Renal Cancer Expression of Interest - Detailed Proposals

Transcription

1

2 Renal Cancer Expression of Interest - Detailed Proposals

3 Trust Clinical Lead Managerial Lead Royal Free London NHS Foundation Trust Robin Woolfson, Divisional Clinical Director Sue Lyons, Divisional Director of Operations Date completed 30 January 2013 Interested in providing Local pelvic cancer unit x Local renal cancer unit x Pelvic cancer surgical centre Renal cancer surgical centre x Proposed sites Local pelvic cancer unit(s) Complete Part I Royal Free please refer to separate documentation Pelvic cancer surgical centre(s) Complete Part II Local renal cancer unit(s) Complete Part III Renal cancer surgical centre(s) Complete Part IV Royal Free Royal Free Renal Cancer Expression of Interest - Detailed Proposals 2

4 Contents 1 Introduction p 4 2 Renal Cancer Services 2.1 Our understanding of the requirements p The vision for renal cancer services p The Royal Free s governing objectives p 8 3 Updated specification responses to specific Issues 3.1 Leadership p Patient pathway p Joint working p Local services p Transport p Audit and outcomes p Organisational capacity p 27 4 Support from other organisations p 30 5 Outline of proposed local renal cancer unit p 31 6 Outline of proposed renal cancer surgical centre p 35 Appendix 1 Illustrative patient journey interview p 45 Appendix 2 Letter of support from Professor Mark Emberton, Professor of Interventional Oncology, Division of Surgery & Interventional Science, University College London p 48 Appendix 3 Letter of support from Professor Chris Boshoff, Director UCL Cancer Institute p 49 Appendix 4 Renal cancer patient survey p 50 Renal Cancer Expression of Interest - Detailed Proposals 3

5 1 Introduction In response to London Cancer s letter of 19 December 2012 and building upon our previous Expression of Interest submission on 28 September 2012, this document outlines the Royal Free s detailed proposals for the delivery of specialist renal cancer services. It provides further information on the proposed: local renal cancer unit; and renal cancer surgical centre. Our response and submission to become a local pelvic cancer centre is detailed in a separate document. There are five main reasons why we believe we are the most appropriate centre to be designated for renal cancer. Firstly, our vision is to lead the creation of a world class renal cancer platform that delivers both patient focussed and collaborative integrated clinical pathways and an internationally recognised academic centre. We believe that our board s vision is aligned with the ambition and aspirations of London Cancer. Secondly, we believe that our relevant track record of implementing and developing patient centred clinical and research networks, including in renal, HPB (including cancer), plastic surgery and vascular surgery, shows that we are ideally equipped to lead the renal cancer network service. We have the skills and experience in managing the implementation of and transition to internationally renowned clinical and academic platforms. Our close relationship with UCL means that we are able to provide excellent leadership from a clinical and academic perspective, and ensure that the service would deliver both excellent patient outcomes and contributions to research. Thirdly, our world class care principles of positively welcoming, actively respectful, clearly communicating and visibly reassuring structure and guide our patient and staff experience improvement. We have listened to and understood the transport concerns of patient representatives, and have responded to ensure that our proposed model of delivery is accessible to all patients irrespective of their location. An example of our recognition of the importance of this issue is our commitment to deliver free parking for renal cancer patients and their relatives. Fourthly, much of the infrastructure required for the successful implementation of the service outlined in the specification is already in place at the Royal Free. To deliver this vision certain developments are required, but there are significant components which are already in place. This includes our existing relationships and arrangements with local centres, including Barnet & Chase Farm Hospitals NHS Trust, Princess Alexandra Harlow NHS Trust, North Middlesex University NHS Trust, Whittington Hospital NHS Trust and UCLH NHS Foundation Trust. We already run specialist multi-disciplinary team meetings, which other organisations from North Central London join by videoconference. The success of this approach demonstrates both the proof of concept for this model and our ability to develop and provide leadership across a network. The vision outlined in this document is therefore well grounded in the reality of the existing service and infrastructure. Finally, our status as an NHS Foundation Trust with strong financial performance and governance systems, and our strong existing relationship with UCL, are evidence of an organisation that has the ambition and capability to realise this vision to agreed timescales. We have a robust academic plan, confirmed by written support from our partners, to help realise this vision for renal cancer services. Our board has made an absolute commitment to working in partnership with other members of UCLP to achieve this ambition, and will make the necessary investment in leadership and facilities. Renal Cancer Expression of Interest - Detailed Proposals 4

