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SP Paper 426

  AU/S2/05/R6

6th Report, 2005 (Session 2)

Bowel Cancer Services

CONTENTS

REMIT AND MEMBERSHIP

THE REPORT

ANNEXE A – EXTRACTS FROM THE MINUTES

Extract from the Minutes – 8th Meeting 2005 (Session 2)
Extract from the Minutes – 9th Meeting 2005 (Session 2)
Extract from the Minutes – 10th Meeting 2005 (Session 2)
Extract from the Minutes – 13th Meeting 2005 (Session 2)
Extract from the Minutes – 14th Meeting 2005 (Session 2)

ANNEXE B – ORAL EVIDENCE AND ASSOCIATED WRITTEN EVIDENCE

10th Meeting 2005 (Session 2), 17 May 2005

ORAL EVIDENCE

Dr Kevin Woods, Head of Scottish Executive Health Department and Chief Executive of the NHS in Scotland

David Steel, Chief Executive, NHS Quality Improvement Scotland

Mr Ian Finlay, Consultant Surgeon, Glasgow Royal Infirmary

Mrs Pauline Ferguson, Programme Manager, Cancer Services Improvement Programme, Centre for Change and Innovation

Mr Fergus Millan, Head of Screening and Surveillance Branch, Cancer Branch, Scottish Executive

Mrs Liz Porterfield, Head of Clinical Strategies: Cancer Branch, Scottish Executive

SUPPLEMENTARY WRITTEN EVIDENCE

Letter from Dr Kevin Woods, Head of Scottish Executive Health Department and Chief Executive of the NHS in Scotland to the Clerk

Email from the Clerk to Dr Kevin Woods, Head of Scottish Executive Health Department and Chief Executive of the NHS in Scotland to the Clerk

Email from Dr Kevin Woods, Head of Scottish Executive Health Department and Chief Executive of the NHS in Scotland to the Clerk

Email submission from the Scottish Executive to the Clerk

ANNEXE C – OTHER WRITTEN EVIDENCE
Evidence received by the Committee but not reproduced in this report.

Top 20 Actions for Change, “Making it Happen”, Cancer Service Improvement Programme, Scottish Executive, 2005

Trends in Cancer Survival in Scotland, 1977 – 2001. ISD, National Services Scotland August 2004

New ‘Delivery Group’ to scrutinise NHS performance. Scottish Executive press release, 29 July 2005

National eHealth/IM&T Strategy, 2004-2008, NHS Scotland, April 2004

Remit and membership

Remit:

1. The remit of the Audit Committee is to consider and report on-

(a) any accounts laid before the Parliament;

(b) any report laid before or made to the Parliament by the Auditor General for Scotland; and

(c) any other document laid before the Parliament concerning financial control, accounting and auditing in relation to public expenditure.

2. No member of the Scottish Executive or junior Scottish Minister may be a member of the Committee and no member who represents a political party which is represented in the Scottish Executive may be convener of the Committee.

(Standing Orders of the Scottish Parliament, Rule 6.7)

Membership:

Mr Brian Monteith (Convener)
Susan Deacon
Margaret Jamieson
Mrs Mary Mulligan
Eleanor Scott
Margaret Smith
Mr Andrew Welsh (Deputy Convener)

Committee Clerking Team:

Clerk to the Committee
Shelagh McKinlay

Senior Assistant Clerk
Joanna Hardy

Assistant Clerk
Clare O’Neill

Bowel Cancer Services

The Committee reports to the Parliament as follows—

INTRODUCTION

  1. This report sets out the Committee’s findings in relation to the Auditor General for Scotland’s (AGS) report entitled “A review of bowel cancer services: An early diagnosis” (AGS/2005/2).

Evidence

  1. The Committee held one oral evidence session on 17 May 2005.  The following witnesses gave evidence to the inquiry:

Dr Kevin Woods, Head of Scottish Executive Health Department (SEHD) and Chief Executive of the NHS in Scotland, David Steel, Chief Executive NHS Quality Improvement Scotland; Mr Ian Finlay, Consultant Surgeon, Glasgow Royal Infirmary; Mrs Pauline Ferguson, Programme Manager, Cancer Services Improvement Programme and Mr Fergus Millan, Head of Screening and Surveillance Branch Centre for Change and Innovation and Mrs Liz Porterfield, Head of Clinical Strategies: Cancer Branch, Scottish Executive.

  1. Written evidence received by the Committee can be found at Annex B.

Findings and Recommendations

  1. The Committee’s main findings and recommendations are set out at Appendix A.

POSITIVE PROGRESS

  1. The evidence considered by the Committee records positive progress in many key aspects of bowel cancer services. In particular the most recent statistics for Scotland’s survival rates show a marked improvement.1
  1. There are two key factors which are helping to drive these improvements:

    i) Multi-disciplinary teams (MDTs) of medical and nursing staff which plan and co-ordinate care for bowel cancer patients are now in place and working well at most hospitals; and

    ii) Scotland’s three Bowel Cancer Managed Clinical Networks2 (which include medical staff, nurses and NHS managers) have all made good progress in auditing clinical practice and promoting high quality care.

  2. The Committee is pleased to note that as a result of this:  
  • most bowel cancer patients in Scotland receive high quality well co-ordinated care; 3
  • compliance with clinical standards is high and improving;  
  • there are many examples across Scotland of services being redesigned to improve efficiency and make bowel cancer services more patient friendly4.

The Committee therefore commends the positive progress being made in key aspects of Scotland’s bowel cancer services.

  1. However, NHS Scotland still faces some significant challenges in its efforts to improve bowel cancer care.  These issues are summarised below and some are considered in more detail later in the report.
  • Improving Waiting Times Performance – many patients are still waiting too long for the care they need. It is unlikely that the target of all patients starting treatment within 2 months from urgent referral will be met by the end of 2005.
  • Process of GP Referral - more must be done to improve the process of GP referral of suspected bowel cancer patients so that patients do not experience unnecessary delays in diagnosis, specifically the Department must take steps to ensure that GPs follow established national guidelines. 
  • Increasing Capacity – urgent action is needed to train more staff so that waiting times for diagnostic tests can be shortened. But it will take at least a year for extra nurse endoscopy staff to be trained and ready for work.  It is also not clear whether the number of extra nursing and medical staff planned will be enough to improve waiting times and meet the extra demand created by the bowel cancer screening programme which is to be introduced in 2006.
  • Delivering Consistent Best Practice - Systems for ensuring that individual  examples of good practice are translated into consistent best practice need to improve.
  • Securing Better Value – cost and performance information should be improved to enable value for money to be demonstrated and to identify where improvements in efficiency are required.
  1. The Committee supports the recommendations made in the Auditor General’s report and recommends that in responding to this report the Department;
  • confirm whether it accepts these recommendations; and
  • set out what actions it intends to take to ensure that they are implemented.

