London Cancer: External clinical review of oesophago- gastric specialist centre submissions August 2013 Version 20130812
1. Introduction 1.1. London Cancer The cancer care providers of North East London and North Central London and West Essex agreed in July 2011 to develop an integrated cancer system in response to the requirements of London s Strategic Health Authority and commissioners. Since April 2012 this integrated cancer system, London Cancer, has been commissioned to provide cancer services for a resident population of 3.2 million. Its mission is to drive superior outcomes and experience for our patients and local communities, and thereby position its staff as leaders in cancer care locally, nationally and globally. London Cancer will be underpinned by patient- empowerment, research, evidence and information sharing. It will radically refocus hospitals into working in partnership with each other, primary care and patients, to deliver coordinated, comprehensive pathways of excellent care for every patient irrespective of where they access our system or the type of cancer that they have. The agreed priorities of the integrated cancer system are: Being patient- focused through listening, communication, involvement, information, education, choice, and personalisation Optimising care along a co- ordinated pathway earlier diagnosis, exceptional treatment for all, local treatment where appropriate, compassionate aftercare and empowering/supporting patient self- management Embedding research for personalised care, equitable access to trials, the discovery of new treatments and evaluating new ways of working together with patients Increasing value superior outcomes for patients per pound invested. In addition to these priorities, London Cancer has carried out extensive research on what matters to patients and has distilled this work into ten key themes that will be central to everything that we do: 1. Diagnosis patients are diagnosed at an earlier stage 2. 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 3. Communication patients receive written and verbal information about diagnosis and all treatment options, including side effects and quality of life implications 4. Choice patients and carers are fully involved in the choice of hospital and treatment options 5. Support patients are given information on support groups, benefits entitlement and are offered emotional and psychosocial support 6. Carers carers are fully involved and supported throughout the pathway 7. Holistic assessment patients have holistic assessments at appropriate stages throughout the pathway, with action to meet their needs taken as a result 8. Seamless care all patients are assigned a CNS when diagnosed and a community keyworker on discharge 9. Transport patients should only travel when necessary and appropriate arrangements should be made for the immunosuppressed; patients should be provided with free parking or transport vouchers 10. Discharge patients and their GPs should be provided with discharge information and follow- up advice. 2
1.2. Oesophago- gastric pathway board The Oesphago- gastric cancer Pathway Board has agreed and published its work programme to achieve better outcomes for patients with oesophageal and gastric cancer in the geographical area covered by the London Cancer integrated Cancer system. The board has identified the following areas as a priority: Early diagnosis patients who present late with symptoms for OG cancer tend to suffer poorer outcomes Improving patient pathways for diagnostics and staging given the complexity of OG cancer, patients are often seen at over 6 different sites before definitive treatment commences Improving dietetics support due to the nature of some types of surgery, patients often suffer from problems associated with diet. Patient representative, AHPs and CNS are working on developing a tool for prompt dietetic discussion. In addition, the group hopes to improve access to one to one consultation with a dietitian from diagnosis to discharge and beyond Working towards a model of care looking at service reconfiguration across the patch to provide the best possible care for our demographics Developing a research programme in the management of OG cancer 1.3. OG Service specifications London Cancer vision is to deliver a step- change in cancer services in North East London and North Central London and West Essex. To instigate change, pathway boards will constitute a technical group, which is responsible for developing a specification for future delivery of services along their pathways within the integrated cancer system. The organisations of London Cancer that contribute to the pathway will then be invited to demonstrate how they could meet the requirements of these specifications for the components of the pathway that they wish to provide. The London Cancer OG technical group will meet on several occasions from January March 2013. A pre- meet of surgeons took place in December 2012. Each Trust and speciality has been invited to participate in the technical sub group.the result is found in the following pages. A full list of those who sat on the group can be found in the appendix. The OG technical sub group was tasked with developing a service specificationto implement the recommendations of the London model of care for cancer. The group was asked to consider the optimal care pathway for a patient with OG cancer across the London Cancer jurisdiction. In doing so, the group was advised to consider every element of the patient journey from initial diagnosis right through to end of life care or survivorship. Due to the impasse the group found itself in regarding the changes that need to be made to improve the Upper GI (OG) cancer pathway, the London Cancer board decided it would obtain independent clinical expert advice on the optimal number of sites we should be aiming for to serve our population for specialist surgery in OG cancer. This will then allow members of the technical group to complete writing the service specification, and to focus on the principal elements of a quality service for a specialist centre and a local diagnostic, treatment and follow up unit whilst this external advice is being obtained. The centre should be meet the NHS commissioning specification and be Peer Review compliant. 3