6 2 Renal Cancer Services Section 2.1 (Our understanding of the requirements) explains which sections of the proposal demonstrate how we meet the specification criteria so as to deliver the agreed priorities of an integrated cancer system and the ten key themes identified by London Cancer s research on what matters to patients. Section 2.2 (The vision for renal cancer services) details our vision for delivering a global platform for renal cancer. Section 2.3 (The Royal Free s governing objectives) demonstrates how the core objectives of the Royal Free are aligned with the values and aspirations of London Cancer. 2.1) Our understanding of the requirements In both our previous EOI submission and this response we have worked hard to ensure that the model of care underpins our vision for an integrated renal cancer service: meets the service specification; is aligned with the agreed priorities of an integrated cancer system; and appropriately considers the ten key themes identified from London Cancer s research into what matters to patients. How we meet the service specification Section 5 (Outline of Proposed Local Renal Cancer Unit) and Section 6 (Outline of Proposed Renal Cancer Surgical Centre) of our response demonstrate how our existing clinical and academic infrastructure will enable us to meet the service specifications. Where service developments are necessary these are also clearly identified. Section 3.7 (Organisational Capacity) outlines our ability to successfully implement, manage and lead specialist urological cancer services, describes our existing multi-disciplinary team who would deliver the service, and includes a breakdown of the associated step up costs and an indicative implementation plan. How we will be aligned with the agreed priorities of an integrated cancer system Being patient focussed through listening, communicating, involvement, information, education, choice and personalisation Section 3.2 (Patient pathway) explains the proposed pathway for patients referred for renal cancer surgery or ablation, and that for patients referred with metastatic disease. To design these pathways a wide group of individuals were involved. An example of the patient interviews that were undertaken to ensure that we fully understood what patients want is included as Appendix 1 ( Illustrative patient journey interview). Section 3.5 (Transport) demonstrates that we have heard from patient representatives the importance of access and transport across the network, and this has influenced the design of the pathway to ensure that it is equitable and accessible for patients, irrespective of where they live. Renal Cancer Expression of Interest - Detailed Proposals 5

7 Optimising care along a co-ordinated pathway earlier diagnosis, exceptional treatment for all, local treatment where appropriate, compassionate aftercare and empowering/supporting patient selfmanagement Section 3.3 (Joint working) and Section 3.4 (Local services) explain how we propose to lead an integrated system of collaborative working across a range of organisations, ensuring that patients are treated by local services when appropriate, and the processes that will ensure that only what is necessary takes place in the centre. Increasing value superior outcomes for patients per pound invested Section 2.3 (The Royal Free s governing objectives) demonstrates how one of our governing objectives Excellent value for the taxpayer: improving efficiency and productivity and reducing costs ensures that achieving value has been an organising principle in the development of this model. Section 3.6 (Audit and outcomes) details our approach to measuring patient outcomes and experience to demonstrate that we are delivering a positive and clinically effective service for both the patient and value for the taxpayer. Embedding research for personalised care, equitable access to trials, the discovery of new treatments and evaluating new ways of working together with patients Section 3.1 (Leadership) explains our proposed approach to both clinical and academic leadership and their relationship. Our strong existing relationships with UCL reflecting our tripartite mission of service, research and teaching means that we are well placed to build upon our existing track record of embedding research within patient care and the research participation across the network, for example through clinical trials at the local centres. Section 3.6 (Audit and outcomes) shows our pioneering approach to the measurement and evaluation of patient outcomes, building upon our existing programme of publishing clinical indicators at service line level, which is being led by Professor Steve Powis across UCLP. What matters to patients Whilst making sure that our proposal meets the service specifications and achieves the agreed priorities of an integrated cancer system, we have meanwhile tried to ensure that the proposal will also meet the specific expectations of patients. In order to do this we have used our own patient experience data, patient journey interviews and the ten key themes identified by London Cancer as organising principles for the development of these models of care: Diagnosis patients are diagnosed at an earlier stage. Ethos patients are treated holistically as individuals and with dignity, sensitivity and respect, so that they do not feel that they are treated as a set of cancer symptoms. Communication patients receive written and verbal information about diagnosis and all treatment options, including side effects and quality of life implications. Choice patients and carers are fully involved in the choice of hospital and treatment options. Support patients are given information on support groups, benefit entitlement and are offered emotional and psychological support. Carers carers are fully involved and supported throughout the pathway. Holistic assessment patients have holistic assessments at appropriate stages throughout the pathway, with action to meet their needs taken as a result. Seamless care all patients are assigned a CNS when diagnosed and a community keyworker on discharge. Transport patients should travel only when necessary, and appropriate arrangements should be made for the immunosuppressed; patients should be offered free parking or transport vouchers. Discharge patients and their GPs should be provided with discharge information and follow-up advice. Renal Cancer Expression of Interest - Detailed Proposals 6

