Cancer Access Policy

Transcription

1 Cancer Access Policy SPONSOR (Information Asset Owner) Jon Findlay, Chief Operations Officer AUTHOR: Femi Odewale, Interim General Manager Nathan Hall, Cancer Access Manager RATIFIED BY: Procedural Document group APPROVED BY: Cancer Services Board TARGET AUDIENCE: All staff involved in the care of patients with cancer POLICY NUMBER: CM93 STRATEGY CATEGORY: Corporate Management (CM) This document is available in large print and alternative formats. Should you or someone you know require this in an alternative format please contact us on Ext or VERSION AND REVISION RECORD: Date Ver. No Details Review date April New Policy April 2015 Page 1 of 26

2 Contents 1 Introduction Purpose Definitions Duties and Responsibilities Main Procedural Document Points (Process) Monitoring Compliance and Effectiveness Associated Documents Equality Impact Assessment References Page 2 of 26

3 1 Introduction This policy outlines the Trust s approach to the management of patients requiring chemotherapy treatment whilst ensuring patients are seen: According to their clinical urgency (including 2 week wait target patients) in order of date received (i.e. on a first come first served basis) In the shortest time appropriate for their clinical need This policy applies to all members of staff dealing with patients who have cancer and require chemotherapy treatment. 2 Purpose This policy describes how the Trust manages and reports performance relating to cancer waiting times. For patients it will make sure that people: Suspected to have cancer and/or with a confirmed cancer diagnosis receive treatment in accordance with the cancer standards relevant to their cancer pathway and according to their choice Are treated according to clinical priority and those with the same clinical priority are treated in chronological order. For clinician and non-clinicians it will make sure that: Teams and individuals are aware of their responsibilities for moving patients along the agreed clinical pathway in accordance with the national Cancer Reform Strategy standards as set out in the Cancer Waiting Times CWTs 8.0. Clinical support departments adhere to and monitor performance against agreed maximum waiting times for tests/investigations in their department. Everyone involved in the Cancer pathway has a clear understanding of their roles and responsibilities. Accurate and complete data on the Trust s performance against the National Cancer Waiting Times is recorded in Somerset and reported to the National Cancer Waiting Times Database (Open Exeter) within predetermined timescales. This policy applies to all SUH staff involved in the management of patients within the cancer pathways. Please note that In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain on-going patient and staff safety. This policy is applicable to patients cared for under Cancer Wait Times. Within the NHS in England this is defined as activity with ICD codes C00-C97 (excluding basal cell carcinoma) or D05 (carcinoma in situ with the exception of breast). This includes: Page 3 of 26

4 Patients treated as part of a clinical trial Patients whose cancer care is undertaken by a private provider on behalf of the NHS Patients with care sub contracted to another provider private or NHS and paid for by an English trust Patients diagnosed with a second new cancer Any skin squamous cell carcinoma The 31 day standard applies to NHS patients with a newly diagnosed cancer, recurrence of a previously diagnosed cancer; regardless of the route of referral. It includes patients who may be diagnosed during routine investigation for another condition e.g. an incidental finding. The 62 day standard applies to patients referred through a two week referral route by the GP or GDP with suspected cancer, patients who are referred to a specialist because of breast symptoms where cancer is suspected, when cancer is suspected from any national cancer screening programme, or the patient is upgraded by a consultant because cancer is suspected. Patients excluded from the cancer waiting times standard: Any patient with a non-invasive cancer i.e. carcinoma in situ (with the exception of breast) basal cell carcinoma the patient dies before treatment can begin receiving diagnostic and treatment privately unless the patient chooses to be seen privately but is then referred for treatment under the NHS or the patient is seen under the 2 week standard chooses to have diagnostic tests privately but returns to the NHS for further treatment. patients who refuse to undergo diagnostic tests are excluded for the 62 day standard, but if they are subsequently diagnosed with cancer they will follow the 31 day treatment standard. patients who decline treatment 3 Definitions TERM DEFINITION Active monitoring Where it is clinically decided to start a period of monitoring in secondary care without clinical intervention or diagnostic procedure at that stage. Active waiting list The list of elective patients who are fit and able to be treated at (elective waiting that point in time. The active waiting lists is also used to report and elective national waiting time statistics planned) Cancelled operations / procedures MDS (Minimum Dataset Form) If the trust cancels a patient s operation or procedure on the day of, or after admission for non-clinical reasons the Trust is required to rearrange treatment within 28 days of the cancelled date or within target wait time whichever is soonest. A MDS form is agreed by the cancer Network to be completed when a patient s care is transferred between NHS trusts. A Page 4 of 26