DRIVING CHANGE AND QUALITY OF CARE

  1. The drive to improve services must encompass improving the quality of clinical care and improving the way in which services are delivered, including the extent to which resources are used efficiently. Regional Cancer Advisory Groups, Managed Clinical Networks, the Bowel Cancer Framework Group and the Centre for Change and Innovation (CCI) play an important part in improving services. 

Improving Performance Against Clinical Standards

  1. The AGS report sets out the role of Regional Cancer Advisory Groups (RCAGs), Managed Clinical Networks (MCNs) and NHS Boards.5  In essence RCAGs are concerned with the range and quality of all cancer services in an area (North, West or East of Scotland), MCNs focus on the quality of specific cancer services in each of those areas (e.g. lung, breast, ovarian or colorectal cancer.)
  1. Scotland’s three Regional Cancer Advisory Groups are working well in delivering the Cancer in Scotland Strategy 6 by;
  • determining regional cancer service investment priorities;
  • monitoring how regional action plans are being delivered; and
  • accounting for the new cancer monies.
  1. Bowel Cancer MCNs are working well to address issues of quality and clinical practice.7 Mr Finlay gave evidence on the benefits of the work of MCNs (Cols 1147 and 1148). Evidence was also submitted by the Department on the performance of all managed clinical networks in meeting important clinical outcome measures.8 This evidence shows that Scotland’s managed clinical networks for bowel cancer can demonstrate steady progress in improving performance against key clinical standards. The Committee commends the work done to improve performance against clinical standards.
  1. While this positive progress is to be welcomed, it should be noted that there may still be individual hospital sites that are not meeting specific standards. In addition, the clinical performance evidence submitted by the Department does not specify how missing data has been treated in the presentation of performance.  The Committee is aware that if missing data is excluded, rather than counted as a failure to meet the standard, this will result in a better performance against the standard. The Committee recommends that in responding to this report the Department confirm how missing data is treated by all three MCNs for bowel cancer in assessing performance against clinical standards.

Improving Service Delivery
     
GP Referral

  1. The AGS report records that while national guidelines have been prepared to help GPs in deciding whether to refer patients for specialist bowel cancer tests, GPs do not always follow these guidelines.  The report also states that fewer than half of health boards have agreed formal referral arrangements with primary care.
  1. The Department identified examples where parts of Scotland (e.g. Tayside) had made progress in securing GP adoption of referral guidelines.9  Dr Woods stated in evidence that improving the process of GP referral of suspected bowel cancer patients was “almost the number one” action under the Cancer Services Improvement Programme (CSIP) and the “Top 20 Actions for Change” guide10. (Col 1152).
  1. However, the fact that many services may choose not to engage with the Centre for Change and Innovation over implementation of the action plan raises questions about how the Department will ensure that good practice of this kind is consistently delivered across NHS Scotland.
  1. The Committee therefore remains concerned that GP practice in referring suspected cases of bowel cancer will remain inconsistent, with some patients continuing to experience unnecessary delays in referral to specialist diagnostic services.  
  1. The Committee recommends that the Department put arrangements in place to ensure effective local referral, including the agreement and  implementation of GP referral guidelines and the subsequent audit of GP compliance.

The Role of Regional Cancer Advisory Groups and Managed Clinical Networks

  1. The AGS report records good progress made by RCAGs and MCNs in using new money to good effect but the report goes on to state that there is little evidence of RCAGs and MCNs making significant progress in securing the efficient use of mainstream resources.11
  1. The Committee considers that, while Managed Clinical Networks are making progress in improving performance against clinical standards, they have not been enabled to drive change and influence a shift in resources.
  1. Improving bowel cancer services is a complex task which requires a multi-disciplinary and inclusive approach involving a range of bodies. It is therefore essential that there is clarity about who is responsible for delivering change and those charged with securing that change must have the authority to do so. 
  1. The Committee considers that there is overlap in the roles of Regional Cancer Advisory Groups and Managed Clinical Networks and NHS Boards and their operating divisions.  Most importantly the Networks should be further empowered to effect change.  The Committee recommends that the Department review the role and powers of these bodies. 
  1. In evidence to the Committee Dr Woods stated that the right management relationships must be in place to ensure that the conclusions of managed clinical networks turn into “change on the ground” (Col 1137). The Committee notes the creation of the Health Department Delivery Group which will bring together the National Waiting Times Unit, the Centre for Change and Innovation and Performance Management Division12. The Committee recommends that the Department ensure that the new Delivery Group engages with MCNs and RCAGs to ensure that its work is successfully aligned with mainstream NHS management.

The Cancer Services Improvement Programme and the Centre for Change and Innovation

  1. The Committee took evidence on the work that had been carried out under the Cancer Services Improvement Programme (CSIP)(Cols 1134 and 1135) and the development of the “Top 20 Actions for Change” guide.
  1. In relation to improving performance Dr Woods stated “it is increasingly clear that we need to align better on our delivery objectives and on the detailed work that the Centre for Change and Innovation is undertaking.” (Col 1134) The Department confirmed that beginning in June the CSIP will produce a monthly report which will detail take up of the 20 actions for change13 and which will be sent to a range of bodies including the performance management division within SEHD. However, it was not clear from the evidence how the Department will ensure that any slow progress in implementing the actions for change will be addressed.
  1. Dr Woods also stated that in many instances improvements in services have “been achieved by highly motivated staff wanting to…work together and apply lessons…We need to ensure that we always leave space and time for people to be enterprising and innovative at local level.” (Col 1151)
  1. However, not all areas of the service will be in a position to undertake this kind of work without further support and encouragement. One way in which this support is provided is through the work of the Centre for Change and Innovation, but the Centre’s approach relies heavily on services “self-referring” for help and support.  
  1. Good practice and service improvement should be rooted in day to day working practice.  As such it is a fundamental part of service delivery and should not be seen as an optional “add-on”. The Committee recommends that the Department take steps to ensure that all services are implementing best practice in bowel cancer services as set out in the “Top 20 Actions for Change Guide” and elsewhere. 
  1. The Committee welcomes the recognition implicit in the creation of the new Delivery Group that more needs to be done to deliver improvements and to ensure the consistent roll out of best practice. It is important however that the creation of the group does not undermine the philosophy of front-line staff leading the improvement effort.
  1. The Committee recommends that more incentives be developed  to encourage local teams of clinicians and managers to deliver improvements. These should address the needs of services which wish to improve but are struggling to do so due to service demands.