8 As a result the patient pathway described in section 3.2 (Patient pathway) reflect the values of renal cancer patients, developed in section 5 (Outline of proposed local renal cancer unit) and section 6 (Outline of proposed renal cancer surgical centre). The key theme of transport is dealt with separately in section 3.5 (Transport). Section 4 (Support from other organisations) and appendices 2 and 3 demonstrate how we have engaged with other organisations, including CCGs, and the support that we have for our proposal from the key stakeholders. 2.2) The vision for future urological cancer services The vision of Royal Free London NHS Foundation Trust is to deliver a world class service for patients with renal cancer. Our bid to improve renal cancer services has a number of key features: Patient focused pathways across a wide network, supporting excellent outcomes, supported by a strong history of partnership working; The creation of an international academic centre to promote and deliver basic, clinical and translational research; Strong academic support and leadership; and An absolute commitment to investment and delivery within agreed timescales. We wish to lead the development of a specialist renal cancer service with services that are patient focused and delivered as integrated clinical pathways with excellent outcomes. This will be underpinned by high quality research and innovation. As demonstrated by external assessment the Royal Free is a strong, progressive organisation, with a reputation for effective partnership working across the NHS and academia. We are experienced in collaborating with fellow secondary and primary care providers to ensure successful outcomes from clinical pathways. It is proposed that the specialist centre would be the Royal Free, and local centres would be those current providers who treat and care for adult renal cancer patients, should they receive accreditation. Therefore, local centres may include: Barnet and Chase Farm Hospitals NHS Trust; Barts Health NHS Trust; Barking, Havering and Redbridge NHS Trust; Homerton University Hospital NHS Foundation Trust; North Middlesex University Hospital NHS Trust; Princess Alexandra Hospital NHS Trust; University College London Hospitals NHS Foundation Trust; and Whittington Health NHS Trust. Renal Cancer Expression of Interest - Detailed Proposals 7

9 The figure below illustrates the relationship between the renal cancer centre and local centres, and the respective functions within each setting. Figure 1 Relationship between renal cancer centre and local centres renal cancer centre CLINICAL ACADEMIC Clinical Leadership across network Appointment of 4 WTE Consultant Urologists Appointment of additional interventional radiologist Surgery Complex clinical trials Ablative therapies 24 hour emergency renal surgeon on call cover 24 hour emergency international radiology on call cover Sprecialist Multi Disciplinary Team Training (including simulator training) Free parking spaces Collection of outcome data Collection of patient experience data Appointment Leadership across network Appointment of UCL chair in Uro-Oncology Appointment of UCL Chair in Renal Cancer Surgery Materials & tissue research Energy & tissue research Nanotechnology research Surgical oncology research Development of renal oncology academic unit at centre Formal links to London Research Institute Formal links to Centre for Medical Imaging Computing Formal links to Yale University School of Medicine Local centre Radiotherapy Standard targeted therapy, supported by oncologist +/- CNS from renal cancer centre Links to Specialist Multi Disciplinary Team Diagnosis OP clinics Follow up OP clinics Appropriate clinical trials Collection of outcome data Collection of patient experience data 2.3) The Royal Free s governing objectives Fundamental to all that we plan and deliver are our five enduring governing objectives. Our governance is structured according to these objectives. Not only do they guide our options and actions, but they recognise that we operate in a context of partnerships, for example with commissioners who need better and affordable outcomes, and ensuring that we meet the standards that are required of us and our networks. They are: excellent outcomes in clinical services, teaching and research; excellent experience for patients, staff and GPs; excellent value for the taxpayer: improving efficiency and productivity and reducing costs; full compliance; and a strong organisation, effectively investing in our staff and our infrastructure to ensure that we are fit for the future. Renal Cancer Expression of Interest - Detailed Proposals 8

10 Excellent outcomes We believe that this is a unique opportunity for the UK that we must not miss and that will provide excellent patient outcomes, and a global academic platform from which to promote excellent teaching and research. Together with UCL, we aim to build a world class service. We describe our vision to lead the network and our robust academic plan further in section 3.1 (Leadership). The Royal Free has consistently been rated as having the best or very close to the best hospital mortality rates in England, and the latest summary level mortality indicator set (SHMI) for 2010/12 confirms that position. We are committed to the delivery and measurement of excellent outcomes as demonstrated by the clinical outcomes reporting work which is currently being led by our Medical Director, Professor Steve Powis, on behalf of ULCP, further detail on which is included section 3.6 (Audit and outcomes). Building upon this existing programme of work we would demonstrate our outcomes by regularly publishing this information. Excellent experience Both patient and staff experience are assessed at board committee and main board levels. Two key indicators of in-patient satisfaction, the degree to which patients have confidence in the clinical staff, and patients recommendations rates, are shown below. Both have significantly improved over the past year. Figure 2 - Improvement in Royal Free in-patient experience, January 2011 to November 2012 Confidence in Staff Recommendation Rate Renal Cancer Expression of Interest - Detailed Proposals 9

