Upper GI Peer Review Aneurin Bevan University Health Board Nevill Hall & Royal Gwent Hospitals

Transcription

1 Upper GI Peer Review Aneurin Bevan University Health Board Nevill Hall & Royal Gwent Hospitals MEETING ATTENDANCE Peer Review Team Name Job Title Organisation Damian Heron Andrew Baker Yvonne Lush Thirilonganathan Mathialahan Associate Chief of Staff, Cancer CPG Consultant Upper GI & Laparoscopic Surgeon Senior Macmillan Development Manager-Wales Consultant Gastroenterologist Betsi Cadwaladr UHB Betsi Cadwaladr UHB Macmillan Cancer Support Betsi Cadwaladr UHB Mansel Thomas Lay Reviewer Healthcare Inspectorate Wales Duncan Wilkins Consultant Medical Oncologist Betsi Cadwaladr UHB Gareth Brydon Peer Review Lead Healthcare Inspectorate Wales Hywel Morgan Network Director South Wales Cancer Network Network Title Organisation Title Team title South Wales Cancer Network Aneurin Bevan University Health Board Aneurin Bevan Review Date Title 18 September 2013 Name Job Title Organisation Jane Hart Lead Cancer Nurse Jane Dixon Marek Czajkowski Miles Allison CNS Palliative Care Consultant Gastroenterologist/ Chair Upper GI MDT Clinical Director, Gastroenterology Anita Willicombe Judith Willis Upper GI Surgical Care Practitioner Upper GI CNS Cardiff & Vale UHB / Aneurin Bevan UHB

2 Jackie Sliczny Nicola Rogers Paul Edwards Wyn Lewis Chris Coslett Helen Shannon Doug Hymers Julie Smart Deputy Support Manager, Cancer Services MDT Co-ordinator Consultant Surgeon Consultant Surgeon Directorate Manager Dietitian Cancer Services Manager Upper GI CNS Annie Jones Oncology CNS Velindre NHS Trust Hilary Williams Consultant Medical Oncologist Velindre NHS Trust

3 REVIEWERS REPORT Key Themes 1 Structure and Function of the Service Aneurin Bevan Health Board serves a population of over 600,000. Upper GI Cancer services are provided at the two District General Hospitals (DGHs), the Royal Gwent Hospital at Newport and Nevill Hall Hospital at Abergavenny, in addition diagnostic services are provided at a Local General Hospital, Ysbyty Ystrad Fawr at Ystrad Mynach. There is a single Upper GI MDT which meets weekly at the Royal Gwent Hospital. The MDT forms part of the South East Wales Regional Upper GI Service which is based at University Hospital of Wales, Cardiff. The Number of oesophageal and gastric cancer patients managed by the local MDT during the period 2012/13 was 144. Patients may be referred by their GP to either Royal Gwent or Nevill hall or to the endoscopy unit at Ysbyty Ystrad Fawr. Most patients referred to Nevill Hall have their diagnostic pathway managed by a locally based Surgeon. Once a diagnosis is made the patient is referred through to the Royal Gwent MDT, though a small number of cases may be referred through directly to the S E Wales Regional MDT. The Nevill Hall based surgeon is unable to attend the Local MDT meeting at the Royal Gwent because it is the same time as his operating list and there was no Upper GI CNS at Nevill Hall, which meant that there was no-one at the Local MDT who had been directly involved in their diagnostic pathway. A CNS has recently been appointed, and will attend the Royal Gwent MDT. At the Royal Gwent, patients may be referred through a variety of channels including through out-patient clinics, via endoscopy or via emergency intakes. Once a diagnosis has been made, patients will be referred through to the Local Upper GI MDT. Patients who come via nurse-led endoscopy will be sent through to either the weekly out-patient clinic led by a visiting Upper GI Surgeon from University Hospital of Wales, or to the MDTs lead gastroenterologist. There is a large endoscopy service at Ysbyty Ystrad Fawr; patients diagnosed through this route will be referred directly to the MDT at Royal Gwent. Although there were clear differences in the pathways, the MDT were not aware of any evidence of geographical variation in accessing treatment. The Peer Review team noted that there was a very high ratio of non-urgent suspected cancer (non-usc) referrals to urgent suspected cancer referrals (USC) but the MDT feels that this mirrors reality. It was recognised the endoscopy waiting times for Non-USC patients were very long (up to 22 weeks for routine referrals and over 10 weeks for urgent cases) but the MDT lead felt that there was little difference in the pathways for USC and non-usc patients once the diagnosis is made. Following endoscopy, patients have a staging CT locally. USC cases are flagged for radiology and patients receive a letter asking them to ring the radiology department to arrange an appointment. It was accepted that this could sometimes lead to a delay in the pathway. The MDT felt that they had little problem in getting CT scans done quickly. Since 2010 Endoscopic Ultrasound (EUS) has been available at the Royal Gwent and is undertaken by a sole gastroenterologist. Although there is only one list a week, waiting