The Role of Clinical Nurse Specialists

  1. Colorectal cancer clinical nurse specialists have an important role in co-ordinating the care of patients and providing reassurance through what can be a complex and worrying set of interactions with the health service. 14
  1. The written evidence from the Department acknowledges that the clinical nurse specialist role in bowel cancer has developed inconsistently throughout Scotland15 – but the evidence lacks clarity about how best practice is to be shared and applied. 
  1. There is to be a review of the role and remit of clinical nurse specialists in cancer, which will be underpinned by the Framework for Role Development in Nursing and Allied Health Professions which was launched in July 2005.16 
  1. The Committee recommends that the Department take steps to  ensure that the role of  the clinical nurse specialist is effectively developed. This should ensure that NHS Boards;
  • achieve consistent development of and access to clinical nurse specialist expertise; and
  • direct the work of clinical nurse specialists to ensure maximum benefit for patients.

Involving Patients

  1. In evidence to the Committee Mrs Ferguson of the Centre for Change and Innovation (CCI) set out some of the work that is being carried out by the CCI and others on seeking patients’ views and involving them in improving services. Dr Woods confirmed that the way in which patient views were used to inform the management process needed to be more systematic. (Cols 1127, 1153 and 1154)
  1. The Committee welcomes the undertaking to review how patient views can be used more effectively to inform development of the service.  The Committee recommends that in responding to this report the Department provide a report on the progress of this work.
  1. Patients’ views are particularly useful in work to improve patients’ overall experience in receiving care. Improvements in communication and the accessibility of services cannot be achieved without patients’ feedback.   For example, high quality information for patients has been developed by the West of Scotland Cancer Network (WOSCAN) following research with past and current patients17.  This information enables cancer care professionals in that area to provide information and support which is sensitive to the particular needs of individual patients.  The Committee recommends that performance targets for cancer services should include patient satisfaction standards. (See paragraph 61)

WAITING TIMES

  1. The Audit Scotland report highlights the challenge that bowel cancer services face in meeting the 2005 waiting times target that, by the end of that year, maximum wait from urgent referral to treatment will be two months.   The report shows that in the period July - September 2004 only 60% of patients were seen within that time and indicates that whilst performance in this area is improving, if current trends continue it is unlikely that the target will be met. 
  1. Almost all of the issues considered in this report will impact on waiting times – improving the process of GP referral, increasing capacity, and implementing risk based diagnosis. There is little time remaining to address this wide range of issues which must be resolved if the waiting time target is to be met.
  1. A Departmental National Delivery Group whose remit is to secure actions to deliver waiting time targets and monitor delivery has been established. The group met for the first time on the 9th June to consider a National Delivery Plan18.
  1. The Committee is disappointed by the content of the Plan which is limited to generic statements of strategic services changes that are needed across Scotland. Clearly plans to address the specific challenges within each NHS Board area are required and it is essential that the Department monitors progress against local plans. The Committee recommends that in responding to this report the Department advise how the actions to improve waiting times required in each Board area will be recorded and monitored.
  1. The Committee firmly believes that a centralised “top-down” approach will not deliver the improvement in waiting times needed. Rather, incentives must be developed which encourage local groups of clinicians and managers to address the issues which will bring waiting times down.
  1. The Committee concludes that it is unlikely that the waiting time target for bowel cancer services will be met. The Committee further considers that sustained progress on waiting times will not be achieved without effective incentives which are currently lacking. The Committee recommends that the Department develop proposals on a range of incentives to enable the service to meet the waiting times target for bowel cancer services.

CAPACITY PLANNING

  1. The AGS report found that the absence of key staff such as radiologists and endoscopists was impacting on waiting times performance and leading to under-utilisation of diagnostic equipment.19 In addition, numbers of endoscopists must be increased to meet the demands that will arise from the introduction of the bowel cancer screening programme.
  1. In evidence to the Committee the Department confirmed its plans to increase the number of endoscopists. The Department wants half of all endoscopies to be carried out by nurse endoscopists.  Following submission of a business case for the enhancement of endoscopy services £741, 775 is being provided. With this funding NHS Education for Scotland (NES) will develop a project plan for;
  •  50 “train the trainer” and 100 short skills courses for medical endoscopists; and
  • training through Glasgow Caledonian University for up to 25 nurse/non-doctor endoscopists, with an emphasis on expanding numbers significantly in January 2006.20
  1. The Committee welcomes the commitment to increase the total number of endoscopies performed and to increase the number performed by nurse endoscopists.  However, the Committee is concerned at the length of time it will take to have new endoscopy staff in place - probably not until the summer of 2006 at the earliest. 
  2. In addition the increased numbers of nurse endoscopists proposed may not be sufficient to address current waiting times performance and at the same time support the national roll-out of bowel cancer screening. If promised service improvements are to be achieved, the Department must ensure that increased capacity is delivered more quickly. The Committee recommends that the Department put arrangements in place to deliver the increased capacity required more quickly.
  1. The evidence submitted does not clearly explain why other options for increasing the number of endoscopists (such as training more GP endoscopists or medical/surgical endoscopists) are not being pursued.
  1. The Committee requests that in responding to this report the Department set out their reasons for concentrating on increasing the number of nurse endoscopists.

SECURING BETTER VALUE

Cost Information

  1. The AGS report found that the future direction for bowel cancer services in Scotland is clear but that more emphasis is needed on securing better value from existing resources.21 A lot of good work has been done on how to achieve the best use of resources– the challenge is to deliver this.
  1. The AGS report found that the work of Scotland’s three managed clinical networks (MCNs) and Regional Cancer Advisory Groups (RCAGs) had focused largely on the new funds which have been made available. Dr Woods confirmed that the Department was to introduce a tariff system over the next two years which would enable the relative cost efficiency of different parts of the NHS to be considered. (Col 1126)
  • In its written submission, and in its response to the Committee’s 5th report22, the Department stated that the tariff system will help to resolve financial disagreements for cross-boundary flows. It is also envisaged that it will create an incentive for improving efficiency in costs and over time improve the quality of data being collected and recorded. 23
  1. In its 5th report the Committee recommended that the Department improve the quality of financial and cost information.24 The Committee welcomes the Department’s recognition that cost information needs to be improved and it is hoped that the tariff system will help to achieve this. However the initiative is clearly at a very early stage.    As the AGS report states “the real challenge will come in redesigning existing services (including reallocating existing resources) which equate to over 90 per cent of total cancer spend in Scotland…”.25  Progress on these issues is essential if the best possible investment decisions are to be made and the objectives of the efficient government agenda achieved.
  1. The Committee considers that the introduction of the tariff system provides an opportunity for the Department to gain a better understanding of the overall cancer spend.
  1. The Committee acknowledges that the relative costs and benefits of such work must be borne in mind. However  the Committee considers that, despite the complexities involved, the Department should know what is being spent on cancer services in Scotland.  In particular it should be able to identify in broad terms what is spent on prevention, detection and treatment. 26
  1. The Committee recommends that the Department utilises tariff data to:
  • improve efficiency within and across NHS Boards; and
  • develop a better understanding of the balance of cancer services expenditure on prevention, detection and treatment.

