84% Self Assessment WORCESTERSHIRE ROYAL HOSPITAL. Key. Quality and Performance Summary. Trust Results

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1 WORCESTERSHIRE ROAL HOSPITAL Report Type Self Assessment National Benchmark Position: Overall Compliance (% score) Trust WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST Key Guide This service Highest Performing Team Lowest Performing Team Service UAT and UAT/Thyroid Team Measures Publication Date 29th June 2015 Quality and Performance Summary Overall Compliance 84% Self Assessment No assessment took place in cycle Performance range for the majority uat - uat/thyroid cancer services National middle score This benchmark is based on the 46 uat - uat/thyroid cancer services who have completed their assessment in Serious Concerns and Immediate Risks A Serious Concern was identified when the service was last assessed SEE BELOW FOR PROBLEM RESOLUTION 2014 Patient Experience Survey National Tumour Results Patient understood what was wrong 75% Easy to contact CNS 73% Patient had confidence in doctors 86% Patient contact post discharge 93% Patient given enough care 53% The Service has a complete team Members do not cover all relevant disciplines. Trust Results 2014 Patient Experience Survey Trust Tumour Results Given complete explanation - Patient told sensitively - Patient's views taken into account - Patient involved in decisions - Taking part in research discussed - Waiting Times for Trust - All Cancer Services July - September 2015 Treated in targeted time 2 Weeks 82% 31 Days 98% 62 Days 77%

2 Structure and function of the service Measure There is a lead clinician and the core team includes all relevant members Each role needs to attend 95% of the MDT meetings MDT will discuss the treatment plan of all patients All MDT core members attend two thirds of the meetings There are additional members who don't need to attend as part of the core team Patients are offered pre-treatment assessment sessions Key consultants in the MDT spend at least half their time caring for this type of cancer Each thyroid surgeon perform a minimum of 20 operations The MDT discusses a minimum of 100 patients Specified doctors are able to perform lymph node resections All surgery for this type of cancer will take place in the same hospital There is a specific service available for the rescue of a reconstructive surgical flap failure Met N N N SELF ASSESSMENT COMMENTS The joint Head and Neck Multidisciplinary Team (MDT) is a multi-professional group serving a population of approximately 1.5 million living predominantly in Gloucestershire, Herefordshire, Worcestershire and parts of Powys. In addition patients from Shropshire, South Birmingham, Warwickshire, Oxfordshire and North Bristol access the service. The team has services at Gloucestershire Hospitals NHS Foundation Trust GHNHSFT) -Gloucester Royal hospital (GRH) -Cheltenham General Hospital (CGH) Worcestershire Acute Hospitals NHS Trust (WAHNHS) -Worcestershire Royal Hospital (WRH) -The Alexandra Hospital Redditch (AHR) -Kidderminster Treatment Centre (KTC) Hereford Hospitals NHS Trust (HHNHST) -Hereford County Hospital. Outpatients, diagnostics and minor surgery are performed at all six sites with major surgery being undertaken at Gloucester Royal Hospital and Worcestershire Royal Hospital. There are dedicated rapid

3 access clinics for patients referred through the two week wait cancer pathway and those in particular with head and neck lumps. These are held weekly at Gloucester, Cheltenham and Worcester. The team has evolved strong leadership and the sharing of the leadership role works well within this MDT. The Team has support from general, vascular and plastic surgeons and has excellent links with the head and neck team in University Hospital Birmingham Foundation Trust (UHBFT) for the north of the region and University Hospitals Bristol NHS Trust for the region of the 3 Counties. The team functions through a joint MDT on split sites. Weekly MDT meetings are performed using video-conferencing with discussion of all new cases, new recurrences and other difficult decisions through this medium. Discussion of thyroid cancers is now performed on a weekly basis at the same meeting. Recent improvements to the video-conferencing systems at all sites have improved this facility although occasional technical issues still occur. MDT Meetings continue to run run on a Tuesday morning from 8.15am to 10am followed by a head and neck joint oncology clinic on both sites. The 5th Tuesday of the month still is problematic in that the Gloucestershire part of the MDT has no formalised meeting, due to a lack of pathology and radiology support, but can still video-link if there are patients to be discussed. Key Achievements Combined MDT -The formation of the combined Worcestershire and Gloucestershire Head and Neck Team with one linked MDT meeting - All CNS and AHP s at Worcester are Macmillan Professionals. - The agreement and working practice for sharing the clinical lead of the joint MDT - Radiotherapy previously only available at Cheltenham, is now online in Hereford and will be available in Worcestershire later in A separate key worker identified for each county Key achievements site specific GHNHSFT Recent new appointments: Oro-maxillo-facial and reconstructive consultant, Dental Hygienist, Two new Speech and language therapists. Upgrade of Video-Conferencing facilities on Cheltenham Site WAHNHST -New appointments:-support CNS and new - MaxFac Consultant -On treatment clinic at Worcester due to commence in Summer Living well programmes -FEES clinic twice a month Clinical Developments and Service Improvement:

4 Surgery: Surgical services are well established at both GRH and WRH and continue to provide year round cover for major procedures at both sites. Six consultants in the team are trained in microvascular techniques and using them on a regular basis. Agreement has been reached that one of the Gloucestershire consultants is the lead for pharyngolaryngectomy surgery with reconstruction. Now that there is appropriate SaLT support in Worcester two consultants are providing laryngectomy surgery with surgical voice restoration. Oncology: The team s Oncologists now have capacity to treat patients with IMRT if appropriate, with a view to increasing the numbers of patients treated this way as resources allow. Patients are being entered onto Clinical Trials if eligible and consenting; trial recruitment has increased significantly over the last few years. Radiology: WAHNHST: Overall the service is excellent with no difficulty in achieving the treatment targets. Consultant radiology attendance at MDT meetings is exemplary. Agreed guidelines have been developed with the PCTs for PET/CT requests. GHNHSFT: The service in Gloucestershire has been severely limited over the last 12 months through movement of radiology consultant staff to other trusts and an inability to recruit suitable replacements in a timely manner. Radiology support at MDT meetings has been very poor (<50%). The trust has been unable / unwilling to provide support from the remaining pool of radiology consultants to fill this gap in service. Radiology waits for urgent scans have been in excess of 4 weeks at times during the same period making adherence to 2-week-wait pathways very difficult. Pathology: An ultrasound guided FNAC service for neck lumps is now operational on both sites. Both sites offer centralised 2 week wait / neck lump clinics for thyroid and non-thyroid neck lump. A one stop service with cytologist and radiologist / radiographer is now established in Gloucestershire in development as part of the work programme for the next year on the WAHNHST site. Other areas of work: -Looking to gain ethics approval for the Outcomes in Oropharyngeal Cancer The Severn Experience protocol, with a view to Gloucestershire taking part in this audit. - Working towards having a plastics reconstruction surgeon on site Recently presented audits - IMRT data by clinical oncologist -Airway Management in Head and Neck Oncology Patients-overnight intubation versus tracheostomy a comparative study - 24hr GP Notification Audit. - Follow up data with recurrent disease are we following the guidelines - Recurrent laryngeal nerve audit in thyroid patients. - Laryngectomy outcomes audit (part of a regional data collection) - One-Stop Neck lump FNA adequacy audit Attendance at MDT for the past year covering Core members With the recent updates in video conferencing facilities, the attendance for all disciplines across the 3