11 The renal cancer service will be designed around the needs and experience of patients to deliver the requirements of the renal cancer service specification. This is described further in the section 5 (Outline of proposed local renal cancer unit) and in section 6 (Outline of proposed renal cancer surgical centre). Through effective collaboration and partnership we have delivered real progress in the development and improvement of existing renal cancer services. As a future specialist renal cancer centre, we will work collaboratively with all trusts in the network and with primary care colleagues to strengthen and develop a seamless renal cancer service for patients. The existing specialist MDT will be expanded to build upon our existing links within NCL and expand this to include NEL, thus covering London Cancer s full catchment area. The Royal Free led renal cancer network service will maintain and develop local assessment and followup for all patients with equity of access. Round the clock surgical and interventional radiology services will be based at the Royal Free and out-patient and systemic therapies will be delivered at several sites, including the Royal Free Hospital and Barts Health where patients currently receive targeted therapy. Standard targeted therapies and appropriate clinical trials will also be delivered in other local units pending appropriate oncological appointments. This structure will improve recruitment to clinical trials, and mean that patients will travel only for those parts of the pathway that require centralised expertise or technology. In the 2011 national staff survey (the last year for which full comparable data are available) the Royal Free was in the top 20% of trusts for staff engagement, and was the top rated member of the Association of UK University Hospitals for the number of improved scores over the previous year. Excellent value By investing now in a modern service and consolidating existing activity we will be able to ensure that we are providing value to commissioners and the taxpayer. Our planned and current financial risk rating as a foundation trust is a 4. We recognise that commissioners are likely in real terms to have static or reducing spending power in the years to come, and therefore we must plan to deliver better outcomes in that context. Full compliance As standards, whether of governance or quality and outcome, rightly rise, and as the regulatory framework continues to develop, providers are required who have strong and self critical governance. At the Royal Free we have a well established corporate and quality governance structure that has in the last 12 months been successfully tested through the rigorous Monitor assessment process. We are compliant with the CQC outcomes, and are achieving all the cancer national targets, and we recognise that these standards do matter to patients. The board and its committees are ensuring that full compliance is maintained as new networks and partnerships are developed. Strong organisation Our foundation trust status, and sustained positive performance against Monitor risk ratings and the range of national indicators, demonstrate that we have the necessary leadership, executive scope and resources in place to deliver and realise the vision outlined in the service specification and this document. Section 7 (Organisational capacity) provides further detail. Renal Cancer Expression of Interest - Detailed Proposals 10

12 3 Updated specification - responses to specific issues In addition to our response to the specifications in section 5 (Outline of proposed local renal cancer unit) and section 6 (Outline of proposed renal cancer surgical centre) we have given more information on the seven areas on which London Cancer requested specific detail, namely: 1 Leadership 2 Patient pathway 3 Joint working 4 Local services 5 Transport 6 Audit and outcomes 7 Organisational capacity 3.1) Leadership Show your plans for a named leader for the specialist centre who takes responsibility for system wide collaborative working to ensure availability of relevant specialist expertise for clinical care and research at local units. This section details the leadership arrangements for the renal cancer surgical centre and network and describes the role of the named leader in ensuring system-wide collaborative working. It also outlines the academic leadership role and its relationship with the specialist renal cancer surgical centre, and how this will foster research participation at local units. The academic and clinical leadership will be looking to play a part in the AHSN/UCLP strategy, including for example in wealth creation opportunities. Should the Royal Free be successful in becoming the designated specialist renal cancer surgical centre, we will appoint the best clinical leadership from resources available across the network. We will appoint service directors for both Urology Renal Cancer and for Uro-Oncology within weeks (see Figure 3 below), and we will involve the UCLP Leadership Academy to help ensure a transparent and appropriate process. These posts will provide integrated clinical and SMDT leadership for the service across both NCL and NEL. Renal cancer specialist surgeons will have joint appointments at the Royal Free and local hospitals. These appointments will release sessions at local centres, and these will be backfilled to maintain diagnostic and other clinical services at those hospitals. From various previous service integrations, such as renal, HPB (including cancer), plastic surgery and vascular surgery, we have extensive clinical and managerial experience in the successful development and delivery of both networked clinical services and academic partnerships. We have had helpful discussions with Barts Health colleagues about arrangements were this proposal to be accepted. Renal Cancer Expression of Interest - Detailed Proposals 11

13 Figure 3 Renal surgical cancer leadership structure UCL RFL Division of Surgery [Mark Emberton] Division of Oncology [Chris Boschoff] Division of Transplantation & Immunology & Specialist Services - services include Institute of Immunology & Infection / HPB Services / Sarcoma services / Renal services [Robin Woolfson] Chair of Urology [tba] Chair of Uro-oncology [tba] Renal Cancer Service Director [tba] Uro-oncology Lead [tba] In order to provide leadership across the network the Renal Cancer Service Director would be responsible for the delivery of the following, which would be included in their job description and job plan: Clinical leadership within the renal cancer specialist centre; Providing leadership and direction for the renal cancer network across local centres; Developing optimal relationships with the academic leadership at UCL, Royal Free and UCLH; Ensuring system-wide collaborative working for both clinical and academic matters; Responsible for ensuring research participation at local centres through the identification and implementation of suitable trials to be delivered in local units with support from the medical oncologist and research CNS from the specialist centre; Responsible for the harmonisation of referral pathways and protocols across the local centres; and Responsible for the implementation of MDTs across local centres. At the Royal Free the Departments of Urology and Oncology are managed within the Division of Transplantation and Specialist Services (together with Nephrology, HPB surgery, Immunology and multiple other services). That division is led by Robin Woolfson (Divisional Medical Director), Sue Lyons (Divisional Director of Operations) and Rebecca Longmate (Divisional Nurse Director). They have substantial experience in service mergers and in the delivery of the Royal Free academic agenda. This team is committed to the successful development of a world class renal cancer service. Should the Royal Free s proposal be successful, the process to recruit the Urology Renal Cancer Service Director would begin immediately. In the interim period, leadership would be provided by Miss Gillian Smith (Consultant Urologist & Clinical Lead in Urology), Mr Senthil Nathan (Renal Cancer SMDT chair and interim Surgical Lead) and Dr Ekaterina Boleti (Oncology Lead) who are currently responsible for Renal Cancer Expression of Interest - Detailed Proposals 12