Performance Information

  1. The AGS report records that the absence of specific improvement measures for bowel cancer services makes it difficult to judge progress.27
  1. In evidence to the Committee Dr Woods highlighted the target of reducing cancer mortality in the under 75’s by 20 per cent by 2010 and emphasised the importance of survival rates which would be considered in audit work undertaken by the MCNs. (Col 1126)
  1. Dr Woods also stated that the Department had “reached the view that it would be beneficial to introduce some intermediate milestones… on progress on waiting times.“ (Col 1126) Dr Woods confirmed that the Executive should also become more systematic in the way in which it measures patients’ views and feeds those views into the planning process.(Cols 1127 and 1154)
  1. The Committee considers that more specific targets are needed within Scotland’s Cancer Strategies to measure improvement.  The Committee therefore recommends that the Department develop specific targets for cancer servicesincluding survival rates, waiting times, cost and performance information and measuring patient satisfaction.

Appendix A

KEY FINDINGS AND RECOMMENDATIONS

POSITIVE PROGRESS

  • The Committee is pleased to note that:  
    • most bowel cancer patients in Scotland receive high quality well co-ordinated care;
    • compliance with clinical standards is high and improving;  
    • there are many examples across Scotland of services being redesigned to improve efficiency and make bowel cancer services more patient friendly. (Para 7)
  • The Committee therefore commends the positive progress being made in key aspects of Scotland’s bowel cancer services. (Para 7)
  • The Committee supports the recommendations made in the Auditor General’s report and recommends that in responding to this report the Department;
    • confirm whether it accepts these recommendations; and
    • set out what actions it  intends to take to ensure that they are implemented. (Para 9)

DRIVING CHANGE AND QUALITY OF CARE

Improving Performance Against Clinical Standards

  • The Committee commends the work done to improve performance against clinical standards. (Para 13)
  • The Committee recommends that in responding to this report the Department confirm how missing data is to be treated by all three MCNs for bowel cancer in assessing performance against clinical standards. (Para 14)

Improving Service Delivery
           
GP Referral

  • The Committee therefore remains concerned that GP practice in referring suspected cases of bowel cancer will remain inconsistent, with some patients continuing to experience unnecessary delays in referral to specialist diagnostic services. (Para 18)  
  • The Committee recommends that the Department put arrangements in place to ensure effective local referral, including the agreement and  implementation of GP referral guidelines and the subsequent audit of GP compliance. (Para 19)

The Role of Regional Cancer Advisory Groups and Managed Clinical Networks

  • Improving bowel cancer services is a complex task which requires a multi-disciplinary and inclusive approach involving a range of bodies. It is therefore essential that there is clarity about who is responsible for delivering change and those charged with securing that change must have the authority to do so. (Para 22)  
  • The Committee considers that there is overlap in the roles of Regional Cancer Advisory Groups and Managed Clinical Networks and NHS Boards and their operating divisions.  Most importantly the Networks should be further empowered to effect change.  The Committee recommends that the Department review the role and powers of these bodies. (Para 23)  
  • The Committee recommends that the Department ensure that the new Delivery Group engage with MCNs and RCAGs to ensure that its work is successfully aligned with mainstream NHS management. (Para 24)

The Cancer Services Improvement Programme and the Centre for Change and Innovation

  • The Committee recommends that the Department take steps to ensure that all services are implementing best practice in bowel cancer services as set out in the “Top 20 Actions for Change Guide” and elsewhere. (Para 29)  
  • The Committee recommends that more incentives be developed  to encourage local teams of clinicians and managers to deliver improvements. These should address the needs of services which wish to improve but are struggling to do so due to service demands. (Para 31)

The Role of Clinical Nurse Specialists

  • The Committee recommends that the Department take steps to  ensure that the role of  the clinical nurse specialist is effectively developed. This should ensure that NHS Boards;
    •  achieve consistent development of and access to clinical nurse specialist expertise; and
    • direct the work of clinical nurse specialists to ensure maximum benefit for patients. (Para 35)

Involving Patients

  • The Committee welcomes the undertaking to review how patient views can be used more effectively to inform development of the service.  The Committee recommends that in responding to this report the Department provide a report on the progress of this work. (Para 37)
  • The Committee recommends that performance targets for cancer services should include patient satisfaction standards. (Para 38)

WAITING TIMES

  • The Committee recommends that in responding to this report the Department advise how the actions to improve waiting times required in each Board area will be recorded and monitored. (Para 42)
  • The Committee concludes that it is unlikely that the waiting time target for bowel cancer services will be met. (Para 44)
  • The Committee recommends that the Department develop proposals on a range of incentives to enable the service to meet the waiting times target for bowel cancer services. (Para 44)

CAPACITY PLANNING

  • The Committee welcomes the commitment to increase the total number of endoscopies performed and to increase the number performed by nurse endoscopists. (Para 47)  

  • The Committee recommends that the Department put arrangements in place to deliver the increased capacity required more quickly. (Para 48)
  • The Committee requests that in responding to this report the Department set out their reasons for concentrating on increasing the number of nurse endoscopists. (Para 50)

SECURING BETTER VALUE
           
            Cost Information

  • The Committee considers that the introduction of the tariff system provides an opportunity for the Department to gain a better understanding of the overall cancer spend. (Para 55)
  • The Committee recommends that the Department utilises tariff data to:
    • improve efficiency within and across NHS Boards; and
    • Develop a better understanding of the balance of cancer services expenditure on prevention, detection and treatment. (Para 57)

Performance Information

  • The Committee considers that more specific targets are needed within Scotland’s Cancer Strategies to measure improvement.  The Committee therefore recommends that the Department develop specific targets for cancer servicesincluding survival rates, waiting times, cost and performance information and measuring patient satisfaction. (Para 61)

ANNEXE A

AUDIT COMMITTEE
EXTRACT FROM THE MINUTES
8th Meeting, 2005 (Session 2)
Tuesday 19 April 2005

Members Present:

Susan Deacon Margaret Jamieson
George Lyon Mr Brian Monteith (Convener)
Mary Mulligan Mr Andrew Welsh

Apologies were received from Robin Harper

AGS Report on Bowel Cancer Services: The Committee received a briefing on the report by the Auditor General for Scotland entitled “A Review of Bowel Cancer Services: An early diagnosis” (AGS/2005/2).