4 times are deemed acceptable by the MDT, however during periods of leave there can be delays, because of the single-handed service. The only alternative available is to refer them to the University Hospital of Wales for EUS. The Royal Gwent began undertaking EUS guided Fine Needle Aspirations (FNA) in the last year. Following diagnosis and staging, patients referred via Nevill Hall Hospital are reviewed by the locally based Upper GI surgeon, and those considered potentially resectable,or borderline, are booked for discussion at the next weekly MDT meeting at the Royal Gwent. Other supportive surgical procedures are carried out by the Nevill Hall based surgeon, and palliative care is also provided locally. All patients diagnosed via the Royal Gwent or Ysbyty Ystrad Fawr are discussed at the next local MDT meeting at the Royal Gwent. If the Royal Gwent MDT agrees that a patient is suitable for curative resectional surgery, or is borderline, they are referred for discussions at the next weekly South East Wales regional MDT meeting. A surgeon from the South East Wales regional MDT is a core member of the local MDT, as is the regional team s Upper GI Surgical Care Practitioner Emergency resectional surgical cover is provided from UHW, the usual practice would be to transfer the patient to UHW. The MDT accepted that there was no written policy for this. The MDT also agreed that whilst they would look to transfer emergencies to Bristol if UHW were unable to admit, there was no formal agreement with the United Hospitals Bristol Trust. Patients are given the option to receive follow-up locally or go to UHW, most choose to receive it locally. All hospitals use the same protocols, and in addition the local CNS and the regional team s Surgical Care Practitioner act as a link between the surgical centre and local follow-up clinics. Chemotherapy is given as locally as possible. Oncologists from Velindre hold weekly outreach clinics. There are Chemotherapy Day Units at both Nevill Hall and Royal Gwent Hospitals, together with an outreach chemotherapy clinic based at a day centre operated by a local charity, St David s Foundation, and a mobile chemotherapy unit operated by Tenovus. All these chemotherapy services are managed by Velindre Cancer Centre, and staffed by Velindre s out-reach chemotherapy team. Recently a pilot Acute Oncology Service (AOS) has been established by the Health Board with three dedicated AOS nurses providing a service 9-5 at both Nevill Hall and Royal Gwent, together with out-reach support to Ysbyty Ystrad Fawr as required. There are very close links with the 24 hour AOS service at Velindre which has a chemotherapy nurse, specialist registrar and consultant on call at all times. There are no formal arrangements for visiting oncologists to review in-patients, although they will see patients whenever possible. Palliative Care is provided by the Aneurin Bevan palliative care service which operates across the health board. Hospice and hospice at home services are also provided by local third sector partners. If a patient is diagnosed at endoscopy, a proforma letter is faxed to the GP within 24 hours. Letters detailing the outcome of the MDT meeting, including details of management plans etc, are currently faxed to the patients GP within 24 hours. The health board is investigating making them available electronically via the Clinical Work Station, which all GPs in the area can access. 2. Patient Centred Care and Experience There is an Upper GI Cancer Clinical Nurse Specialist (CNS) based at the Royal Gwent Hospital, and recently an Upper GI Nurse has been appointed at Nevill Hall Hospital. The

5 two CNSs provide cross cover for each other. Patients diagnosed at Ysbyty Ystrad Fawr receive are referred post endoscopy to the CNS based at Royal Gwent for support. Benefits advice is provided locally by St David s Foundation and Hospice of the Valleys, or via the service based at Velindre Cancer Centre. There is a specialist Psycho-Social Oncology service available across the health Board, with two specialist Clinical Psychologists. a. Evidence of Key worker The Upper GI CNSs are recognised as the Key Worker for all Upper GI patients. In its review of a sample of patients notes, the Review Team found that the Key Worker recorded in 4 out of the 5 written notes, but were unable to find a record in the Canisc electronic notes. 3 Service Quality and Delivery a. MDT Service Support The Nevill Hall non-resectional surgeon is unable to attend the local MDT at the Royal Gwent because it clashes with his operating list, although it is something he would like to do. As a result, it was possible that patents would not be presented at the local MDT by a clinician involved in their diagnosis. The team feel that the recent appointment of a CNS based at Nevill Hall will provide the link into the MDT. Surgical support to the local MDT is provided by a surgeon from UHW who also holds a weekly out-patient clinic at the Royal Gwent. Cover is provided by a surgeon from Cwm Taf, however there was no surgeon present at 12/51 MDT meetings. The team agreed that this was a concern, but a lecturer had recently been appointed to work with the UHW surgeon and would work 50% at UHW and 50% at the Royal Gwent. In addition the regional team s Surgical Care Practitioner also attended the local MDT as a link with the surgical centre. The MDT lead explained that, if a surgeon wasn t at the MDT, they would refer any patient where resectional surgery may be an option to the next weekly surgical clinic at the Royal Gwent. In this case they may then be referred directly to the regional MDT. Palliative care had not been present at 22/51 MDT meetings, however there had been a change in CNS membership since 2012, and attendance had now improved. b. Service Outcome Data