14 the renal cancer service within the North Central London service, which encompasses Barnet and Chase Farm, UCLH and Whittington Trusts, as well as contributing to management of patients from the North Middlesex and Princess Alexandra Harlow Trusts. This interim leadership would ensure a smooth transitional period before the substantive Urology Renal Cancer Service Director came into post. Management resources would be in place to ensure that the clinical leadership was appropriately supported. The Royal Free board and executive have committed to both the investment required to create the network and to deliver a transitional plan. It will review and assess the progress made in the cancer unit and surgical centre to ensure that commitments made are being delivered. Academic leadership The vision is to establish a world class renal cancer service supported by academic development in both urological surgery and uro-oncology, offering patients the greatest opportunity to benefit from research in basic science, health technology development, clinical research, and participation in translational first-in-man research studies. The support of two key UCL academic appointments in the Departments of Surgery and Oncology underpin this strategy. UCL Division of Surgery In April 2012 Professor Mark Emberton, honorary consultant urologist, was appointed to the position of Director of the Division of Surgery and Interventional Science at UCL. To expand and consolidate a modern and progressive academic unit, the Division has been restructured into four research streams: Materials and tissue Energy and tissue Nanotechnology Surgical oncology. Contingent on site designation, the Royal Free is committed to funding a UCL Chair in Renal Cancer Surgery. Professor Emberton has already identified individuals who would be well placed to provide academic leadership to a Centre of Renal Cancer Surgery, with strong statements of interest from world leaders in the field. The development of an academic unit in renal oncology at the Royal Free campus is the Division of Surgery s first priority as described in Prof Emberton s strategy document. This strategy is fully supported by the UCL Dean, Professor David Lomas. [Ref Appendix 2, letter of support] As well as providing considerable resource and infrastructure for this post, Professor Emberton will help to develop formal links between the new academic unit and Professor Charles Swanton (Genetics) at the London Research Institute (soon to move to the Crick Institute), Professor David Hawkes (Imaging) at the Centre for Medical Imaging Computing, and with Professor Peter Schulam, Chair of Urology at Yale University School of Medicine through the established Yale-UCL collaborative. The creation of a UCL Renal Cancer Unit is a unique opportunity for the UK. Research into renal cancer in the UK has not been strong compared with our major international partners, particularly in relation to surgical management. Our proposal provides an opportunity to reverse this position since all elements are in place to create a globally competitive centre of clinical and academic excellence based at the Royal Free. See letter of support at appendix 2. Renal Cancer Expression of Interest - Detailed Proposals 13

15 UCL Division of Oncology Contingent on site designation, the Royal Free is committed to funding a UCL Chair in Uro-Oncology. The renal cancer publication from UCL/LRI, by Professor Swanton ( ), is the most cited paper in renal cancer over the past 24 months. To complement Professor Swanton s appointment and to strengthen clinical and academic medical uro-oncology, UCL is finalising the business case to permit the recruitment of a world-leading academic medical urooncologist with a Clinical Senior Lecturer in Medical Oncology (following the retirement of Dr S Harland). This post will lead urological oncology at UCL, focusing the prostate and bladder research programmes at the Bloomsbury site, and further developing the renal cancer programme, with Dr Boleti, at the Royal Free Campus. This position will complement other UCL recruitment drives in radiation oncology, molecular pathology, and haemato-oncology. To ensure that the benefit of this strong academic relationship is shared across the local units, the oncologists and research CNS from the specialist centre would support the running of suitable trials to be delivered in local units. The specialist centre would focus on more complex trials and translational research, whilst supporting the local units and providing training and education. See letter of support at appendix ) Patient pathway Give a clear outline of the patient pathway and how patients will be supported through it. The patient pathways for renal cancer surgery, ablative therapies and the treatment of metastatic disease are included as figures 4 and 5. These patient pathways were designed around the key themes that matter to patients and will expand existing Royal Free models of working across the London Cancer catchment area. In addition to the ten key themes that matter to patients identified by London Cancer s research, we have also conducted patient interviews with existing service users to ensure that pathways are grounded by the reality of services as currently experienced by patients. Our key principle is to provide an excellent patient experience and outcome in designing the pathway. An example of a semistructured interview that we undertook with patients is included as Appendix 1 (Illustrative patient journey interview). Figure 2 in section 2.2 (The vision for renal cancer services) describes what activities will take place in the specialist renal cancer centre and what will take place in the local centres; and Figure 6 in this section demonstrates the role of the SMDT in ensuring consistent governance and decision making. Section 5 (Outline of proposed local renal cancer unit) and section 6 (Outline of proposed renal cancer surgical centre) provide our detailed response to the specification. Renal Cancer Expression of Interest - Detailed Proposals 14