5 counties has been improved. With the exception of radiology and pathology at the Gloucestershire sites all core and cover members have met the required attendance. The ability to communicate effectively via video-link has improved pathways for patients travelling across the network for treatment. Operational policies for key worker and principal clinicians are working well, with the transfer of key worker for the radiotherapy patients. Work Load for the Head and Neck MDT. Total Head and Neck Total Head and Neck Taken from the DAHNO report published in 2014 year November 2012 October 2013 The Number of patients registered with new head and neck primaries of the larynx, oral cavity, oropharynx,hypopharynx, nasopharynx, major salivary glands, nasal and sinus cavity, and bone tumours is 195 Minimum Individual workload for Thyroid Surgeons All surgeons undertaking thyroid procedures are documenting procedures on the BAETS National Thyroid Audit. Over the previous 12 months (Jan 2014 Dec 2014), all have performed and recorded in excess of the agreed minimum of 20 procedures a year. The number of surgeons performing thyroid procedures across the network has slowly reduced in accordance with national guidelines. Areas of Concern Inadequate radiology support for MDT meetings on Gloucestershire sites: The attendance for radiology support at MDT meetings has fallen below 50% over the last 12 months. This has been flagged as a safety issue to Head of Service for Radiology and the Medical Director. It was also reported during a recent CQC visit. As yet no action has been taken by the Trust to resolve the current gap in service, but a new H&N radiologist appointment is anticipated later in the year. Inadequate CNS support on Gloucestershire Hospitals Sites: This has been a long-running issue that remains unresolved despite repeated business cases. There is currently a single full-time CNS supporting the service on this site. Since, to date, all radiotherapy and chemotherapy patients are treated in Cheltenham and all the more complex surgical cases, this falls well below the expected level of support for this number of patients. This has been reflected in Patient Experience Feedback. There is no CNS to support the thyroid service across the MDT. IV PANEL COMMENTS This is a well led forward thinking team that have overcome significant technical and logistical issues to come together as one joint team covering 3 Trusts with a combined population of approximately 1.5 million The MDT have all core members named apart from the CNS cover and radiology cover on the Gloucestershire Hospitals (GHNHSFT)Sites, radiology cover is due to commence in July 2015.The panel note the limited attendance from GHNHSFT radiology but acknowledge there is always a radiology presence (WAHNHST) at the MDT meeting to comment on all patients as required.on discussion with the MDT lead (WAHNSHT)the panel are reassured that currently patients discussions at MDT are not being delayed. The weekly meetings are held via video conferencing facilities, it is attended by all relevant core members

6 . During 2014 the attendance from the WAHNHST endocrinologist has not been compliant. There is now a named endocrinologist from (GHNHSFT)who can act as a core member and cover for the meeting The development of the weekly thyroid meeting has resulted in less than the required attendance of one of the thyroid surgeons from each site.this is being addressed by the MDT leads The team operates on 2 resectional sites for UAT and Thyroids at WRH and GLOS with all the surgeons demonstrating adequate work load complying with the numbers required With the recent opening of the WRH site Oncology centre the IV panel note there is an imminent appointment of a new oncologist (WAHNHST)with head a neck interest and there is excellent attendance from other oncologists in 2014 Although senior ward sisters are in the core membership of the MDT from both sites, they are unable to attend the MDT meeting due to work pressures. The Clinical Nurse Specialists (CNS) from all sites spend time on the specialist wards helping and supporting the ward sisters and staff. Coordination of care/patient pathway Measure Network agreed clinical guidelines are in place Network-agreed patient pathways are specified There is a discharge policy A record is kepy of the treatment planning decisions Lead clinician attends at least two thirds of the network group meetings. Met SELF ASSESSMENT COMMENTS There has been a lot of work completed over the 12 months since our last peer review to tighten patient pathways. An agreement has been reached to ensure patients stay within the locality team of their named consultant. This aims to facilitate locality support teams to provide the services required by those patients. Communication across the 3 Counties for transfer of patients continues to be excellent with all patients attending for radiotherapy having transfer forms completed by the commencement of radiotherapy via safe and secure . Communication with the TA CNS s has been streamlined across the MDT with direct access to the CNS and young adults specialist team. The TA CNS will refer the patient to the principal treatment centre psychosocial MDT. Both sites have access to the Cancer of Unknown Primary pathways. The 3CCN Head and Neck guidelines are due for renewal and the team have agreed to now follow the