2. External review process 2.1. Submission process The OG service specification was sent to all Trusts in the London Cancer group in April 2013 with a request for those Trusts to submit an application to host either local or specialist services for the diagnosis and treatment of Oesophago- gastric cancer. These applications were received on Friday 14th June 2013 and were sent to the external review panel prior to a formal review meeting on Wednesday 19th June 2013 where the three Trusts applying for specialist status were asked to present their applications in order for the two experts to question the Trust representatives further on their respective submissions. The Trusts were: Barts Health NHS Trust (Barts Health) University College London Hospitals (UCLH) Barking, Havering and Redbridge University NHS Trust (BHRUT) 2.2. External assessment criteria The panel assessed the applications on eight criteria which are listed below: 1. Leadership: Show your plans for a named leader for the specialist centre or local service who takes responsibility for system- wide collaborative working to ensure availability of relevant specialist expertise for clinical care and research participation, including at local units, and acting as a point of local leadership in units. 2. Patient pathway: Give a clear outline of the patient pathway and how patients will be supported through it. This should include reference to co- dependent services which may or may not be available locally (e.g. accessing an opinion from a related specialty, supporting emergency surgery, etc.). 3. Joint working: Demonstrate how joint working across the pathway will be encouraged and maintained. Include, for example, consultant job plans/working patterns and proposals for specialist MDT working across the system. 4. Local services: Show how you will ensure that only what is necessary takes place at the centre. Include plans to enhance access to best practice care at local units and how emergency readmissions will be managed. 5. Impact of change: If your current OG cancer or any co- dependent services would need to change in response to a successful and/or unsuccessful application from your trust (e.g. relocation of specialist surgery), please provide details of how this will be managed. 6. Transport: Outline your proposals for supporting patients and relatives to travel when necessary. 7. Audit and outcomes: Give an outline of how you propose to measure and publish information on the outcomes and experience of diagnosis, treatment and supportive care for OG cancer patients. 4
8. Organisational capacity: Please provide more information on your proposed timescales for implementation, the investment that will be required, the commitment of your trust board to make this process a priority, and your personal confidence that your trust will be able to achieve these plans. 2.3. External review panel The external panel was provided by Professor Derek Alderson (Professor of Surgery, University of Birmingham; Honorary Consultant Surgeon, University Hospitals Trust, Birmingham; Past- President Association of Upper Gastro- intestinal Surgeons of Great Britain and Ireland; Council Member Royal College of Surgeons of England) and Mr Nick Maynard (Consultant Surgeon and Clinical Director for Surgery, Oxford University Hospitals Trust; Executive Council Member, Chair of Clinical Standards and Audit, Association of Upper Gastrointestinal Surgeons). 2.4. Comments The external panel was impressed by the quality of the Trust submissions and by the presentations that each group gave at the external review. The depth of knowledge and passion that each Trust demonstrated was evident. All three Trusts demonstrated excellent outcomes for patients having surgical resections, while accepting that existing arrangements were not fully compliant with guidance broadly accepted in England and Wales following the publication of Improving Outcomes in Upper GI cancer by the NHS Executive in 2001. All three Trusts acknowledged the need that existing arrangements were not sustainable to fully satisfy the requirements of London Cancer. It should be pointed out that demonstrating clear improvements in these surgical outcomes will not be easy. As such, the case for an urgent change in the model of service delivery cannot be made on the basis of a strong likelihood of improving surgical mortality rates, as they are already low and better than the national average. On the other hand, the current system is probably not sustainable beyond the next few years. Earlier diagnosis, improved non- surgical treatments and better patient selection all contribute to limit the numbers of patients needing surgery. The numbers of surgeons needed therefore should reduce and this must result in unworkable on call arrangements if three centres are retained. There must also be impact on training and the development of non- surgical elements of the service that are likely to be sub- optimal with three surgical sites. While it is outside the panel s expertise to advise on cost- effectiveness, the recognised association between higher volume centres and lower costs is at least worthy of consideration. 2.5. External review findings The findings of the external panel are based on the applications received and the responses to questions asked of all three Trusts. The following numbered points relate to specific issues highlighted in the oral presentations made by each Trust and these were then considered in conjunction with the written submissions. 1. Leadership: All three Trusts had a similar vision for leadership and how they would achieve this, proposing a democratic process to select a clinical lead for the service. 2. Pathway: Barts Health strongly favoured a one- site model (single specialist centre) with initial staging provided locally and specialist staging to remain at UCLH, BHRUT and the Royal London/Barts. The favoured model involved 4 surgeons at the centre supported by 4 in- reach surgeons, although ultimately they would work towards a stable workforce of 6 Consultant Surgeons as part of the development of a brand new clinical team. 5