AGS Report on Bowel Cancer Services (in private): The Committee considered its approach to the report by the Auditor General for Scotland entitled “A Review of Bowel Cancer Services: An early diagnosis” (AGS/2005/2). The Committee agreed to hold an inquiry and take evidence from the Accountable Officer at a future meeting. 

AUDIT COMMITTEE
EXTRACT FROM THE MINUTES
9th Meeting, 2005 (Session 2)
Tuesday 26 April 2005

Members Present:

Susan Deacon  Robin Harper
Margaret Jamieson George Lyon
Mr Brian Monteith (Convener) Mary Mulligan
Mr Andrew Welsh  

Apologies were received from George Lyon

AGS Report on Bowel Cancer Services (in private): The Committee considered arrangements for its inquiry into the report by the Auditor General for Scotland entitled “A Review of Bowel Cancer Services: An early diagnosis” (AGS/2005/2).

AUDIT COMMITTEE
EXTRACT FROM THE MINUTES
10th Meeting, 2005 (Session 2)
Tuesday 17 May 2005

Members Present:

Susan Deacon  Robin Harper
Margaret Jamieson George Lyon
Mr Brian Monteith (Convener) Mary Mulligan
Mr Andrew Welsh  

AGS Report on Bowel Cancer Services: The Committee took evidence from

Dr Kevin Woods, Head of Scottish Executive Health Department and Chief Executive of the NHS in Scotland; David Steel, Chief Executive, NHS Quality Improvement Scotland; Mr Ian Finlay, Consultant Surgeon, Glasgow Royal Infirmary; Mrs Pauline Ferguson, Programme Manager, Cancer Services Improvement Programme, Centre for Change and Innovation; and Mr Fergus Millan, Head of Screening and Surveillance Branch and Mrs Liz Porterfield, Head of Clinical Strategies: Cancer Branch, Scottish Executive.

AGS Report on Bowel Cancer Services (in prviate): The Committee considered the evidence taken AND also considered further arrangements for this inquiry. The Committee agreed to write to Dr Kevin Woods for further information.

AUDIT COMMITTEE
EXTRACT FROM THE MINUTES
13th Meeting, 2005 (Session 2)
Tuesday 13 September 2005

Members Present:

Susan Deacon Margaret Jamieson
Mr Brian Monteith (Convener) Mary Mulligan
Eleanor Scott    Margaret Smith

Apologies were received from Andrew Welsh

AGS Report on Bowel Cancer Services (in private):The Committee considered a draft report on its inquiry into the report by the Auditor General for Scotland entitled “A Review of Bowel Cancer Services: An early diagnosis” (AGS/2005/2). The Committee agreed to consider a further draft report at its meeting on 20 September.

AUDIT COMMITTEE
EXTRACT FROM THE MINUTES
14th Meeting, 2005 (Session 2)
Tuesday 20 September 2005

Members Present:

Susan Deacon Mr Brian Monteith (Convener)
Mary Mulligan Margaret Smith
Andrew Welsh  

Apologies were received from Margaret Jamieson and Eleanor Scott

AGS Report on Bowel Cancer Services (in private):The Committee considered a draft report on its inquiry into the report by the Auditor General for Scotland entitled “A Review of Bowel Cancer Services: An early diagnosis” (AGS/2005/2). The report was agreed to.

ANNEXE B

10th Meeting 2005 (Session 2), 17 May 2005 - Oral Evidence

SUPPLEMENTARY WRITTEN EVIDENCE

LETTER FROM DR KEVIN WOODS TO THE CLERK 10 JUNE 2005

Dear Ms McKinlay

A REVIEW OF BOWEL CANCER SERVICES – FOLLOW-UP EVIDENCE

Further to your letters of 24 and 26 May requesting further information following the evidence session on 17 May 2005,  this is attached as set out below. 

Waiting times action plan Annex A
Electronic patient records   Annex B
Staff retention Annex C
Tariff system Annex D
Best Practice and Top 20 Actions for Change Annex E
Capacity planning   Annex F
Quality of care    Annex G
Monitoring performance and compliance with clinical standards Annex H

I can also confirm that I am content with the Official Report subject only to two suggested amendments:

  1. Column 1125 – “Mr Graham” should be changed to “Ms Graham”
  2. Column 1140 – the current number of Nurse Endoscopists should be 39 not 29.

I am enclosing 20 copies of the Top 20 Actions for Change document as requested at the meeting, copies of which have also been placed in SPICE. 

I trust the Audit Committee will find this additional information helpful.

Yours sincerely

KEVIN WOODS

ANNEX A

A REVIEW OF BOWEL CANCER SERVICES – FOLLOW-UP EVIDENCE

NATIONAL CANCER WAITING TIMES DELIVERY PLAN

Provide a copy of this plan

As you know the achievement of the national waiting time targets for cancer is a key commitment in the Partnership Agreement published in 2003.  The Minister for Health and Community Care and Chief Executive of NHS Scotland have made it clear that meeting the target is a top priority for NHS Boards.  To help accelerate the pace of change we have established a Departmental National Delivery Group whose remit is to secure actions that will deliver the waiting time targets and to monitor delivery across Scotland.  The first task of this group is to agree a National Delivery Plan setting out the key actions and timescales associated with delivery of the target.  The group meets for the first time on Thursday 9 June when they will consider and ratify the draft National Delivery Plan.  I will send the final version of the plan after it is agreed by the Group.

In the meantime I can confirm that the areas likely to be addressed are urgent referral protocols and procedures, rapid assessment and diagnosis, multidisciplinary team meetings and reducing delays in first treatment.

Clinical Strategies: Cancer

June 2005

ANNEX B

A REVIEW OF BOWEL CANCER SERVICES – FOLLOW-UP EVIDENCE

ELECTRONIC PATIENT RECORDS

Provide further information on the working group including timescales for the roll out of electronic patient records.