5 Chronological order (in turn) BU CWT Decision to admit (DTA) Decision to treat (DTT) Did Not Attend (DNA) DoH Elective admission / elective patients Elective Planned Elective waiting EROD First definitive treatment Incomplete pathways Somerset Multi-Disciplinary Team (MDT) MDM Coordinator PTL Peer Review TCI (To Come In) form provides information to the on the current pathway status of a patient, including the referral and breach dates. The general principle that applies to patients categorized as requiring routine treatment. All routine patients should be seen or treated in the order they were initially referred for treatment. Business Unit Cancer Waiting Times Where a clinical decision is made to admit the patient for either day case or inpatient treatment. Where a clinical decision is taken to treat a patient as an inpatient, day case or outpatient setting. Patients who have agreed or been given reasonable notice of their appointment / treatment and who without notifying the Trust fail to attend. Department of Health Inpatients are classified in two groups, emergency and elective. Elective patients are so called because the Trust can elect when to treat them. Patients admitted having been given a date or approximate date at the time that the decision to admit was made. This is usually part of a planned sequence of clinical care determined mainly on clinical criteria. Patients waiting elective admission Earliest reasonable offer date An intervention intended to manage a patients disease, condition or injury and avoid further intervention. What constitutes first definitive treatment is a matter of clinical judgment in consultation with other as appropriate, including the patient. Patients either on an admitted, non-admitted or diagnostic pathway still waiting for treatment. A system in which all cancer patients are tracked and monitored. Somerset is also used to support our reporting processes. An MDT comprises of medical and non-medical professionals who are responsible for the cancer patient's care. It includes clinicians from a variety of disciplines, the exact constituent are described for each tumor site as part of Peer Review requirements. Multi-Disciplinary Meeting Coordinator Patient Tracking List, a report used to ensure the maximum waiting time targets are achieved by identifying the patient wait time along that pathways and patients who are at risk of being treated outside the pathway requirements An annual assessment specific to each specialty against national standards. A proposed future date for an elective admission. Page 5 of 26

6 4 Duties and Responsibilities 4.1 Duties within the Trust (Committees) Southend University Hospital NHS Foundation Trust Clinical Assurance Committee (CAC) is responsible for providing assurance and support on patient access to the Trust Board. It will monitor through the receipt of regular audit reports; that national and statutory requirements for access to services are being met. Referrals Management Group is responsible for the review and update of this policy, ensuring national and statutory requirements are fully reflected. In addition, it will facilitate the embedding of patient access requirements within Trust processes. Information about Cancer Services Board The Trust Cancer Services Board (TCSB) will report into the Trust Executive as part of the trust-wide Governance arrangements. Key areas of responsible include: Overseeing the successful delivery of the Trust s Cancer Action Plan, providing assurance to the Trust Board that the Plan is being adequately managed Overseeing compliance with Improving Outcomes Guidance, Peer Review and related action plans Overseeing the development of, and delivery of the Trust s Cancer Strategy, including service change and development in discussion with Commissioners and key stakeholders Monitoring performance across the Trust and tumour sites against cancer standards, supporting the Multidisciplinary Teams and Business Units in the delivery of their action plans to address issues relating to patient pathways and care delivery 4.2 Duties within the Trust (Individuals) Business Unit (BU) Directors and Assistant/Associate Business Unit Directors (ABUD) The Business Unit Directors/Assistant Directors and General Managers for each BU have overall responsibility for implementing and adherence to this policy within their BU. This includes: Ensuring that effective processes are in place to manage patient care and treatment that meet national, local and NHS Constitution targets and standards for each specialty within the BU. Managing resources allocated to the BU with the aim of achieving access targets. This includes having the staff and other resources available to operate scheduled outpatient clinics, patient treatment and operating theatre sessions and avoid the need to cancel patient treatment. Working with other BU Directors/Assistant Directors and General Managers of service to provide a joined-up approach to implementing this policy and achieving the cancer access targets, particularly around outpatient and operating theatre capacity and availability of diagnostic services. Page 6 of 26

7 Achieving cancer access targets. Ensuring that the duties, responsibilities and processes laid down in this policy are implemented within the BU. Ensuring all BU staff that need to operate this policy are aware of this policy and receive training so that they can meet the policy requirements. Implement effective monitoring systems within the BU to ensure compliance with this policy and avoid breaches of the targets: escalate any actual or potential breaches to the Chief Operating Officer. Implementing systems and processes that support data quality and for validating data to ensure that all reports are accurate and produced within agreed timescales Day to day operational management of this policy will be delegated to Business Units and Service/Operational managers as set out in the governance arrangements for each BU. Consultants Each consultant is responsible for: Managing the patients care and treatment and working with their BU Directors/Assistant Directors, General Managers and clinical colleagues to ensure that this is provided within timescales laid down in national, local and NHS constitution targets and standards. Alerting the BU General Manager of any potential or actual breaches of targets Managing staff within the medical team to ensure that scheduled outpatient clinics, patient treatment and operating theatre sessions are held and avoid the need to cancel patients. Managing waiting lists and deciding on patient admissions / treatments in line with clinical priority. Working with colleagues to prevent the cancellation of patient admissions for nonclinical reasons and taking action to reschedule any patients cancelled in line with timescales set out in this policy. Communicating accurate waiting time information to patients, their families and carers and dealing with any queries, problems or complaints in line with trust policy. Assisting with the monitoring of data quality and production of reports. Multi-Disciplinary Meeting Coordinators Tracking patients on the PTL for the tumour site that they are responsible for coordinating Monitoring the PTL relevant to their tumour site to identify where interventions are not being planned within the appropriate timescale Escalating to the relevant individual where necessary when alternative action needs to be taken so that the patients pathway can achieve the required standard Make sure that all the necessary clinical and non-clinical information is available to allow the patient to be discussed holistically Provide the administrative support so that there is accurate, accessible and timely recording of the treatment plan agreed by the MDT Planning communicating and interacting with clinicians regarding issues relating to the patient pathway Page 7 of 26