7 BAHNO head and neck guidelines at the operational meeting in May IV PANEL COMMENTS The team currently works to 2012 agreed guidelines. They are now committed to working within national guidelines and have agreed as part of the operational policy there will be robust local interpretation with clear local patient pathways across the 3 trusts, 2 being resectional centres and all 3 having radiotherapy facilities on site. The IV panel commend the comprehensive availability of the multidisciplinary clinics on all sites offering a high quality experience to patients by facilitating a complete explanation of the various modalities and treatment options available. The two specific ward area policies cover the necessary pathway details including a discharge criteria. Members of the joint MDT have attended the West Midlands Strategic Clinical network Head and Neck Expert Advisory group. Patient Experience Measure A patient should have a named clinician who is primary contact for decision-making about their clinical treatment throughout journey A key worker is in place Patients are encouraged to discuss treatment options before they first have treatment MDT provides written material for patients and carers The patient is offered a record of the consultation MDT looks at patient feedback in the last two years and act on at least one point Met SELF ASSESSMENT COMMENTS Patient Experience The both trusts have again taken part in the national Cancer Patient Experience survey (2013/14) and results were discussed in the teams operational meeting in May 2015 with the following actions instigated: GHNHSFT 36 patients included -action agreed -current CNS support inadequate. Named cover to ensure all aspects of patient pathway supported, in particular the need to offer written information to the patient WAHNHST-21 patients included action agreed -Review of written information offered to patients specifically around information on the 1st surgical treatment. Joint MDT- action agreed - to ensure patients aware they are able to bring a friend or carer to outpatient

8 appointment Patient Support There continues to be 3 support groups across the 3 counties region for head and neck cancer; one in each locality. These are supported by allied healthcare professionals The Worcestershire and Herefordshire locality are supported by the Living Well Programme. facilitated by our Head & Neck Counsellor. This is a 6 day course, over six months, covering at least 6 different topics. The course is Head & Neck patients living with and beyond a cancer diagnosis and treatment The laryngectomee focus days run across the region with one a year at each site. These have been well received by the patients and there is a hope that maybe there will be a separate laryngectomee support group also The Facing Forward is a post treatment course that runs one day per week for three weeks, covering a variety of topics,designed to enable patients to get back yo their new normal. The course is run at an off-site venue to promote the idea of moving away from treatment. Guest professional speaker cover topics such as returning to eating, lymphodema management and psychological wellbeing. There is also the opportunity for patients to network with others in a similar position. An annual Living with and beyond Cancer day is held at the Gloucestershire Rugby Club for patients who have been through treatment in the past year, with guest speakers, workshops and market stalls. With the arrival of the Worcestershire Radiotherapy unit on site the patients have amalgamated all the previous cancer user groups around Worcestershire into a Worcestershire wide user group IV PANEL COMMENTS The key worker role across all sites is fully embedded in practice and clearly identifiable from the medical notes and proforma's reviewed. The Trust took part in the National Cancer Patient Experience survey (2013/2014), the head and neck results have been discussed at the operational meeting held in May 2015, actions have been decided upon and included in the teams work programme. The panel note the excellent use of the holistic needs assessment for all patients across the region with access to psychological support on all sites. The WAHNHST CNS's travel to Hereford to support patients located in this county, in addition there is now a nurse based in Hereford to support patients through radiotherapy treatment. The IV panel would suggest her attendance on occasion at MDT would be good practice. The panel reviewed the comprehensive patient information submitted and understand that the team have excellent links with the Macmillan Cancer Information and Support centres. The permanent record of consultation was reviewed from both sites.

9 Local support teams are in place, the GHNHSFT site are looking to confirm the name of a new patient representative for the team. Clinical Outcomes Measure MDT reviews clinical indicators and/or audit data each year and discuss at the network meeting MDT produces an annual report on clinical trials and discuss with the network group Met N SELF ASSESSMENT COMMENTS The 3 Counties Team runs a regular programme of educational activities with two educational afternoons every year. (May & December) All sites upload MDT data to the DAHNO database. The following data is taken from the 2013 DAHNO report patient cohort from November 2012 to October Index outcome measures: Percentage of new cases of head and neck cancer discussed at MDT Patient and IOG expectations are that all care discussions are made at a MDT. Taken from the 2013 DAHNO report -100% of all cases where discussed at MDT The number of patients registered with new head and neck primaries of the larynx, oral cavity, oropharynx, hypopharynx, nasopharynx, major salivary glands, nasal and sinus cavity, and bone tumours was 195. Number of patients registered with new head and neck primaries of the larynx, oral cavity, oropharynx, hypopharynx nasopharynx, major salivary glands, nasal and sinus cavity and bone tumours - by first diagnosis provider is as follows: - RTE Gloucestershire Hospitals NHS Foundation Trust 83 - RWP Worcestershire Acute Hospitals NHS Trust 88 - RLQ Wye Valley NHS Trust 24 Percentage of new cases of head and neck cancer discussed at MDT where recorded T, N, M staging category is evident: Recording cancer site and accurate stage is a key medical responsibility, with best practice suggesting that this should be clearly documented and captured at the MDT prior to treatment. Staging remains a key influence on outcome, and if risk adjustment is to be applied it is essential this is effectively recorded. Total n Both T and N Previous audit M recorded Previous audit