Discussions with Ministers and the eHealth Programme Board have been on the high level plan for how NHSScotland will achieve the objective of a single EPR for each patient, pan NHS.   This is very much in line with the IT recommendations of the Kerr Report.

These discussions, now reaching final stages, envisage a three-pronged strategy which avoids the high risk of leaping straight to a new IT system:

  1. Exploiting what exists.  For example by increasing numbers of GP referrals which are electronic.  This  addresses the cancer waiting time targets.

  2. Filling the gaps.  For example this month we expect to conclude a contract for a system to enable digital images/X-Rays to be accessed online from anywhere in NHS Scotland.  More directly pertinent to cancer services will be to conclude procurement then implement a 'Generic Clinical System' to support patient-related communication within three cancer Managed Clinical Networks initially.

  3. Planning for the future – the single electronic health record system for NHSScotland by the end of the decade. Target is to commence procurement by end 2005.

Further information on the eHealth/IM & T Programme Board can be accessed on the Scottish Health on the Web (SHOW) website at http://www.show.scot.nhs.uk/ehealth/

ANNEX C

A REVIEW OF BOWEL CANCER SERVICES – FOLLOW-UP EVIDENCE

STAFF RETENTION

Clarify how staff turnover levels in key disciplines such as radiography and endoscopy compare with average staff turnover levels across NHSScotland.

It is the responsibility of Health Boards to monitor their staff turnover levels and these figures are not collected and analysed nationally so average national levels are not available.

In looking at any staff turnover figures it is important to establish between staff moving from one NHS Scotland health board and another and those leaving NHS Scotland altogether. NHS Scotland has put in place employment policies designed to develop and retain staff and will continue to work with NHS Scotland employers and staff organisations to ensure workforce plans provide information on future trends.

Workforce planning for bowel cancer is part of wider workforce planning arrangements being taken forward at national, regional and local levels.  The National Workforce Plan-Framework 2005 is due to be published in June 2005 and provides an overview of the main factors impacting on the supply and demand of the workforce and identifies actions that need to be taken at each level to maintain and grow healthcare workforce that will be required by the NHS in Scotland.

ANNEX D

A REVIEW OF BOWEL CANCER SERVICES – FOLLOW-UP EVIDENCE

TARRIFF SYSTEM

Provide further details of this sytem including information on how the system will operate.

The Department is continuing with work to develop a methodology for setting national tariffs in Scotland.  The outcome of this exercise will improve the way in which information on NHS costs for the acute hospital sector can be presented.  It will enable costs to be extracted at disease-level (e.g. cancer), or at procedure level, by using HRG-level information. 

The tariff system is to be applied to cross-boundary flows.  This will, in effect, set a standard price for all activity undertaken by host Boards on behalf of patients that come from other Boards in Scotland. 

The aim of the system is to resolve financial disagreements for cross-boundary flows, thereby helping patients to get treatment quicker by making the arrangements for moving between Health Boards more transparent.  The tariff system will also create an incentive for improving efficiency in costs and over time, improve the quality of data being collected and recorded. 

The introduction of the tariff system will be progressive, starting in 2005/06.  No decision as yet has been made on precisely how the system will operate or how it will be phased in.  A ‘tariff reference group’ comprising representatives from 5 NHS Boards and officials from SEHD and ISD, has been set up to consider options and approaches for implementation.  It is expected that a paper outlining some proposals will be presented to NHS Chief Executives in July.

ANNEX E

A REVIEW OF BOWEL CANCER SERVICES – FOLLOW-UP EVIDENCE

BEST PRACTICE AND TOP 20 ACTIONS FOR CHANGE

(1) Set out how the Department is promoting Top 20 Actions for change, current levels of participatin in the CSIP process (i.e. how many bowel cancer services are currently participating), the steps that are being taken to ensure that the actions are implemented at Boards level and then rolled out consistently across Scotland and how the impact of the programme is being monitored.

Best practice and Top 20 Actions for Change

Promoting the Cancer Service Improvement Programme (CSIP) Top 20 Guide

  • Over 2,500 copies distributed since publication at end March 2005.
  • Widely distributed across NHS Scotland, including all cancer networks.
  • National Spread and Share Day held 24th May 2005 to further raise awareness of guide and to focus on where support can be provided by CSIP.

Current levels of participation in CSIP process

It is important to recognise that CSIP provides support to all 3 regional cancer networks.  Practical, on site support has been  provided by a facilitator for a period of between one and one and a half years. The team advise on tools and techniques of redesign and facilitate process mapping.
 
For example, for  Bowel cancer:

  • SCAN –  work within 7 hospitals in South East Scotland
  • NOSCAN – work within each of the 3 main geographical regions: Tayside, Highland, Grampian
  • WOSCAN – Generic support across the regional cancer network.  

During 2005 - 06 work will focus on the implementation of “Top 20 Actions for Change” relevant to the network/tumour site service.  This will heighten the focus of clinical teams.

Monitoring

CSIP  Monthly Report  (Implementation Progress Report), to be available from end June 2005.  This report will monitor the uptake of the Top 20 Actions for Change across each of the 3 Regional Cancer Networks.   This report  will be sent to the following bodies:

  • Regional cancer networks for their own purposes and tumour specific groups/networks
  • Regional Cancer Advisory Groups
  • National Waiting Times Unit
  • Performance Management
  • Cancer Branch

(2) During the session sharing and applying best practice within the service was discussed. Dr Woods stated “it is increasingly clear that we need to align better our delivery objectives and the detailed work that the centre for change and innovation is undertaken” – Expand on this comment, addressing more specificially what issues need to be tackled particaly in relation to – the role of clinical nurse specialists; systematically measuring and feeding in the view of patients; primary care referral

Clinical Nurse Specialists

A clinical nurse specialist (CNS)  is a registered nursing professional who has acquired specialist knowledge, skills and experience together with a professionally and/or academically accredited post-registration qualification (if available) in a clinical speciality. They practice at an advanced level and may have sole responsibility for a care episode or defined client/group.

Significant progress has been made by Clinical Nurse Specialists in Cancer in Scotland in planning, delivering and evaluating care for people with cancer and their carers.