UCLH favoured a central model (single specialist centre) with a 48 hour diagnostic pathway but agreed that initial staging could be delivered locally, access to PET scanning being an issue for some local OG service providers. The favoured model was based on a reduction to 6 surgeons providing the resection service as retirements occurred. BHRUT also favoured a central location for diagnosis and staging but agreed that this could be provided locally. However where services are not available locally, BHRUT will have the infrastructure in place to accommodate all patients for diagnostics and staging, including PET scanning and EUS. 3. Joint working: All trusts had included in their written submissions that they were prepared to work in partnership through a two- centre model, with Barts Health and UCLH preferring a single centre model as the desired end state within a short timescale whereas BHRUT recognised that this was a possible direction of evolution of a joint service. This aspect was specifically addressed in direct questioning with all three Trusts, from which the panel drew the following conclusions: Barts Health felt that a single centre was the only option and did not support a two centre model even on a temporary basis. UCLH favoured a one centre model but envisaged a transitional model as the number of surgeons would be reduced, working down to six in total. BHRUT favoured a two centre model at the outset accepting that a further evolution to a single centre may be appropriate. Their two centre model would use a joint specialist MDT. The MDT will work as a single unit developing multi- professional networks, joint research programmes and an overarching clinical governance structure. 4. Local services: All three Trusts agreed that resection surgery would be done in a specialist centre All agreed that initial diagnosis and CT scanning can be done locally. All agreed that for local hospitals to provide diagnostic (staging) laparoscopy and EUS, a balance between in- reach and local surgeons will need to be found. All agreed that non- surgical treatments should be delivered locally whenever possible to reduce travel times for patients. 5. Impact of change: What would be the impact if the Trust lost OG surgery? Barts Health felt that the loss of OG cancer surgery would undermine the trauma service significantly. UCLH felt that the loss of OG cancer surgery would impact on their overall cancer strategy and on research. It would also undermine their therapeutic gastrointestinal endoscopic service. BHRUT felt that the loss of OG cancer surgery will diminish the recruitment and training of future surgeons. They were also concerned that the loss of OG resectional surgery will make retention of expert staff unlikely and the provision of emergency cover for upper GI emergencies will prove unsustainable. 6. Transport: Barts Health emphasised that 90% of London Cancer patients live within one hour of travel to both Barts Hospital and the Royal London Hospital sites and therefore felt that the travel required for patients and their relatives during the specialist part of the pathway was reasonable. Barts Health offers hostel accommodation facilities for patients and relatives. 6
UCLH emphasised their location with strong public transport links by rail and road, along with the provision of a hotel for patients and their relatives, both in the diagnostic part of the pathway and surgery. BHRUT favoured a two centre model but emphasised the fact that patient access is currently excellent with good public transport links and dedicated cancer car parking for the population that they would anticipate in their proposal. 7. Audit and outcomes: All have excellent outcome data and all three units are led by experienced surgeons with a proven track record in OG surgery. 8. Organisational capacity: All three trusts were confident that they could deliver the capacity needed according to their preferred model. 7
2.6. External review conclusions 1. While a single centre model provides the simplest solution, the panel are aware that such a move could not occur without other service relocations at Bart s Health and without some further building work at UCLH. Realistically, neither site could take on all of the surgical work for a population in excess of 3 million people, in the short term. For this reason the panel favours a transitional move to two centres that could be achieved immediately with no need for major changes in infrastructure or associated services. This has the slight further advantage of reducing the number of surgeons involved gradually, with less impact on other hospitals as detailed later. It also makes the justification for functioning on two sites or reducing to a single site easier in future. Based on this model, the panel felt that UCLH had the clearest plan regarding how transitional arrangements might work with both in- and out- reach models of care. 2. The need to have OG surgery co- located with Trauma by Bart s Health and BHRUT was over- emphasised and the panel did not agree that this was essential. 3. The panel did not agree with BHRUT s concern that the loss of OG resectional surgery would make recruitment and retention of expert staff more difficult as this has not been substantiated in other centres, which have lost OG surgery. 4. Service co- locations to optimise outcomes and minimise patient transfers were considered in detail. All three centres have a full range of associated services and described efficient systems for diagnosis and staging based on their preferred models. There was no essential service co- location that might be described as deficient in the plans of all three centres. 5. The panel considered the strengths and weaknesses of the written individual centre proposals. The Bart s Health single centre model was based on in reach and core surgeons, involving an equal split of either 6 or 8 surgeons. The arrangement involved pairing surgeons to achieve continuity of care. The problem with this model was that the on call arrangements for the in reach surgeon and the knock on effect at the in reach surgeon s base hospital in terms of a commitment to acute surgery were poorly described. The panel did not see this as a sustainable model. The Bart s Health presenters specifically saw no benefits in a two site model on either an interim or permanent basis. UCLH also favoured a single site model with a progressive reduction in numbers of surgeons based on individual s wishes and retirements, acknowledging that this could be achieved also with a two site model. 6. All three Trusts were asked to detail their research activities, in particular, NCRN portfolio trials. The presentation by UCLH was clearly superior to the other two presentations in terms of publication, current participation and future plans for research. 7. The panel felt that if a move to a single centre was to be adopted then this could be best provided by UCLH. The panel felt however that the most appropriate way of achieving this would be through a two centre arrangement based on UCLH and BHRUT. 8
