Urological cancers – why we need to change Clinical workshop – 12 March 2013
Introduction and welcome Today’s event aims to cover: 1. London Cancer’s recommendations for Professor Kathy Pritchard-Jones change Chief Medical Officer, London Cancer 2. The evidence and practicalities Mr John Hines Q&As Consultant Urological Surgeon 3. Group discussion and feedback Led by Neil Kennett-Brown Programme Director Change Programmes, North and East London Commissioning Support Unit 4. Engagement process and next steps Neil Kennett-Brown
Who’s who • London Cancer – an integrated cancer system that joins up NHS cancer care providers of north east London, north central London and west Essex. London Cancer ’ s aim is to drive superior outcomes and experience for our patients and population of 3.5 million. • NHS commissioners are responsible for ensuring that health and social care services meet the needs of the population: – NHS Commissioning Board is the future commissioner of specialist cancer services and will make decisions on any proposed changes to urological cancer services. – The cluster primary care trusts (PCTs) – NHS North East London and the City and NHS North Central London – are the current commissioners of the services and are leading this engagement process. – Clinical Commissioning Groups are important stakeholders in ensuring the whole pathway, from early diagnosis to high quality after care support, delivers the best patient outcomes. • North and East London Commissioning Support Unit is supporting commissioners on this engagement.
Background to London Cancer’s review
Drivers for change • Pan-London case for change and Model of Care, 2010 • Cancer outcomes in London are not good enough • Poor patient satisfaction • Poor trial recruitment in many tumour types • Fragmented training • Institutionally focused research at insufficient scale • Need to reflect modern practices • Can achieve ‘better value’ for the resources available
Key changes in urology pathway • Implement a pathway that starts in the community, ends in the community and emphasises early diagnosis and survivorship • Implement a patient-centric pathway • Develop state-of-the-art diagnosis and staging • Develop enhanced clinical decision making • Treat patients as much as possible locally whilst improving access to ‘best practice’, innovation and clinical trials • Facilitate better information and patient empowerment to live well at every stage of cancer treatment and beyond • Ensure ‘equipoise’ for all patients in consideration of their options
What we aim to achieve • To deliver services that provide the best outcomes for patients and stand up to international standards • Introduce a pathway that starts in the community, ends in the community that is centred around the patient • To exceed national, regional, and local care and quality standards • For NHS services to work more closely together to provide more cohesive and better care for cancer patients • To support and foster cancer research and clinical trials as well as provide excellent training and education • To make better use of the urological cancer clinical workforce
London Cancer’s recommendations for change
London Cancer’s proposals • Consolidate complex surgery for bladder and prostate cancer in one specialist centre • Consolidate complex surgery for kidney cancer in one specialist centre • Continue to provide less complex surgery for urological cancers at local units • Improve services at all hospitals providing urological cancer care • Improve earlier diagnosis of urological cancers • Improve support for people who are living with or beyond cancer Scope: • Around two people a day in North East, North Central London and West Essex require complex urological cancer surgery • Specialist treatment is only a small part of a urological cancer patient’s care. The vast majority of patient care would always take place at local urological units and GP surgeries.
Work with providers during engagement • Clinical specification and standards were developed Standards / for the care we would expect from local and specialist specification units • Working with trusts to determine how they could work Initial expressions together to implement the proposed model of care of interest • Trusts submitted expressions of interest, outlining how they would meet specifications • The London Cancer Board is recommending to Formal commitment commissioners that complex bladder and prostate to standards surgery should be based at University College London Hospitals (UCLH) NHS Foundation Trust; and that complex renal cancer surgery should be Evaluation of based at the Royal Free London NHS Foundation submissions Trust. • Recommendations are independent of other service reviews currently taking place in London. The Recommendations requirements for each service will be considered on to NHS CB their own merits, based on improving the outcome and experience of patients.
Centralising specialist services – the evidence
What volume confers • Efficiencies • Training opportunity • Knowledge transfer • Metrics with sufficient precision • Improved outcome • Innovation • Clinical trials • Attracts talent
Volume-outcome relationship • International evidence dating back to 1970s shows that for complex procedures, a higher volume of patients results in fewer complications and better outcomes for patients • Rich research showing both a surgeon-volume effect and a hospital- volume effect Some examples: • A study from the late 1990s supported the hypothesis that when complex surgical oncological procedures are provided by surgical teams in hospitals with specialty expertise, mortality rates are lower (Begg CB, Cramer LD, Hoskins WJ, Brennan MF) • A review of the literature in 2005, noted that high-volume providers have a significantly better outcome for complex cancer surgery (S.D. Killeen, M. J.O’Sullivan , J. C. Coffey, W.O. Kirwan and H. P. Redmond)
The practicalities of specialist surgical centres
Surgical centre activity Bladder and prostate cancer • Radical prostatectomies, radical cystectomies and bladder substitution, pelvic lymph node surgery • Small number of benign cystectomies • 400 operations per annum Kidney cancer • Radical nephrectomy, partial nephrectomy, nephro-ureterectomy • Benign renal surgery, renal pelvis surgery, ureteric surgery • Retroperitoneal lymph node dissection for testicular cancer • 400 cases per annum
Surgeon and Clinical Nurse Specialist activity Surgeons • All will work at the specialist surgical centre and at least one local diagnostic and treatment unit • Continuity of care for diagnosis, surgery and post-operative care • Emergencies will be dealt with in local diagnostic and treatment units • Subsequent operations and procedures will be undertaken in local diagnostic and treatment units Clinical Nurse Specialists (CNS) • Work across specialist centres and local diagnostic units • Main point of contact for patients • CNSs will ‘mirror’ surgeons to maintain patient continuity
Options considered • Two specialist centres – three surgeons, on call 1:2.5, 200 operations per annum • One specialist centre – six surgeons, on call 1:5, 400 operations per annum • More surgeons – two centre model with four, five or six surgeons
Role of local diagnostic and treatment units • A significant role in caring for patients with urological cancers. • Provide all diagnostic tests, most elements of treatment including some types of surgery, the majority of post-treatment follow-up, and ongoing care and rehabilitation. • The first point of contact for early specialist advice required by GPs. • High quality medical and nursing care. • Doctors would work jointly in both the specialist and local units to make sure that patients experience continuous excellent care. • All existing urology units which meet standards of care would continue to provide local services.
One centre advantages • Concentrates other medical services – e.g. interventional radiology, histopathology etc • Concentrates research and trials activity • Video-conferencing facilitated • Patient "who goes where" conundrum • Easier to down-size than up-size • National and international reputation will suffer if we have more than one centre
Questions and answers Understanding your views
Engagement on clinical recommendations
Indicative engagement process Formally discuss Discuss clinical the Formally discuss Decision making case for change recommendations the by NHS and / requirements for recommendations Commissioning recommendations further with Clinical Board taking with patients and engagement with Commissioning account views the public, LINks, Joint Health Groups to received during Overview and councils and other understand their engagement representatives Scrutiny views Committees Engagement until end of Discussions with CCGs Discussions with JHOSCs Following engagement and March during Feb/March during March and April development of final clinical recommendations, decisions made by NHS CB
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