8 Ensuring that referrals/appointments for patients on the cancer pathway are made in timely manner Receive and process referrals into the MDT so that they are tracked and bought to the MDT in a timely manner for discussion and planning of treatment Multi-Disciplinary Team An MDT comprises of medical and non-medical professionals who are responsible for the cancer patient's care. It includes clinicians from a variety of disciplines, the exact constituent are described for each tumor site as part of Peer Review requirements. It supports delivery of cancer standards by: Bringing together designated cancer specialists to discuss patient care and agree a treatment plan for individual patients Making sure care is planned according to national guidelines and to support clinical governance Identifying and supporting entry of patients into clinical trials Monitoring attendance so that there is good attendance by core members of the MDT so that decision making relevant to good practice and achievement of the cancer pathway Supporting the collection of good quality data relevant to clinical care and service improvement Reviewing its performance in terms of achieving safe and timely care in line with good practice and Cancer pathways standards Taking responsibility for changing pathways as required and identified as a result of audit, data collection and performance information MDT Clinical Lead Each tumor site will be led by a clinician who has site specific specialist knowledge of treating cancer. The clinical lead will: Make sure that objectives of MDT working are met. Have in place mechanisms to support entry of eligible patients into clinical trials, subject to patients giving fully informed consent. Take overall responsibility for ensuring that the MDT meet peer review quality measures. Make sure attendance levels of core members are maintained, in line with quality measures. Ensure that a target of 100% of cancer patients discussed at the MDT is met. Provide the link to network and other relevant speciality groups, either by attendance at meetings or by nominating another MDT member to attend. Lead on, or nominate lead for service improvement. Organise and chair an annual meeting, examining the functioning of the team and reviewing operational policies and collate any activities that are required to ensure optimal functioning of the team (for example training for team members). Ensure MDT s activities are audited and results documented. Ensure that the outcomes of the meeting are clearly recorded and clinically validated and that appropriate data collection is supported. Page 8 of 26

9 Ensure target of communicating MDT outcomes to primary care is met. General Medical / Dental Practitioners and other referrers The trust relies on GP s and other referral sources, supported by local commissioners to ensure patients understand their responsibilities and potential pathway steps and timescales when being referred. This will help ensure patients are: Referred under appropriate clinical guidelines Offered a choice of provider as outlined in national guidance Aware of the speed at which their pathway may be progressed In the best possible position to accept timely appointments throughout their treatment All staff All staff are responsible for ensuring that any data created, edited, used or recorded on the Trusts information systems (Medway PAS and Somerset) within their area of responsibility is accurate and recorded in accordance with this policy and other trust polices relating to the collection, storage and use of data in order to maintain the highest standards of data quality and maintain patient confidentiality. All patient referrals, treatment episodes and waiting lists must be managed on the Trust s Medway PAS system and all information relating to patient activity must be recorded accurately and in a timely fashion. 4.3 Monitoring Responsibilities This policy will be formally approved by the Senior Management Team and agreed with commissioning partners. Alterations and amendments to this policy will be approved and ratified by these bodies. Issues around interruption and application of this policy will be initially resolved by Head of Performance where any matter cannot be resolved at this level it will be escalated to the Cancer Service Group and Chief Operating Officer for resolution. Compliance with this policy will be monitored as outlined in the Monitoring Compliance and Effectiveness section. 5 Main Procedural Document Points (Process) 5.1 Key Principles This policy will be applied consistently and without exception across the Trust. This will ensure that all patients are treated equitably and according to their clinical need. This is inclusive of military patients. Cancer patients will be prioritised according to national guidance. Non-NHS patients including overseas visitors are not covered by this policy and should be managed according to the overseas visitor policy and clinical priority. The process of waiting list management for patients suspected of or diagnosed with cancer will be transparent to the public and communications with patients (or parents/carers and vulnerable patients) will be timely and informative clear and concise. Page 9 of 26