Addendum Comments on the written submissions from Professor Derek Alderson - 6 August 2013 1. General remarks All three Trusts made high quality submissions. There were many areas of overlap and similarities regarding resources, service structure, work volumes and outcomes. While all three Trusts responded to the specific key themes set out by London Cancer, the evidence provided for some generic issues expected by London Cancer, were set out poorly by each Trust, notably, embedding research and increasing value. For all three Trusts, the surgical work volumes cannot support an increase in the numbers of surgeons at any location. This then limits the ability of each centre to provide 24/7 cover, maximise training opportunities and provide better services in future. This must be accepted as a strong driver for change. The following assessment therefore focuses on differences and shortcomings identified in the three submissions. 2. Barts Health The emphasis within the statement of intent was to build on the success of their existing hub and spoke model. The vision specifically mentioned emphasis on world class research and education and improved outcomes. The hub and spoke model offered suggested either a single surgical centre involving 3 centre and 2 in- reach surgeons or a 2 centre model with 3 centre and 1 in- reach surgeon at each site. Neither model represents a satisfactory solution. The first model is not sustainable or commensurate with full cover. The second model seems more concerned with the continuation of existing surgical practices rather than a patient focused model. The arrangements for the in- reach surgeon seem unsatisfactory. The impact on the spoke hospital was not adequately considered. There was no clear description of diagnostic service development. All patients requiring a PET scan have to travel to Barts for this test. The impact of co- location with London s busiest major trauma centre was inadequately addressed. The research and education output in the proposal was small. There were no clinical publications in highly ranked surgical journals and a substantial number referred to work conducted primarily elsewhere. While acknowledging basic science work and facilities there was no mention of translational work, clinical trials, on- going research or evidence of academic achievement, outwith surgical simulation. There was nothing that provided evidence of a plan to deliver world class research and education. There was no text that described how the proposed service would improve outcomes beyond those already achieved. No specific innovations in any element of the service were specifically highlighted as elements that were considered likely to improve particular aspects of outcome, such as survival, less morbidity related to treatment or health- related quality of life, or deliver economic advantages. 3. BHRUT The Trust envisaged providing a surgical service for 2 million people based around a 2- centre model. The precise geographic split was not described so it was impossible to properly evaluate the exact population that might exist at the other centre. The documentation essentially described refinements and expansion of their existing working practices and local service arrangements. The Trust vision specifically states as an aspiration to have an oesophago- gastric centre that would be a world leader in care provision, innovation, education, training and research. The submission describes care provision in detail (but broadly in a similar way to the other applications). No information was provided on any specific innovation, what specific education or training might be offered and how this might be delivered or any type of research strategy (other than participation in clinical trials and a collaboration with colleagues in Cambridge). 9
4. UCLH The Trust advocated a single centre model, with the intention of being recognised as a centre of excellence in surgery and oncology. There was a specific commitment to the delivery of high quality care close to patients homes whenever possible. The submission described a strategic development of the service more accurately than the other applications. Clear timelines were set for the achievement of change and the development of a research infrastructure was described in detail. Having said that, apart from research into early diagnosis and treatment of early cancer, there was little in the way of detail explaining how specific strategies to deliver research would impact on oesophago- gastric cancer. The documentation made no mention of commitments to education and training and how these might be improved by the proposed service reconfiguration. It was not clear how the modified service arrangements would result in more care being delivered close to home. 5. Conclusion On the basis of the written submissions alone a single centre model appears preferable. Any two- site arrangement can only be viewed as a transitional step. On balance, the UCLH proposal has the best vision for the future. 6. Timescales In terms of surgical capacity, it seems that both Trusts advocating single centre models could absorb the additional work in any interim arrangement that maintains surgery on two sites, within the next 12 months. The contraction of the surgical service to a single site should then be achievable within a further 12 months. 10