16 Figure 4 Renal cancer surgery or ablation pathway LOCAL HOSPITAL New Kidney Cancer Local MDT Decision Suitable for Surgery or Ablation Clinical Details to RFL Renal Cancer MDT Co-ordinator Electronic Transfer of Imaging Ongoing Follow Up MDT Co-ordinator Books appointment in Kidney & Urology Centre Adds to SMDM Discussion at SMDM ROYAL FREE LONDON Appointment in Kidney and Urology Centre with surgeon, interventional radiologist, CNS, pre-operative assessment Surgery Discharge Plan confirmed with patient by CNS and sent out to GP, local hospital and patient by Co-ordinator SMDM Review of Histology or FU Imaging First FU Renal Cancer Expression of Interest - Detailed Proposals 15

17 Figure 5 Treatment of metastatic disease pathway LOCAL HOSPITAL New Metastatic Kidney Cancer Local MDT Discussion Clinical Details to RFL Renal Cancer MDT Co-ordinator Electronic Transfer of Imaging Ongoing Follow Up Oncology Clinic with SMDT Oncologist Community Palliative Care MDT Co-ordinator adds to SMDM Discussion at SMDT meeting Standard Systemic Therapy, Radiotherapy Best Supportive Care ROYAL FREE LONDON Decision communicated to GP and local hospital Surgery in Presence of Metastases, Novel or IV Agents RFL Joint Renal Oncology Clinic SMDM Review of Histology or FU Imaging First FU Consider subsequent FU at local hospital Renal Cancer Expression of Interest - Detailed Proposals 16

18 Joint working across the pathway will facilitate the shared governance and improved communication between hospitals to ensure that the experience, quality and outcome of the patient journey do not depend upon where they are treated. Patients will travel for treatment only when necessary, for example surgery. The proposed pathway is streamlined to ensure a minimum number of visits and to enable treatment as appropriate at local centres. The key sections of the pathway are described in greater detail below. Diagnosis (early detection) We will engage with local communities, GPs, CCGs, and health and wellbeing boards to raise awareness and ensure effective access to pathways. We will use our experience in working successfully with GPs and the new CCG leaders to identify whether it may be helpful to apply integrated care principles in aspects of these pathways. All organisations across the network will share common protocols and outcomes across the network. Patients will continue to attend their local centre with review at the local MDT and subsequent referral on to the specialist MDT (SMDT) which will have common membership. Referral to specialist centre SMDT The specialist renal cancer MDT holds two clinics, the first involving medical and clinical oncologists, surgeons, CNS, research nurses, and the second involving surgeons, interventional radiologists and CNS to facilitate streamlined care with minimum travel and therefore maximum use of clinical time. We propose that this established process will be expanded to cover North East London. The management of renal cancer patients from all of London Cancer s catchment area will therefore be based on decisions made at the specialist multidisciplinary meeting. Ensuring the success of this approach across the network for all accredited centres would be the responsibility of the Renal Cancer Service Director. The Royal Free has already established a videolinked specialist renal cancer MDT (SMDT) for the NCL network. This weekly SMDT meeting is coordinated by a dedicated renal cancer MDT co-ordinator and is attended by consultant urologists, consultant medical and clinical oncologists including the acute oncology team, consultant radiologists (including attendance by the UCH interventional cryotherapy team), consultant pathologist, consultant nephrologist, specialist renal cancer nurses and research nurses as well as junior doctors from all specialities. Videoconferencing currently links the Royal Free, Barnet and Chase Farm, UCH and the North Middlesex, with attendance by clinicians from Princess Alexandra (Harlow) and the Whittington Hospitals. The treatment decisions are delivered to patients at local multidisciplinary renal surgery/oncology clinics. Renal cancer CNSs from local hospitals participate in the SMDT meeting, either by attending in person or via video link. Figure 6 shows the how the SMDT sits in relation to the specialist centre and the local centres. Renal Cancer Expression of Interest - Detailed Proposals 17

