinical Network (SCN) – Cancer Programme
The SCN has developed the High Value Populations Workstream, which aims to improve and
standardise cancer pathways across the East Midlands. The Workstream aims to develop cancer
pathways which deliver consistent patient outcomes and costs across the East Midlands. To date,
the SCN is nearing completion of the Upper Gastrointestinal pathway and has launched the Prostate
Cancer Workstream in November 2014.
d. Need to strengthen the links between Specialised Commissioning and local CCG
commissioning functions, particularly in relation to Chemotherapy and Radiotherapy
commissioning.
e. Primary Care and GP Engagement /Leadership
10
Recovery package – series of interventions aimed at improving information sharing to improve patient
outcomes NCSI 2013.
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Newark and Sherwood CCG has an identified Primary Care Cancer Lead – Dr Thilan Bartholomeuz. Dr
Bartholomeuz with Dr Julie Barker are also Macmillan GPs, with dedicated time to support cancer
commissioning and education across the CCG. The CCG has established a Cancer Champions forum in
Primary care which provides a regular opportunity to engage with all practices across the CCG on all
cancer issues.
Mansfield and Ashfield CCG is in the process of appointing a Primary Care Cancer Lead to support
clinical engagement across Primary and Secondary Care.
f.
Cross County working with Lincolnshire.
Lincolnshire CCGs are currently working with NHSIQ to address challenges at ULHT cancer services. A
joint approach is being developed in partnership with Newark and Sherwood CCG. This provides a
unique opportunity to work together to deliver service improvements across the pathways and
planning footprint. Key challenges include their Breast Pathways.
11. Patient Experience
NHS England has continued its commitment to delivery of the annual National Cancer Patient
Experience Survey. The survey is sent to in-patients and asks for feedback on all aspects of the
patient cancer journey, from GP referral through to discharge arrangements.
The survey results for 2014 were published in September 2014. Both NUH and SFHFT develop
improvement plans in response to the NCPES.
Summary results from the Patient Survey by CCG can be found here.
12. Summary
a. Cancer incidence and prevalence across Mid Nottinghamshire continues to increase, with
the associated increasing demand and cost on secondary care services, which is not
sustainable.
b. Scope exists to improve earlier diagnosis through public health education, commissioning
providers to support public health activity, e.g. smoking cessation and weight management
programmes; support for GPs through education and use of decision support tools.
c. Secondary care service capacity is under increasing pressure, at all points along the pathway;
Increasing referral on 2 week waits, increasing complexity of clinical need and treatment
regimes, increasing demand for follow-up.
Cancer survival rates at 1 and 5 years across Mid Notts are significantly lower than England.
d. Breast, colorectal, prostate and lung have been identified as key tumour sites outliers within
the Deep Dive for outcomes and spend. These 4 sites account for more than 54% of all
cancers.
e. Early indicators suggest proactively management of cancer patients undergoing treatment in
Primary/Community care may reduce demand on Emergency services.
f. Growing clinical engagement at SFHFT and NUH and agreement to work across the health
community to improve cancer outcomes and address sustainability.
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g. EMSCN is leading the review and development of key cancer pathways, and developing
service specifications for local commissioning.
h. EMCN legacy includes risk stratified pathways for Colorectal and Breast – one of which is
being piloted currently.
i. NCSI recommendations for redesign of cancer pathways, increased focus on the role of
primary and community care are based on evidence collated from national pilots and best
practice.
Commissioning Intentions for Mid Nottinghamshire CCGs
The Cancer Strategy, (March 2015) described the growing need to review and redesign cancer
services across Mid Nottinghamshire, from prevention through to end of life for people with cancer
and its consequences; and the current opportunities to deliver structural and cultural change as part
of a wider health economy cancer service redesign programme.
Considering the pathway in its entirety realises the enormity of the challenge for the Health and
Social care services.
In 2012, Newark and Sherwood CCG agreed with Macmillan the potential for developing community
based services for people affected by cancer, which in themselves, could provide opportunity to
improve cancer outcomes, patient experience and reduce unplanned activity in both Primary and
Secondary Care Services, and developed the partnership, with the aim of integrating cancer as a long
term condition within the PRISM programme.
Since this time, NHSE, EMSCN and Macmillan, have recommended commissioning a range of
interventions which can make an immediate impact on patients outcomes, which will support the
outcome of redesigning cancer pathways through secondary care services.
This programme identifies the priority interventions for development at both CCG and Better
Together Programme level.
1. Primary Prevention – Public Health Programmes
NHSE and PHE support and drive the Be Clear on Cancer campaigns, which are delivered nationally
and locally. As described within the Strategy, there are further recommendations to support Primary
prevention, which local CCGs and the BT programme will consider that in the longer term, aim to
reduce the incidence and prevalence of cancer.
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2. Earlier Diagnosis.
CCGs will support a range of interventions to deliver earlier diagnosis within Primary Care, which will
need a level of CCG investment. NAEDI recommendations and national findings11 suggest several
interventions which will release cost pressures as more people will require less complex treatments.
Mid Nottinghamshire Cancer Prevalence and outcomes compare low against the national average
for cancer survival at 1 and 5 years, while England itself ranks low when compared with Europe,
Canada and Australia.
Key interventions may include but are not limited to:







Direct Access to investigations from Primary Care, including CT and gastroscopy12.
Early Diagnosis decision Support Tool in every practice13
Early Referral (NICE Guidelines to support this are in consultation – impact statement
attached)
Increasing access to specialist advice and support for Primary Care
New Cancer Case Audit within Primary Care / Peer Review / increased uptake of the NCIN
Practice Profiles 14 as a supportive tool.
Raised local Public Awareness of screening programmes to increase uptake across all
programmes and increased consideration of the Prostate Cancer Risk Management
Programme.
Need to consider the role of a diagnostic hub – detail to follow.
3. Commissioning of the Recovery Package through SFHFT and Primary Care
At a recent Commissioning the Recovery Package meeting across Nottinghamshire, both M+A and
N+S CCGs recognised the need and have recommended commissioning of the recovery package
through either CQUIN or contract to enable SFHFT to implement the secondary care elements of the
package in its entirety across all cancer pathways, promoting quality and equality for all patients
with a cancer diagnosis, irrespective of their tumour type.
A decision is required as to the most appropriate commissioning approach to ensure SFHFT has the
required resources available to deliver this intervention.
11
Peter Rose: National Differences in Cancer Outcomes Macmillan Primary Care Conference 2014– details to
follow
12
NICE 2WW guidelines predict a potential doubling of 2ww referrals by lowering the referral threshold. See
Appendix 1.
13
A range of CDS Toolkits are available, and some are currently used in Newark and Sherwood – will be
discussed further at the PLT in January 2014.
14
NCIN Practice Profiles provide readily available and comparative information for benchmarking and
reviewing variation at a general practice level. GP profiles published before 2012 are mapped to Primary Care
Trust (PCT) only. GP Profiles are available via the CCT (public and NHS professional view).
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The Recovery Package has been designed to complement the stratified care pathway (NHS
Improvement 2012) which enables individualised follow-up care as a supported self-management
programme, shared care or complex care.
The recovery package includes:

A holistic needs assessment (HNA) (NCAT 2010) which is carried out at two key points in
the care pathway and if health and social needs change. The HNA should be conducted
using a standard assessment tool and process within the care pathway (Macmillan
2012). The patient receives a copy of the care plan to enable self-management; further
copies are stored in the medical records and are sent to the GP.

The treatment summary is developed by the multidisciplinary team to inform the patient
and the GP of the care and treatment received (NCSI 2012). The summary includes
possible treatment toxicities and /or late effects, alert symptoms that require referral
back to a specialist team, an on-going management plan, and a summary of information
given to the patient about their cancer and future progress and any required GP actions
to support the patient. The Treatment Summary informs the GP database the Cancer
Care Review. The patient receives a copy to share with other family members and health
care providers. Further copies are stored in the medical records and inform
emergency/unplanned admissions.

A Cancer Care Review is carried out by the GP practice six months following a diagnosis
of cancer (Macmillan 2012), and covers post-treatment support, financial impact of
Cancer, patient awareness of prescription exemptions, possible late effects of cancer
and cancer treatment and the information needs to enable self-management. This is a
QOF requirement currently.