10 Waiting lists will be managed equitably with no preference shown on the basis of provider or source of referral. Patients will be added to the waiting list if there is a real expectation that they will be treated and are willing to make themselves available for treatment. The Cancer Waits standards are described in detail in Going Further on Cancer Waits (GFOCW). The standards are summarized below: 2 week wait All patients referred from GP/GDP as suspected cancer will be seen within 14 days of receipt of referral All patients referred with breast symptoms irrespective of whether cancer is suspected or not, will be seen within 14 days of receipt of referral. 62 day All patients referred by their GP/GDP as suspected cancer or breast symptomatic, who are subsequently diagnosed with cancer, will commence treatment within 62 days of receipt of referral. All patients referred from screening programmes (bowel, breast, cervical) as suspected cancer who are subsequently diagnosed with cancer, will commence treatment within 62 days of receipt of referral. All patients that are upgraded by Consultants as suspected cancer will commence treatment within 62 days of the date of upgrade. 31 day All patients that are having a subsequent treatment for cancer will receive treatment within 31 days of the decision to treat. All patients diagnosed as a new cancer will receive treatment within 31 days of decision to treat irrespective of treatment. Page 10 of 26

11 As a general principle, the Trust expects that before a referral is made on a cancer pathway the patient is both clinically fit for assessment and possible treatment of their condition, and ready to start their pathway within two weeks of the initial referral. Any referral made under the 2 week rule guidance starts the 62 day clock. This includes referrals from the following: General Practitioners (GPs) and General Dental Practitioners (GDPs) Optometrists and Orthoptists Accident and Emergency, Minor Injury Units or Walk in Centres Genito-urinary medicine clinics National screening programs Prison health services Military Medical Centre s / Sickbays Consultant or Consultant led services Triage service The 62 day clock starts at the point the referral is received. 5.2 Private Patients transferring to NHS Care Where a patient has been seen by a clinician privately but then decides to transfer their care to the NHS, and they are transferring onto a Cancer pathway then the relevant clock (62/31 day) starts at the point at which clinical responsibility for the patients care transfers to the NHS (i.e. when the Trust accepts the referral for the patient.) Private patients transferring in this way will be treated in turn within the terms of this access policy. If first definitive treatment has already started or been given, then a referral from private to NHS care would not start a new 62 day clock unless the patient requires a substantially new course of treatment in which case the clock would start at the point clinical responsibility for the patients care transfers to the NHS (i.e. when the Trust accepts the referral for the patient). 5.3 Clock Stops 2 Week Wait The 2 weeks wait clock stops when a patient is first seen in outpatients. 62 or 31 day clock Page 11 of 26

12 The 62 or 31 day clock stops when the patient receives the first definitive treatment or subsequent treatment as required by the MDT plan for the treatment of their cancer. First Definitive Treatment is defined as an intervention intended to manage a patient s disease condition. Clinical Decisions The following clinical decisions stop the clock, on the date the decision is communicated to the patient, GP or original referrer if not the GP: First definitive treatment (consultant led, treatment in an interface service or therapy in secondary care if most appropriate way to manage the patient.) Decision not to treat e.g. decision is for non-specialist palliative care Decision to start a period of active monitoring Patient declines treatment Patients have a right to expect to be seen and treated within national operational standards for waiting times. In addition to this the department of health has set out other patient expectations which include: To be seen by a health professional whom they trust To get a clear explanation of their condition and what treatments are available To know what the risks, benefits and alternative treatments are To give written consent before any operation or procedure To see their patient records and be sure that the information recorded will remain confidential (data protection act 1998) Young people aged yrs also have standards that affect their care in an outpatient setting (You re welcome standards). 5.4 Patient Choice Going Further on Cancer Waits guidance encourages patients to be referred at the earliest opportunity. The operational standard applied to the two week wait standard (i.e. 93%) takes account of the volume of patients likely to be seen outside of 2 weeks due to patient choice. In order to be able to accommodate patient choice, specialties must be able to offer appointments within both week 1 and week 2 of the 2 week standard. In order to achieve this, median waits of 8 days must be achieved. This must be carefully monitored. Patients should be given appropriate information to help them understand the importance of being seen quickly. Specialties should develop information leaflets to help this. These should be available for download along with the specialty referral proformas. Patients cannot be referred back to the GP because they are unable to accept an appointment within the 2 week standard unless they do not attend or cancel two times or more (see section 7). A referral can only be downgraded by the referring GP. Page 12 of 26