10 (82.7%) 73.3 % 159(83.2%) 74.3% Percentage of new cases of head and neck cancer where confirmed seen by a clinical nurse specialist prior to the commencement of treatment Patient representatives feel it is imperative that a clinical nurse specialist is available from diagnosis to all patients with cancer. Addressing the issue of the lack of appropriate professional support should be seen as a priority requirement for all patients and particularly those undergoing treatment (curative or palliative) the Clinical nurse specialist plays an important role in supporting choice of treatment. Had Treatment n Had pre trt CNS contact Previous year Difference (65.6%) 64.4% 1.2% Percentage of new cases of head and neck cancer confirmed as having any pre-operative/ pre-treatment (includes radio and chemo-therapy) dietetic assessment: Dietetic support is important through all parts of the patient pathway, particularly in those undergoing any form of treatment where the morbidity of the treatment can be reduced by appropriate intervention. The date each new head and neck cancer patient first has contact with a dietician should be routinely recorded. Number Had pre-trt dietetic assess't Previous audit Difference (33.5%) 29.1% 4.4% Percentage of patients having a pre-treatment dental assessment: Dental health during and after treatment for head and neck cancer is a significant contributor to patient wellbeing. MDT s are strongly encouraged to provide written information to confirm that care is being provided. Had trt Had pre trt dental assessment Previous audit Difference 161 (83%) 83 (51.6%) 57% -5.4% The WAHNHST site a new dentist appointment started Nov 2014 IV PANEL COMMENTS There is a small portfolio of trials mainly open at GHNHSFT because of the availability of radiotherapy, patients from Worcestershire and Herefordshire are able to gain access. Currently no clinical trials are set up for patients being treated at WRH site this should change with the recent opening of the new oncology centre It is noted that the team achieve twice a year well structured education and business meetings to review and discuss outcomes clinical indicators, audit and trials

11 The team will be reviewing the next DAHNO data report due out this year Good Practice SELF ASSESSMENT COMMENTS - Twice yearly educational event which is preceded by a business meeting - The excellent working relationship of the combined Head and Neck MDT covering all 3 localities. - Implementing use of holistic needs assessments across MDT - Pre-treatment assessment clinics running across all localities. - 3 level 2 psychological practitioners across the MDT with supervision - Introduction of facing forward survivorship project supported by Macmillan in Gloucestershire. - Living well day in Worcestershire/ Herefordshire - Laryngectomee focus days across the network - Level 3 counsellor (WAHNHST) IV PANEL COMMENTS -The use of holistic needs assessment -Availability of joint clinics including Allied Healthcare Professional presence -Psychological support for patients -Working relationships across 3 sites although complex appear to be working well - Regular business meetings combined with education sessions Immediate Risks No Immediate Risk was identified Serious Concerns 1. The attendance of a radiologist from GHNHSFT site has fallen below 50% over the last 12 months; this has also been highlighted by the clinical team as a serious concern. 2. Inadequate CNS support on GHNHSFT site, there is a lack of CNS cover to support patients with head

12 and neck and thyroid cancer which again has been highlighted as a serious concern by the clinical team and has been reflected in the patient feedback No Serious Concern Resolution was identified Other Concerns SELF ASSESSMENT COMMENTS -Appropriate AHP (SLT, CNS and dietitian) cover on Gloucestershire sites - More specific psychology support at GHNHSFT - Radiology and Pathology cover on GHNHST sites CNS, dietitian and SLT for WAHNHST ( business case submitted ) -Placing of peg tubes in a timely manner to commence radiotherapy at GRH IV PANEL COMMENTS IV panel agree with the above concerns and note the business case in progress General Comments No general comments given.