Urological cancers why we need to change Clinical workshop 12 - - PowerPoint PPT Presentation

Urological cancers – why we need to change

Clinical workshop – 12 March 2013

Introduction and welcome

• 1. London Cancer’s recommendations for

change Professor Kathy Pritchard-Jones Chief Medical Officer, London Cancer

• 2. The evidence and practicalities

Q&As Mr John Hines 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

Today’s event aims to cover:

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

for the care we would expect from local and specialist units

• Working with trusts to determine how they could work

together to implement the proposed model of care

• Trusts submitted expressions of interest, outlining

how they would meet specifications

• The London Cancer Board is recommending to

commissioners that complex bladder and prostate surgery should be based at University College London Hospitals (UCLH) NHS Foundation Trust; and that complex renal cancer surgery should be based at the Royal Free London NHS Foundation Trust.

• Recommendations are independent of other service

reviews currently taking place in London. The requirements for each service will be considered on their own merits, based on improving the outcome and experience of patients. Standards / specification Initial expressions

• f interest

Formal commitment to standards Evaluation of submissions Recommendations to NHS CB

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,
• n 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

• ngoing 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

Discuss clinical case for change and recommendations with patients and the public, LINks, councils and other representatives Formally discuss the recommendations with Clinical Commissioning Groups to understand their views Formally discuss the recommendations / requirements for further engagement with Joint Health Overview and Scrutiny Committees Decision making by NHS Commissioning Board taking account views received during engagement Engagement until end of March Discussions with CCGs during Feb/March Discussions with JHOSCs during March and April Following engagement and development of final clinical recommendations, decisions made by NHS CB

Next steps

• We welcome your active involvement and participation.
• We are discussing the case for change and recommendations with

clinicians, clinical commissioning groups and GPs.

• During March and April, we are formally presenting the proposals,

and the feedback we’ve received, to health overview and scrutiny committees. Questions or feedback?

• Contact Nicole Millane, Communications Lead – Transformational

Change, North and East London Commissioning Support Unit

• Email: nicole.millane@elc.nhs.uk
• Telephone: 020 7683 4251