13 5.5 Suspected Cancer Referrals Southend University Hospital NHS Foundation Trust This policy assumes all GPs/GDPs are informing patients that they are being referred as a 2ww and that as a fast track pathway a patient may be offered a series of appointments at short notice. All suspected cancer referrals should be referred by the GP/GDP on the relevant body site proforma and submitted via choose and book or fax to The Outpatient Booking Centre/Call Centre. All patients must be seen within 14 days of receipt of referral to comply with national standards and day 0 is date the referral is received. 5.6 Patient Cancellations Patients may cancel an appointment due to ill health, social or other reasons. A cancellation where the patient contacts the Trust prior to the appointment regardless of the notice will not stop the clock. Patients must be re-appointed after a first cancellation. In the event where a patient cancels and re-books an appointment, they must still be dated within 14 days of the referral. The Cancer Waiting time guidance does not allow patients to be referred back to the GP after multiple cancellations unless this has been agreed by the patient. However, it is good practice to let the GP know that a patient has deferred appointments, as they may wish to either contact the patient or possibly downgrade the referral. In the event of a patient cancelling two or more first appointments within the 2 weeks rule timescale they will be contacted by the speciality booking administrator and advised of the impact of the cancellation in terms of timely diagnosis and treatment. If the patient agrees to be discharged back to their GP, the consultant should write to the referrer within 5 working days explaining the reason for the discharge. 5.7 Patients who do not attend Patients may DNA (did not attend) an appointment for the same reasons as a cancellation; ill health, social or other reasons. Did not attend means that a patient did not arrive for their appointment and did not cancel the appointment regardless of the notice given. If a patient does not attend, the patient must be seen within 7 days of the date of the DNA. Patients must be re-appointed after the first DNA but can be referred back to the GP after a second DNA, except where a clinician decides the patient should be rebooked for clinical reasons. Patients with a suspected cancer who DNA an appointment will be contacted by the outpatient team to ascertain the reason for the DNA and rebooked if appropriate. All dates for cancer patients, whether for outpatients, diagnostic tests, or treatment should be dates that are subject to choice and agreed with the patient. Page 13 of 26

14 If it is the patients wish not to attend for the agreed care, then a letter will be sent to the GP or referring clinician informing them of the patient s decision. Prior to the patient being discharged back to the referrer the consultant will be informed. The consultant will write to the GP within 5 working days to inform them of the action so that the patient can be followed up if needed within primary care. If the patient does not have an appointment at day 3 the process should be escalated. Please refer to page 23 point 15 for adjustments applicable to patients that did not attend an appointment. 5.8 Emergency admissions/attendances during 2 week rule period In the event of a patient being seen/admitted as an emergency prior to attending for a two week wait appointment for the same condition as the referral; they should no longer be recorded against the two week wait standard. However, such a patient could still be upgraded onto the 62 day upgrade pathway if the Consultant suspects that cancer is the cause of the admission). If it is for another condition, the 2ww referral still applies. 5.9 Downgrading referrals A referral can only be downgraded with the consent of the referring GP. Therefore if a Consultant, on reviewing the proforma, considers the referral should be downgraded they should contact the GP for agreement. Once this has been done Medway PAS must be amended by removing the 2ww criteria and highlighted in additional comments that the referral has been downgraded. If an incomplete referral is received, the Outpatient Booking Centre/Call Centre should contact the referring GP/GDP immediately to minimize the delay in the pathway. This does not constitute a reason for making a pause to the pathway; patients should not be referred back to their GP to stop a pathway. In circumstances where the minimal data set it not complete the referral will not be paused or referred back to the GP. The referral must continue to be processed so that the patient s treatment is not delayed while the missing information is sought from the referring practitioner Two referrals on the same day If two referrals are received on the same day, both referrals must be seen within 14 days and, if two primary cancers are diagnosed, treatment for both cancers must start within 62 days of receipt of referral if clinically appropriate Breast symptomatic referrals Page 14 of 26

15 All patients referred with breast symptoms must be seen within 14 days or receipt of referral. This excludes patients referred for mammoplasty or family history; these referrals should be booked within normal waiting time standards. If there are any doubts over a referral, the patient should be booked within 14 days Referrals to the breast symptomatic service can be received from a wide range of health care professionals including other clinicians in secondary care. All breast symptomatic referrals must therefore be sent immediately to the Outpatient Booking Centre to ensure the 14 day standard is met. Diagnostic & staging part of the referral to treatment pathway 5.12 General Pathway Standards The diagnostic part of the overall pathway is critical to meeting the overall standard. Any patient failing to meet the standards will be flagged via the Cancer Dashboard, and must result in escalation action Booking of diagnostic tests As a result of the first appointment, diagnostic appointments should be directly booked while the patient is in the hospital. No patient should leave the hospital without a date for at least the next step in their pathway. Specialties should create reserve lists, or other means of enabling this. Reserved diagnostic slots for staging examinations are available to each specialty as part of this. All tests should be made for the earliest available appointment and agreed with the patient Patient unavailability, DNA or cancellation The operational standard applied to the 62-day standard takes account of the volume of patients likely to defer appointments or be unfit at stages of their pathway. There is therefore no clock-pause for these reasons and patients cannot be downgraded to a 31- day only pathway for these reasons. For multiple cancellations, the patient should be contacted by the specialty team rather than just giving multiple re-appointments. Patients may not understand the details of the test being requested, or may be anxious and require reassurance. If the patient does not wish to proceed then they should be referred back to their GP. If a patient refuses proposed diagnostic tests that may diagnose cancer, they have effectively removed themselves from the 62-day pathway. If they agree at a later stage they should then be monitored against the 31-day standard only Communication of Diagnosis to the GP or referrer The GP should be notified of confirmed new diagnosis via letter within 24 hours hours of the diagnosis being discussed with the patient. Page 15 of 26