Health and Wellbeing Clinics are education events to give the person affected by cancer
all the information they need to enable rehabilitation and self-management. This may
include the opportunity for advice about work or finance, physical activity and local
services that offer help and support for people living with a long term condition.
NHSE and EMSCN have recommended CCGs commission the Recovery Package to support improved
outcomes for patients with a cancer diagnosis, and is considered the key intervention to support
systematic care coordination and proactive management of cancer treatment, side effects,
consequences of treatment and holistic care aimed at promoting self-care and reducing unplanned
care activity.
As the Mid Nottinghamshire Self Care Strategy is implemented, and the developing self-care models
are piloted and commissioned, their development provides opportunity to integrate Health and
Wellbeing events into the Self-Care programme, building on existing community based resources
and providing a robust self-care for cancer pathway, as a shared delivery model with the Clinical
Mid Nottinghamshire Cancer Strategy - March 2015
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Nurse Specialists and other secondary care clinical staff in community based venues. Macmillan
Cancer Support currently provides a range of patient facing and staff facing interventions to support
the implementation of robust self-care, including education programmes for staff, volunteers and
patients and carers; online and resource centre based information services, support groups and
online support services, which together with emerging self-care interventions and statutory services
aim to provide comprehensive pathways which support self-care and improved outcomes.
4. Proactive Management of Cancer as a Long Term Condition.
Newark and Sherwood CCG undertook in agreement with Macmillan Cancer Support, to develop and
commission community and primary care cancer services, based on local need and best evidence.
Since this time, the Better Together programme and Mansfield and Ashfield CCG has recognised the
need to develop existing cancer services to meet growing demand and complexity of need for
responsive cancer services.
Proactive management and support of patients from the point of diagnosis, through treatment and
at the end of treatment, will improve patient experience, support self-management of the condition,
aims to reduce unplanned activity through ED and in Primary Care and support coordinated
transition into End of Life and Specialist Palliative Care Services. As all cancer treatment and the
majority of follow up is currently managed through secondary care, when patients experience
problems relating to their cancer, its treatment or consequences, the default care provider is
secondary care.
Many patients and Primary care practitioners report however, gaining access to timely and patient
centred response can be difficult and as unmet needs escalate, the patient can often be admitted to
hospital as an emergency. In addition, many of the interventions sought by patients and clinicians
may not require secondary care intervention, rather, access to the appropriate information, support
and advice to enable patients and carers to manage their concerns and symptoms in the local
community.
Audits and monitoring conducted by the developing NUH Acute Oncology Service suggest that many
admissions can be predicted and possibly avoided; for example, many patients on first
chemotherapy for breast cancer experience nausea and vomiting, resulting in admission. However,
active community based monitoring of breast patients on chemo, can trigger earlier intervention,
including support, information, management of expectations, and with agreed prescribing protocols
to enable access to specialist anti-emetic through primary care can reduce unplanned admissions to
AOS services. Active management of a range of treatment related side effects in the community and
primary care can enable planned care activity and increase the AOS teams’ capacity to deliver care
to patients requiring their specialist services, e.g. Neutropaenic sepsis, emergency treatment of
cancer complications advancement including MSCC. Commissioning the recovery package provides
GPs and Primary care staff the opportunity to have a greater understanding of the patient’s needs
and ability to proactively address problems.
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NHS Improvement and the NSCI recommend risk stratifying cancer pathways through secondary care
to reduce clinically unnecessary follow ups and cost pressure across all cancer pathways, but stress
the need for responsive and effective primary care and community based services to support
patients through treatment and as an alternative to traditional models of follow-up.
Based on the emergent evidence base and the opportunities presented by PRISM teams, the CCGs
will support the development of a community based cancer team, and development of the wider
community and primary care workforce, to provide an equitable service to people with cancer as
other LTCs, based on the changing demographic of patient need, and respective pressures on
secondary care.
A community based cancer service will be integrated within the existing locality Integrated Care
teams, and will include:














Proactive patient centred care planning, management and support in Primary care for
patients from the point of diagnosis, through treatment and into survivorship
Monitoring and management of treatment side effects in collaboration with secondary
care specialist services – liaison with Acute Oncology services (potential for development
of an Acute Oncology Outreach Service
Community specialist support and navigation of secondary care services across complex
pathways and multiple care providers
Holistic care planning and signposting to additional community based resources,
management of co-morbidities with other community based and secondary care
specialists
Collation of data relating to unmet needs to inform on-going service developments and
reconfiguration.
Defining further community cancer development opportunities which will improve
patient experience and outcomes, and reduce the burden on secondary care services
Care coordination to support pre- and re-habilitation in relation to cancer treatments
and complications.
Education and Support for primary and community care staff.
Coordination of watchful waiting and monitoring of existing cancer patients (in
particular potential to manage existing prostate monitoring service currently delivered
by LES in N+S).
Proactive management of primary care cancer registers and Cancer Care Reviews
Attendance at Secondary Care MDT meetings and community pathway coordination
Provision of short term psychological support at level 2 (Band 7 Specialists only with
appropriate training and supervision)
Non-Medical Prescribing service
Coordination with End of Life and Specialist Palliative Care Services.
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5.
Risk stratification of Secondary Care Cancer Follow-up pathways
As the incidence and prevalence of cancer increases, and more people with cancer are living
longer after diagnosis, existing systems and pathways are not sustainable. Risk stratification of
key pathways removes activity that has no clinical benefit, provides the opportunity to release
resources from secondary care, increase secondary care capacity and redirect to community and
primary care cancer service development.
Stratified means that the clinical team and the person living with cancer make a decision about
the best form of aftercare based on their knowledge of the disease, (what type of cancer and
what is likely to happen next), the treatment (what the effects or consequences may be both in
the short term and long term) and the person (whether they have other illnesses or conditions,
and how much support that they feel they need). The three levels of aftercare are:




Supported Self-Management – where patients are given the information about selfmanagement support programmes or other types of available support, the signs and
Symptoms to look out for and who to contact if they notice any, what scheduled tests
they may need such as annual mammograms, and how they get in touch with
professionals if they have any concerns.
Shared Care – where patients continue to have face to face, phone or email contact
with professionals as part of continuing follow up.
Complex Case Management – where patients are given intensive support to manage
their cancer and/or other conditions.
The Ribbon Charts below provide a visual representation of the needs of patients by cancer type.
The segments within the diagram represent the stages within the pathway and the volume of
people within the section. (Some double counting for those who are diagnosed and die in the
same year).
The diagram therefore suggests for Breast and Colorectal cancers (two of the most prevalent
cancers) that more people are living longer in ‘survivorship’ and it is this group of patients who
are increasingly developing late effects from treatment, requiring on-going, often primary care
led interventions, or referral back into secondary care. This group will increasingly place greater
demand on Primary care and community services. A proactive management approach will assist
in the identification of needs, ensuring appropriate intervention and onward referral, and ongoing service developments.
Prostate Cancer is not represented here although this remains in the top 4 most prevalent
cancers.
The CCGs will commission risk stratification of key pathways within secondary care, and promote
sharing of information and data across the Primary Secondary care interface to support coordinated care, improved outcomes and reduced unplanned activity for this group of patients.
Consideration of key pathways should include:
Mid Nottinghamshire Cancer Strategy - March 2015
20
•
•
•
•
•
•
Colorectal
Breast
Prostate
Upper Gastrointestinal
Gynaecology
Lung
Prioritisation of these pathways will be negotiated with Secondary care. However, early
discussions with Exec Directors and Clinical Leads align priorities as Colorectal, Prostate and
Breast.
6.
Programme Delivery Enablers
6.1. Communications and Engagement
Success in delivery of such a change programme requires comprehensive engagement,
involvement and communication with key stakeholders, including
• Patients, carers,
• Community staff
• Primary care staff including GPs, Practice Nurses, and admin
• Wider public
Key messages need to align with Better Together strategies, with group specific messaging for
professional groups, and patients, carers and the public. Implementation of the Cancer Strategy
will include an engagement plan for patients and carers to co-create the service developments
and improvements at locality level.
6.2.
Shared Vision and Purpose
The cancer strategy will be delivered within the transformation programme, building on the initial
foundations established through the PRISM programme. The principles of leading Large Scale
Change, (LCS) required to deliver the Transformation Programme will be applied to deliver the
full integration of cancer within this context, through the existing and future partnerships with
Macmillan Cancer Support, CCG, Primary and Secondary care providers, Social Care and other
Third Sector organisations engaged in the programme.
6.3.
Workforce Planning
Initial workforce scoping, workforce engagement and skills audit locally and nationally identify
the need for short and long term workforce planning to meet the changing needs of the
population, and the need to deliver integrated cancer and LTC care based on need not diagnosis.
Existing opportunities including the OD Programme of CHP and the Macmillan Action Learning
programme aim to inform the workforce requirements to support on-going planning. Practice
engagement through the Cancer Champions model and Macmillan GPs will ensure that Primary
care developments are developed in partnership with GPs and Primary staff.
Mid Nottinghamshire Cancer Strategy - March 2015
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6.4.
Testing and Piloting
New innovations, with tried and tested models of care delivery will be explored and tested where
needed, and developed and implemented based on best local and nation evidence of clinical and
cost effectiveness, developed in partnership with key stakeholders across the CCG area, and
offered for roll out across Mid-Nottinghamshire.
6.5.
Evaluation
The integration of cancer into community care long term conditions model across Newark and
Sherwood will be evaluated and the learning shared locally and nationally. The evaluations will
include a range of PROMS, metrics to support QIPP and share the learning of the processes that
supported the transformational change programme, to demonstrate transferability and
sustainability.
7.
Summary
The numbers of patients diagnosed with cancer and living for more than 5 years, is increasing at
more than 3% per year. Increased incidence and prevalence and reducing mortality is providing
increased pressure on traditional models of cancer service delivery which is widely considered
unsustainable.
A wide range of interventions are recommended by the NHS IQ, DH, Macmillan Cancer Support,
NHSE and are described above.
Macmillan and Newark and Sherwood CCG have worked in partnership to define the key issues,
co-create models of care based on local need, which aim to improve patients experience,
outcomes, and reduce future pressures on the health system, by integrating solutions with the
emergent service models and pathways developed through Better Together and
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Colorectal Risk Stratified Pathway – (also represents breast and prostate)
Mid Nottinghamshire Cancer Strategy - March 2015
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24
Mid Nottinghamshire Cancer Delivery Programme