The Clinical Nurse Specialist role in bowel cancer in Scotland has developed inconsistently throughout the country. There are regional and local variations across Scotland which cannot be accounted for solely on the grounds of local need. Examples of Clinical Nurse Specialist roles include:

  • triage of referred patients with gastrointestinal symptoms for urgent consultation;
  • support of new patients at clinic and development of patient information ;
  • telephone contact for patients prior to admission and on discharge;
  • co-ordination of patient care across the clinical team;
  • provision of a  specialist resource for the clinical management of patients in hospital and community;
  • increased out patient capacity by establishing an out patient service for patients with low risk colorectal symptoms;
  • review of patients at agreed intervals following colorectal surgery;
  • follow up telephone call to patients at home after endoscope investigation;
  • patients do not need to return to the hospital for a check up.

Currently a few Clinical Nurse Specialists act as non-medical endosocpists undertaking colonoscopy investigations. NHS Education for Scotland (and including CCI among others) are working on a project to develop the non-medical endoscopy workforce.   It is recommended that many of these will be clinical nurse specialists who will undertake endoscopic procedures as part of their remit.

Changes such as referral letters as highlighted in the CCI Cancer Service Improvement Programme enable the Clinical Nurse Specialist role to have a greater impact on the patient journey.

Nursing People with Cancer: A Framework (SEHD, 2004) recommended a review of the role and remit of Clinical Nurse Specialists in Cancer. It was agreed that any such review would be taken forward within the context of the Framework for Role Development in Nursing and Allied Health Professions. This document will be launched in July 2005.

Views of Patients

Understanding the wants and needs of patients whether children, adults or older people will lead to more effective and high quality healthcare, and must be a core activity of the health service.  It means developing a genuinely responsive health service by seeking input and feedback from patients as a key part of developing services and iimproving quality.

Seeking patient’s views with a view to improving services is a fundamental part of the Patient Focus and Public Involvement programme of work which NHSScotland has been undertaking.  The development of policies which aspire towards patient-focussed services has been underpinned by a new legal duty of public involvement directly upon NHS Boards by the NHS Reform Act (Scotland) 2004.  All NHS Boards have a designated director for Patient Focus and Public Involvement who is  responsible for driving this culture into every aspect of health services.  Improvements in the delivery of this agenda will be measured and supported by the Scottish Health Council.
 
Apart from the evidence provided to the committee on 17 May, CSIP facilitators feedback to cancer networks via the Patient Involvement Workers.  The patient involvement workers are included and involved in the improvement process.

Primary Care Referral

The National Cancer Waiting Times Delivery Plan (being finalised) will set out the key actions and timescales which are required to accelerate progress towards delivery of the national cancer waiting times target “By 2005, the maximum wait from urgent referral to treatment for all cancers will be two months”. 

Top 20 guide highlights 6 high impact actions for referral. These examples of good practice will be referenced in the National Delivery Plan.

An example of how work is being taken forward with networks:

In Tayside local referral guidelines and protocols have been reviewed in line with the Top 20 Actions around referral with support from the CSIP facilitator. A process mapping event has taken place involving key stakeholders in the service. The guidelines will be implemented at the end of June. This was a successful exercise helped by having GP input and agreement to adopt the referral guidelines.

The learning from this has been spread to Highland and Grampian and the Clinical Leads of these networks have agreed to adopt the same guidelines.

ANNEX F

A REVIEW OF BOWEL CANCER SERVICES – FOLLOW-UP EVIDENCE

CAPACITY PLANNING

Set out, in general terms, how it was decided how many more endoscopists needed to be trained

A business case has been developed through the collaborative effort of NHS Education for Scotland, SEHD (including cancer branch; NWTU, CCI and HR) and the Scottish Society of Gastroenterology on developing the endoscopy workforce. 

This case is now being considered for funding – it proposes to fund training for medical endoscopists to become trainers of nurse (and other) endoscopists as well as  specific skills courses in endoscopy.

The increased number of nurse endoscopists is based upon an aspiration to see up to half of all endoscopies performed by nurse endoscopists. To achieve this will require better utilisation of existing capacity and additional nurses (25) working 3 sessions a week as endoscopists, combined with specialist roles or nurse consultancy where there is a wider service redesign or leadership role.

Training resources for medical staff can be deployed from 2005 utlising the courses provided by the Cushieri Skills Centre, Dundee but over time it is assumed that other centres will offer accredited training. These are short courses and capacity is available.

Training for nurses is provided through a 10 month course at Glasgow Caledonian University and intakes are planned for September 2005 and January 2006.

NES will involve the service in developing the fine detail of implementation and monitoring over the summer.

Finally, the case recommends that there should be continued oversight of implementation by NES leading to further recommendations on endoscopy training in due course.

The Minister announced in Fair to All, Personal to Each in December last year that new waiting time standards for diagnostic tests will be published in the near future.  These will demonstrate that the Scottish Executive are vigorously purusing a full-scale improvement process.

ANNEX G

A REVIEW OF BOWEL CANCER SERVICES – FOLLOW-UP EVIDENCE

QUALITY OF CARE

Provide the committee with data as presented at the Bowel Cancer Network workshop on Friday 13th May showing that all of the networks now meet important clinical outcome measures.

Copies of the slides presented by Mr Ian Finlay at the Bowel Cancer Network workshop are available but on their own are probably not very helpful and require some clinical narrative to explain what is presented. 

We are currently obtaining that narrative and will forward the slides complete with this narrative as soon as possible.

Provision of comparative improvement data for the last 10 – 15 years across Scotland and a copy of the European cancer institute report reference in the evidence session.

There have been large improvements in survival for cancers of the colon and rectum with around 50% of patients now surviving at least five years after diagnosis comkpared to around 24% of those diagnosed 1977 – 1981. 

Further information can be accessed in an ISD publication – Trends in Cancer Survival in Scotland, 1977 – 2001 (attached).

The reference to the European Cancer Institute referred to a personal communication between Professor Peter Boyle, Mr Finlay, Dr Gregor and Mrs Porterfield.  Professor Boyle advised that he had reviewed the Scottish data and the only reason he could find for the improvement was the reorganisation of the service to provide specialist surgeons. 

ANNEX H

A REVIEW OF BOWEL CANCER SERVICES – FOLLOW-UP EVIDENCE

MONITORING PERFORMANCE AND COMPLIANCE WITH CLINICAL STANDARDS

What actions were taken by bowel cancer networks, NHS Boards, the Health Department, NHS Quality Improvement Scotland in relation to non-compliance issues identified in the 2002 bowel cancer audit data contained in the Audit Scotland report.