19 Figure 6 Specialist multidisciplinary team organogram UCL RFL Division of Surgery [Mark Emberton] Division of Oncology [Chris Boschoff] Division of Transplantation & Immunology & Specialist Services - services include Institute of Immunology & Infection / HPB Services / Sarcoma services / Renal services [Robin Woolfson] Chair of Urology [tba] Chair of Uro-oncology [tba] Renal Cancer Service Director [tba] Uro-oncology Lead [tba] Renal Cancer Specialist Multi-Disciplinary Team surgical lead / surgeons / onology lead / oncologists / CNS / radiology / clinical oncology / acute oncology / nephrology London Cancer strategy, oversight, governance Royal Free surgical hub, interventional radiology, systemic therapies, OPD (urology, oncology, acute oncology) Barts systemic therapies, OPD (urology, oncology) Local Centres Barnet & Chase Farm Hospitals NHSTrust Barking, Havering & Redbridge NHS Trust; Homerton University Hospital NHS Foundation Trust; North Middlesex University Hospital NHS Trust; Princess Alexandra Hospital NHS Trust; University College Hospital London Hospital NHS Trust; Whittington Health Renal Cancer Expression of Interest - Detailed Proposals 18

20 CNS co-ordination Communication will be handled through a single co-ordinator function led by the Royal Free Renal Cancer MDT Co-ordinator, to ensure consistency of patient contact throughout their journey. Patients and their relatives will be supported throughout the pathway by a key worker who will be a CNS member of the Renal Cancer Specialist MDT or a member of the Urological Cancer Local MDT at their local hospital. The keyworker responsibility will pass from the local hospital to the Royal Free at the appropriate point in the pathway, but communication between local and central CNSs will be maintained throughout the patient s journey to ensure that they are appropriately supported. An established communication network exists between CNSs currently managing kidney cancer in North Central London, and this model could be extended to all local hospitals in the network. Surgical management Pre-operative surgical patients will visit the Royal Free Hospital only once prior to admission. This visit will occur after the specialist MDT discussion so that the plan can be finalised with the patient, they can meet their surgeon, and undergo pre-operative assessment at the same visit. This approach will be applied across all local centres. There will usually be a single post-operative or post-treatment visit to the Royal Free, but in appropriate cases this follow up could be scheduled to occur in the local hospital following discussion of the follow up plan in the Renal Cancer Specialist Multidisciplinary Meeting. The surgical pathway builds on the existing services that we run where open, laparoscopic and nephron-sparing surgery are already delivered with the requisite services co-located on site (renal medicine, 24 hour interventional radiology, vascular surgery and established pathways for cardiac surgery, HPB surgery and retroperitoneal sarcoma surgery). At present, patients who require robotic surgery are treated by the team at Chase Farm Hospital. Presently, in addition to current renal cancer surgery, we also deliver laparoscopic nephrectomies for living donor transplants (50 per year) with an enhanced recovery programme. Centralisation of surgical services will provide excellent training opportunities for urology and nephrology trainees. Additional surgical management Cardiac Surgery An established pathway exists between Royal Free and The Heart Hospital for carrying out surgery for caval extension of renal tumours, direct extension into the lung requiring excision of diaphragm and reconstruction and atrial extension requiring bypass surgery. Two of the SMDT surgeons working at RFH are designated network specialists who have clear associations with the cardiac team. This pathway has been running successfully for eight years. The Heart Hospital has all the necessary services and support, including Royal Free nephrology. Neurosurgical management for cerebral metastasectomy will be provided at National Hospital, Queen Square, with neurosurgical clinics and outreach available at the Royal Free. Interventional radiology management There is already an established elective and emergency interventional radiology service at the Royal Free. The service is available 24 hours a day, seven days a week and regularly treats patients transferred as emergencies from other hospitals in the area as well as Royal Free patients. Radiofrequency ablation is provided on site by Dr A Goode and colleagues. At present, the cryotherapy service is provided at UCLH by Dr R Illing and colleagues who attend the SMDT and the multidisciplinary surgical-oncology clinic at the Royal Free to facilitate discussion of treatment options with suitable patients. Renal Cancer Expression of Interest - Detailed Proposals 19

21 Oncological management The Royal Free has an established network for targeted and immune therapy, treating patients from the Whittington, UCLH, Barnet & Chase Farm, North Middlesex, and the Princess Alexandra Harlow. We will expand the clinical network across North East London and West Essex, with harmonised treatment protocols and patient pathways. We already provide consultant medical oncologist support to MDT meetings at other network sites and this will be expanded to all local units. Systemic therapy and access to appropriate clinical trials will be provided at local units dependent on patient numbers. The current service has a strong clinical trials portfolio with high levels of recruitment to NCRN, academic and pharmaceutical studies. Approximately 50% of patients referred to the Royal Free renal cancer medical oncology service are already recruited into clinical trials. The UCL Institute of Infection and Immunity and the UCL biobank are both sited on the Royal Free Campus. The Institute, as a translational research hub, will provide cutting-edge research and innovative treatment options for cancer patients. Radiotherapy will be delivered close to the patient s home, and whenever possible at one of the sites offering radiotherapy within London Cancer. Nephrology / medical management The UCL Centre for Nephrology is based at the Royal Free, and provides renal services across NCL and beyond. There is a weekly multi-disciplinary nephrology clinic linked to the SMDT where patients with chronic kidney disease can be reviewed effectively and efficiently, with advice given regarding strategies for reno-protection and renal replacement therapy. There is an established renal genetics clinic run jointly with the Regional Genetics Service providing testing and surveillance for patients with known genetic causes of renal tumours. Follow-up and surveillance Following surgery, patients will be followed up locally, and surveillance to agreed standards will be provided in local centres. Patient travel to the centre will be minimised. Diagnosis, staging, most long term follow-up, and out-patient treatment with targeted therapies will be provided in clinics in local hospitals. Seamless integrated care will be provided by effective joint working under the auspices of the multidisciplinary team and will allow patients to pursue their everyday activities to the greatest extent possible. 3.3) Joint working Demonstrate how joint working across the pathway will be fostered. Include example consultant job plans and proposals for specialist MDT clinics across the system. Our experience is that joint working leads to seamless integration of care. We are committed at an early stage to engage with renal cancer surgeons across the network to revise job plans so that individuals can deliver renal surgery at the centre with backfilling of their sessions to ensure that diagnostic activity at local centres is fully supported and developed as required. Renal Cancer Expression of Interest - Detailed Proposals 20