6 ABUHB National Target Number / proportion of patients undergoing curative resection Number of USC referrals treated within 62 days Number of non USC referrals treated within 32 days Number of patients with Pretreatment stage recorded Number with pre treatment performance status recorded Number of patients entered into clinical trials Number/proportion of patients receiving adjuvant therapy Number / proportion of patients receiving radical chemo/radiotherapy. 27 Oesoph 15 Gastric Stomach 18% -30% Oesophagus 12% - 24% 20=100% 95% 236=100% 98% % 2 70% 47 10% c. Key audits projects and outcomes The MDT participates in the National Oesophago-Gastric Cancer Audit (NOGCA). The Team also participated in the S E Wales wide audit programme. Local projects included a survey of patient satisfaction with a nurse led telephone follow-up service, together with a satisfaction survey for all Upper GI patients in the health board, undertaken by the CNS. d. General Observations The Review Team noted the high ratio of non-usc to USC referrals, being treated within the 31 and 62 day targets. The MDT stated that the USC/Non-USC split reflected reality; 100% of both USC and Non-USC patients had been treated within the waiting times targets. The MDT felt that this was due to close monitoring of individual pathways and good liaison between the MDT co-ordinator, the CNs and the health board s pathway manager. The MDT accepted that Performance status had not been routinely collected and that the NOGCA audit indicated that stage was only recorded in 114 of 144 cases, but stated that this was being addressed. The MDT agreed that the number of patients receiving adjuvant therapy, (13/42) appears low, and that they would review this.

7 The Review Team welcomed the high level of patients who were entered into clinical trials and also donating tissue to the cancer bank. 4 Review of Clinical Information in the Clinical Notes and Canisc A review of a sample of Clinical Notes both paper and electronic (Canisc), showed that a cancer management plans had been agreed at the MDT meeting were recorded in all cases, together with evidence that the cancer plan had been implemented. Care plans were recorded in 4/5 sets of both paper and electronic notes. Whilst all the Canisc records showed evidence that the GP had been notified of the diagnosis within 24 hours, this was not evident from the paper notes. 5 Engagement with Management The Health Board has a Cancer Lead Clinician and a full-time Lead manager. The Team described their links with Management as being reactive; rather than proactive, although it was recognised that the Health Board management support had been very beneficial in the reconfiguration of the services in S E Wales. The Health Board had been supportive of a number of general cancer initiatives e.g. they had funded the Acute Oncology pilot and also funded a Psycho-social oncology service across the health board. The Team haven t yet held a formal Business Meeting but the need for such a meeting is noted in the team s Operational Plan. 6 Culture of the Teams Although the reconfiguration process had not been easy the team felt that they had developed into a strong and effective team, dedicated to the provision of timely and appropriate care. The MDT was well attended, and there were very strong links with the surgical services at UHW, the oncology services at Velindre as well as the rest of the S E Wales Upper GI service. Services at Nevill Hall were not as fully integrated as would be wished, mainly due to the problems of attending the MDT, but the development of a single point of referral there had standardised management, and the appointment of a CNS would help to further improve communications.

8 GOOD PRACTICE The MDT had quickly developed to form a team with good inter personal relationships backed up by good communication between the local MDT and the regional level MDT, especially the surgical centre and oncology centre.. Effective nursing input with strong relationships between all parts of the SE Wales wide service 100% compliance with waiting times targets for treatment particularly given the complex nature of the pathway. Good trial /Cancer Bank entry CONCERNS The lack of input from visiting oncologists in the Acute Oncology service which was being piloted. This may cause delays in getting an oncology opinion for in-patients. Need to systematically record the Performance Score in Canisc for all patients. The MDT has not held an annual Business Meeting in order to consider performance, outcomes and future work programmes. SERIOUS CONCERNS The inability of the Neville Hall surgeon to participate in the single MDT meeting held at the Royal Gwent, although it was noted that there were initiatives such as the recent appointment of a CNS at Nevill Hall to seek to minimise the consequences. IMMEDIATE RISKS NONE Z:\SWCN 13\Peer Review\Upper GI\HB Peer Review Reports\Final Reports\ABHB Upper GI Final report docx