16 Screening Pathways 5.16 Breast Screening 62-day standard Breast Cancer Screening Abnormality spotted by reader Reader generates referral Cancer referral to treatment period start date (62- days) Date first seen Cancer treatment period start date (31- days) Treatment start date (cancer) Referral is triggered by the final reader who initiates the assessment appointment. The pathway starts from receipt of referral to the assessment clinic (date of receipt of referral is Day 0. Referrals will not be automatically created in Somerset, and the MDT co-ordinator for Breast must therefore manually create a record in Somerset Bowel screening 62-day standard Abnormailty spotted in FOBT sample Automatic referral made by screening service (the hub ) Cancer referral to treatment period start date Date first seen Cancer treatment period start date Treatment start date (cancer). Referral will be triggered by a positive faecal occult blood (OB) result. The pathway will start from the date the hub book the nurse pre-assessment clinic (date booking initiated is day 0). The hub is responsible for entering all information onto the Bowel Screening Open Exeter system. Referrals will not be automatically created in Somerset, and the administration lead for Bowel Screening must therefore manually create a record in Somerset. Page 16 of 26

17 5.18 Bowel Screening Surveillance Southend University Hospital NHS Foundation Trust Patients being monitored under the surveillance scheme who subsequently are diagnosed with cancer will be monitored under the 31 day standard not the 62 day pathway Cervical Screening 62-day standard Potentially significant (non mirror) abnormality spotted in sample Direct referral from screening service Cancer referral to treatment period start date Date first seen Cancer treatment period start date Treatment start date (cancer) Referral back to GP Decision to refer date (cancer and breast symptoms) 2-week wait 62-day wait Suspected cancer referral will be triggered by the following smear result: - Moderate and severe dyskaryosis - Glandular neoplasia (possible adenocarcinoma of cervix) - Invasive (possible squamous cell carcinoma of cervix) The pathway will start from receipt of result/referral from Cytology. Patients that do not fulfil the above criteria but then subsequently are diagnosed with cancer will be tracked on the 31 day pathway. Patients will be seen in accordance with QA screening recommendations. Cytology is responsible for sending all reports/results to the Gynaecology Department. Referrals will not be automatically created in Somerset, and the MDT Co-ordinator for Gynaecology must therefore manually create a record in Somerset Consultant Upgrades Page 17 of 26

18 Hospital specialists have the right to ensure that patients who are not referred urgently as suspected cancer referrals but who have symptoms or signs indicating a high suspicion of cancer are managed on a 62 day pathway. Any patient that is not already on a 62 day pathway i.e. referred from a GP/GDP as an urgent suspicion of cancer referral or with breast symptoms (i.e. 2ww) and who is not referred through the screening programmes may be upgraded onto a 62 day pathway by the receiving specialty. The 62 day target starts on the date the upgrade decision is made. The points in the pathway where a referral may be upgrade are:- On receipt or triage of referral where this may meet IOG criteria for suspicion of cancer During or following initial visit where there is a suspicion of cancer During or following diagnostic procedures where imaging or histology/cytology indicate or confirm the presence of cancer On or before the multi-disciplinary team (MDT) meeting date Upgrade must occur before the decision to treat date. Patients not upgraded by this point will be measured against the 31 day decision to treat to first definitive treatment. The upgrade will only be applicable for patients that have a suspicion of a new cancer not those who may be suspected of a recurrence Rare Cancers Referrals for suspected testicular/children s cancer and acute leukaemia have to meet a 31 day target from receipt of referral to treatment Treatments First treatment For newly diagnosed cancers all patients should be treated within 31 days of decision to treat date (DTT) irrespective of the treatment. First definitive treatment is normally the first intervention which is intended to remove or shrink the tumour. Examples of which are listed below: Surgery Chemotherapy Hormone therapy Immunotherapy Radiotherapy Brachytherapy Specialist palliative care Other treatments may be considered as first definitive treatment provided the intension is therapeutic or no other active intervention is intended. Page 18 of 26