22 The revision of consultant job plans and the roll out of a wider SMDT encompassing all of London Cancer s catchment area will be anchored in the development of shared protocols, governance processes, the co-ordinating role of the CNS and consistent training. The Renal Cancer Service Director will be responsible for the development and harmonisation of processes and protocols across the network. In renal surgery at the Royal Free a team-based approach is taken to workload, with sessional allocation calculated on an annualised basis. Surgeons work flexibly in the way that best meets patients needs, for example operating lists are cross covered in order to minimise the impact of planned leave. This model of care has been successfully employed with two of the specialist renal surgeons in the MDT who have appointments at Barnet and Chase Farm: we would propose that this model be applied across the network to harmonise processes and protocols. An example job plan is given in table 1. Table 1 - Example job plan for a renal specialist surgeon (one which is already implemented) MON TUE WED THU FRI AM PM Operating List BCF Out-Patient Clinic BCF Operating List Renal Royal Free Renal Cancer Clinic Royal Free Renal Cancer Specialist MDM The job plan also includes an SPA allowance for revalidation, audit, teaching and training, in-patient care and specialist renal surgery out of hours on call rota. We have allowed for 4 WTE consultant renal cancer surgeons to provide this service (in addition to the academic urology post). The model allows for 5 PAs to be allocated to participating consultants to provide one full day operating, one out-patient clinic, weekly SMDT attendance and participation in the on-call renal surgery rota. Joint working is also facilitated by a strong CNS network which facilitates communication and ensures integrated support for patients across the pathway. A specialist MDT is currently in operation across NCL, and our proposal is to expand this to include NEL as well and to ensure that London Cancer s catchment population is appropriately covered. We would enable local centres to join the specialist MDT by videoconference, as per the existing arrangements and would include appropriate time in the job plans of the consultants who would be appointed to attend local MDTs. Further detail is included in the Section 6 (Outline of Renal Cancer Surgical Centre), particularly sections MDT and Treatment Decision. Renal Cancer Expression of Interest - Detailed Proposals 21

23 3.4) Local services Show how you will ensure that only what is necessary takes place at the centre. Include plans to deliver oncology at local units and how emergency readmissions will be managed. We will engage with local communities, CCGs, GPs, and health and wellbeing boards to raise awareness and ensure effective access to pathways. We will ensure that local centres share common protocols and outcomes across the network. Patients will continue to attend their local centre for outpatient urological and oncological follow-up and management. The figure in Section 2.2 (The vision for renal cancer services) outlines what we believe should occur in the local centres and their relationship with the specialist centre. The specialist centre will provide the following support to clinical teams in local units: local centres will have access to the on call specialist renal surgeon at all times for advice and management; local centres will have access to a full Acute Oncology service based at the Royal Free when required, emergency admissions will be transferred from the local centre to the Royal Free within 24 hours. Emergency readmissions have been planned for in our bed model, and capacity for emergency readmission is within the 10 beds identified. A key principle of the proposed approach is that patients are repatriated to their local centre as soon as possible to ensure that only necessary activity takes place in the specialist centre. At present, targeted and immune therapies for renal cancer and access to a range of clinical trials are provided at both the Royal Free and Barts Health. This model would continue. Once appropriate oncological and nursing appointments have been made, standard oral targeted therapy and appropriate clinical trials will also be offered in local units. All treatment will be delivered by members of the renal cancer specialist multidisciplinary meeting according to unified protocols. 3.5) Transport Outline your proposals for supporting patient s and relative s travel to your centre when necessary. In the section above we have emphasised how most patient attendances will continue to take place locally. This section considers how transport options change for those who will need to attend or be admitted to the Royal Free Hospital instead of to another centre. It is worth noting that for a large fraction of the London Cancer population, whether for this or for other specialist services, the Royal Free is already their usual and familiar centre. However for others the need to travel to a specialist cancer centre at all will be a new and unfamiliar experience. Renal Cancer Expression of Interest - Detailed Proposals 22