19 Where there is no definitive anti-cancer drug almost all patients will be offered a palliative intervention (e.g. stenting) or Specialist Palliative Care, which would be counted as the first definitive treatment. Subsequent treatments This 31 day standard currently only applies to those treatments either curative or palliative that aim to remove/shrink or delay the growth/spread of tumour/cancer. All patients will be treated within 31 days of Decision To Treat. Offers of treatment All offers of treatment should be made within a reasonable timeframe under the guidance of Section Cancer Waiting Times guidance. Surgery Includes all outpatient, day case and inpatient surgical treatments where intent is to remove the tumour. Admission date is classed as treatment date even if it is before the surgical procedure date. If a patient is admitted as an emergency and during the admission undergoes surgery that subsequently diagnoses a cancer, the admission date is classed as the treatment date for the purposes of cancer waiting times. If on receiving the histology report surgical margins are not clear of cancer as long as the intent was to remove the tumour this will still be classed as a treatment. If a diagnostic procedure is undertaken but it is subsequently found to have removed the entire tumour then this would be classed as a treatment. If a wider excision is required following a previous cancer treat but no tumour is found in the histology, this is still classed as a cancer subsequent treat and tracked/reported for cancer waiting times. If patients are admitted for a procedure which is intended to treat the cancer but on operating the surgeon is unable to proceed due to clinical findings this would be classed as open and close surgery and would still class as treatment as the intent was to treat. This does not apply if the patient is reviewed pre op and deemed unfit to proceed. Specialist palliative care Patients requiring symptomatic and supportive care provided by the specialist palliative care team this could be either a first or subsequent treatment. Treatment commences when the team assess the patient. Enabling treatments Page 19 of 26

20 Most enabling treatments that are carried out prior to active treatments are not classed as first definitive treatments for example: PEG/RIG tube insertions prior to radiotherapy are not classed as first treatment unless the radiotherapy commences during the same admission as the PEG then the date of admission is the date of first treatment. However some exceptions do apply: Colostomy for bowel obstruction as part of a palliative care package Insertion of oesophageal stent NSCLC stent Ureteric stenting for advanced cervical cancer Insertion of pancreatic stent if planned to resolve jaundice before the patient has a resection or starts chemotherapy. Clinical Trials If a patient is entered into a clinical trial and may or may not receive a placebo this would still count as first/subsequent treatment and treatment must still be provided within 31 days of DTT. Blood transfusions If a patient is not planned to have active anti-cancer treatment, a blood transfusion would count as first treatment as part of a palliative care treatment package, in all other cases blood transfusion would not count as first treatment Recurrences A recurrence is defined when a patient has been diagnosed and treated for an original primary and informed that they are free of disease and then cancer returns in the same site. Clinical input is required to determine if the patient has a recurrence or a second primary in the same site. Treatment of a recurrence is classed as a subsequent treatment and such cases are monitored against the 31 day pathway only irrespective of the route of referral. Therefore if a patient on a 62 day pathway is diagnosed with a recurrence then they are removed off the 62 day pathway and will be tracked under the new 31 day target Metastases Metastases are defined as a cancer that has spread from another primary site. Data entry/monitoring is reliant on clinical input to determine if the treatment is to the primary or metastatic site. Treatment to metastatic disease is classed as a first treatment only if there is an unknown primary. If the primary is known and treatment is given to the metastatic site first this is still classed as a subsequent treatment and monitored under the 31 day pathway even if this occurs before the treatment to the primary site. If the patient is on a 62 day pathway the clock does not stop with the metastatic treatment, it continues until the primary site is treated Clock stops, pauses and adjustments The 31 day and 62 day pathways end at treatment, or when a patient refuses treatment. Page 20 of 26

21 Pauses and adjustments to the cancer pathway All cancer targets can be extended for patients under limited circumstances. An explanation for any adjustment must be clearly documented in the patient s notes and or on Somerset. Pause for DNA of Initial outpatients appointment. If the patient does not attend a first appointment, then the clock can be adjusted from the date of referral to the date the patient re-books their appointment: ORIGINAL REFERRAL REQUEST RECEIVED DATE UBRN CONVERSION PATIENT DNA PATIENT RE-BOOKS APPOINTMENT DATE FIRST SEEN 62-DAY START DATE WAITING TIME ADJUSTMENT (FIRST SEEN) Pause or adjustment as a result of decline of reasonable offer for treatment as inpatient If the patient declines an offered date for treatment, in an inpatient setting, for personal reasons provided that the offered date is within target, an adjustment can be made from the date that the patients declines to the date the patient is available for treatment. An adjustment can also be made if the patient volunteers, before a treatment date is offered and accepted that they are unavailable for treatment for a certain amount of time. Clinically initiated delays - as a general rule the clock cannot be adjusted for clinical reasons. Patients who require anaesthetic assessment prior to treatment should be managed within target. Patients whose condition deteriorates so that the intended management is no longer applicable and require a substantially different modality of treatment should be managed within target where possible. Any resulting breaches should be reviewed clinically using national guidance. It should be noted that the tolerance within the target is to allow for clinically complex patients Reasonable offers All patients offered outpatient (both new and follow-up) and diagnostic appointments must be given reasonable notice. Page 21 of 26

22 For a verbal appointment offers, reasonable notice has been agreed locally as two appointment dates on different days within at least 7 days from when the offer is made. For a written appointment offer, reasonable notice has been agreed locally as an appointment date with at least two weeks from when the appointment letter is dated. If a patient accepts an offer at shorter notice this also represents a reasonable offer in respect of subsequent cancellations and delays. Where the patient does not respond to letters or phone calls, i.e. tried for a least a week with two phone calls in working hours plus one out of hours, or have not responded to an appointment letter within two weeks of the letter date, then the patient is not fulfilling their obligation to make themselves available for appointments and they can be discharged back to their GP. In the event that no message can be left then a letter will be sent to the patient explaining the process and that their care is being transferred back to their GP. This will stop the clock. If an offer of admitted care is declined, the clock can be stopped from the date the declined appointment would have been to the point when the patient could make themselves available for an alternative appointment. Patient thinking time It is good practice to allow patients a period of thinking time prior to considering treatment. Where this is short, there is no clock pause. Pathways need to take account of this and be able to accommodate a reasonable period for the patient to consider options. If a longer period of thinking time is agreed, it may be appropriate to agree Active Monitoring as a treatment and therefore a clock stop. For this to be genuine there would need to be a follow-up appointment agreed. It is not acceptable to use Active Monitoring to avoid breaches where the agreed thinking time is reasonable. Earliest Clinically Appropriate Date (ECAD) This applies if there has been a previously agreed and clinically appropriate period of delay before the next treatment can commence. When determining the ECA date, only patient issues should be considered, capacity constraints do not apply. Some examples of ECAD Patient with rectal cancer to have radiotherapy then surgery 6 weeks post radiotherapy. ECAD date would be 6 weeks after radiotherapy completed Patient with breast cancer to have surgery then radiotherapy. The patient would not be fit for radiotherapy until they can lift arm above their head. Therefore the ECAD date would be set when radiotherapy planning commences. An ECAD can be reviewed and changed as long as the date has not passed. If an ECAD is set but on patient review on/prior to the ECAD the patient is clinically not able to progress to the next treatment the ECAD can be changed to a later date. Page 22 of 26

23 If the patient is unwell after the ECAD then the ECAD cannot be reset and a wait time adjustment will not apply. Active monitoring This could be either a first or subsequent treatment where the intention is for long term surveillance where the decision had been taken to monitor the progress of the disease. For example, a slow growing tumour where there is not an immediate problem and it is clinically appropriate to step back and monitor the situation until an active intervention is more appropriate. Treatment starts when this is discussed and agreed with the patient Inter-Trust Referrals A Memorandum of Understanding (MOU) is currently in place between respective Hospitals in South Essex in advance of a more detailed inter-provider transfer policy. This document provides a memorandum of understanding (MOU) between the following organisations: NHS Basildon & Brentwood Clinical Commissioning Group NHS Southend Clinical Commissioning Group Basildon & Thurrock University Hospital Foundation Trust Southend University Hospitals Foundation Trust The MOU sets out breach allocation across four cancer pathways: Lung Gynaecological Urology Gastro-intestinal 5.28 Performance Management Managing Performance Cancer performance needs to be managed on 3 levels, i.e.: Through defined, timed pathways. Through case and caseload tracking, with escalation of exceptions to plan. Through continuous improvement, in particular through root cause analysis of deviations to the Trust standard, with appropriate countermeasures being enacted. Defined, timed pathways All specialties will be expected to operate pathways that have been defined and are timed. Timed means that the time for the completion of each step and when it is expected to take place are explicit. Page 23 of 26

24 In particular, steps in the pathway will be expected to link together through direct booking. No patient should leave the Trust without a date for at least the next step in their pathway. As part of defined pathways, possible risks and causes of delay should be identified and escalation plans devised, so that these can be quickly enacted if required to recover performance. Pathways will be supported by capacity and demand metrics for the identified key steps Case and caseload tracking The Trust s cancer information tool Somerset will be used both to track individual patients (cases) and actions requiring to be undertaken at key stages (caseloads) In particular, the real-time PTL provide the tool for identifying all patients where the Trust standards are not being met for any stage of care. The triggers and escalation process to recover performance are described in the appendices. Continuous improvement Alongside caseload tracking, each specialty will be expected to identify common themes in breaches of either stage of care or of overall targets, to undertake root cause analysis, and to implement countermeasures. Daily, weekly and monthly action required to deliver performance Daily actions Review and update the Somerset worklists for patient tracking, and initiate escalation actions for any patient outside the escalation standards, with a timescale for completion Follow-up the completion of the escalation actions Weekly actions Review the overall PTL and weekly performance data ahead of the weekly corporate PTL meeting. Through the corporate PTL meeting, identify common issues and concerns, and ensure solutions are enacted for any issues not resolved through initial escalation. Review capacity plus any performance issues for the week ahead, escalating any unresolved issues. Monthly actions Review breaches and escalation issues for the month, ensuring root causes and recurring themes are identified and appropriate countermeasures are enacted. Review capacity & demand metrics and ensure the service is able to consistently operate at the pace of demand. Make changes to respond to changes in demand as required. Page 24 of 26