  • NHS QIS looks to NHS Boards to take the necessary action.  In this process, each Clinical Governance Committee has a crucial role in ensuring this happens (and in its clinical governance reviews, NHS QIS examines whether this is being done appropriately). 
  • NHS Boards are accountable to the Scottish Executive - not to NHS QIS – and NHS QIS therefore ensures that the Health Department (and in this case, the Scottish Cancer Group) is aware of its recommendations so that it can follow them up through the performance management process. 
  • Where there are recommendations requiring action by another national organisation, such as NHS Education for Scotland or the Centre for Change and Innovation, NHS QIS draws them to the attention of the relevant body. 
  • NHS QIS itself undertakes follow-up reviews where appropriate.  In some cases (e.g. healthcare associated infection), it undertakes a further round of visits to monitor progress; in others follow up is based on self-assessment and subsequent validation by NHS QIS.
  • The three regional cancer networks’ Quality Assurance Framework have now been accredited.  They will quality assure the work of tumour-specific groups/networks in their own area.

EMAIL FROM THE CLERK TO DR WOODS 16 JUNE 2005

Dear Dr Woods,

Thank you for the further written evidence which you submitted in connection with the Committee's inquiry into bowel cancer services. Having discussed the evidence with the Convener I am writing to request clarification on the following points:

National Cancer Waiting Times Delivery Plan

Your response states that the National Delivery Plan was to be considered at the first meeting of the Delivery Group which was to have been held on 9 June. You kindly agreed to forward the plan after it had been agreed by the Group. If the plan was agreed I would be grateful for a copy.  If not I would be grateful if you could indicate when the Group will next consider the plan.  If the Plan has been agreed it would be very helpful to receive a copy by close of play on Tuesday 21 June so that it can issue to members with papers for our meeting on 28 June. 

Extra Nurse and Medical Endoscopists

Thank-you for the information in relation to the business case to increase the numbers of staff who can carry out endoscopies.  The letter issued on behalf of the Committee asked for information on how it was decided how many more endoscopists would be trained.  I would be grateful for further information on the modelling/methodology used to determine the number of extra nurse and medical endoscopists required.

CCI

The letter issued on behalf of the Committee also asked you to expand on your statement that " it is increasingly clear that we need to align better our delivery objectives and the detailed work that the centre for change and innovation is undertaking." You have helpfully provided information on the specific issues listed such as the role of clinical nurse specialists,. However I would be grateful if you could explain in more general terms what you mean by this statement. Please give examples if you think that would be helpful.

It would be very helpful to have this information in time for it to be considered by the Committee at its next meeting on 28 June, however I appreciate that this is a very tight timescale. I would be grateful if you could let me know whether you think this will be possible. 

Regards,

Shelagh McKinlay
Clerk to the Audit Committee

RESPONSE FROM DR WOODS 21 JUNE 2005

Dear Ms McKinlay

I refer to your e-mail below and where possible attach further clarification as requested.

NATIONAL DELIVERY PLAN

The National Delivery Plan will be published soon, however it will not be available in advance of your deadline (cop on 21 June). As soon as publication is confirmed I will ensure that the Audit Committee is forwarded an early copy.

EXTRA NURSE AND MEDICAL ENDOSCOPISTS

Further information is attached outlining the methodology used to determine the number of training places to be sponsored.

CCI

The Centre for Change and Innovation was established in November 2002. Since then a number of important new policy announcements have been made, for instance, Fair to All, Personal to Each - The next steps for NHSScotland. As existing CCI programmes reach the end of their planned activities we are designing successor programmes to support current delivery priorities, as well as taking account of the recommendations in the recently published Kerr Report. The Cancer Service Improvement Programme is a good example, as is our recently launched work on unscheduled care.

I hope the Committee find this additional information helpful.

NE/ Additional Briefing

The business case was produced under the direction of a multi-agency steering group, including members of the Scottish Society of Gastroenterologists and UK Joint Advisory Group for Gastrointestinal Endoscopy.

The number of training places to be sponsored was derived from an analysis of demand for endoscopy (extrapolated from a West of Scotland study of referrals (2004)) and a consideration of the drivers for change in the provision of endoscopy services, including new waiting time standards, the extension of colorectal cancer screening and the possibility of substitution from barium enema to colonoscopy as waiting time standards are delivered.

Data on the activity of nurse endoscopists suggests that nurses meet up to one fifth of the current demand for endoscopy services and that there is considerable scope to increase this contribution through redesign (freeing up more time and space for existing nurse endoscopists) and by expanding the overall numbers of nurse endoscopists.

The business case aims to raise the contribution of nurse endoscopists to meet 40% of projected demand by 2008/2009 and by freeing up medical time to take on more colonoscopy, complex endoscopy and to develop more robust training arrangements for the endoscopy workforce in Scotland.

The steering group agreed that while it was theoretically possible for nurses and others to undertake even more endoscopy than that proposed, there may be difficulty in recruitment beyond the levels proposed in the plan.

The numbers of “train the trainer” courses and hands-on skills courses (primarily for specialist registrars) does not reflect additional endoscopy capacity but a recognition that the expansion of nurse endoscopy requires a supportive framework and that training for specialist registrars in Scotland is currently delivered in a relatively unstructured and informal manner by consultant gastro-enterologists and surgeons  during routine lists. The level of training proposed was assessed and suggested by representatives of the Scottish Society of Gastroenterologists (including the JAG representative).

Finally, the business case proposes that an active monitoring function be established between NHS Education for Scotland (NES) and the Scottish Society to monitor uptake, progress and future training requirements.

SCOTTISH EXECUTIVE HEALTH DEPARTMENT

CANCER WAITING TIMES:

NATIONAL DELIVERY PLAN

To aid delivery of the national cancer waiting times target “By 2005, the maximum wait from urgent referral to treatment for all cancers will be two months” this National Delivery Plan has been developed which sets out key additional actions agreed with NHS Boards and regional cancer networks.

The diagram overleaf (pdf) summarises the component parts of the total patient pathway of 62 days from urgent referral. Top 20 Actions for Change from Cancer Service Improvement Programme are highlighted in italics throughout document.

  • By end June and end September 2005 NHS Boards to provide interim progress reports

Clinical Strategies: Cancer

June 2005

Component Agreed Actions
Urgent Referral Ensure protocols for all urgent referrals agreed based on Scottish Referral Guidance for Suspected Cancers and in place across NHSScotland.

 

Ensure urgent referrals are processed appropriately and with minimum delay when received in secondary care

Ensure systems in place across NHS Scotland to identify all urgent referrals received – start of tracking system (see also information)

Drive and support electronic transmission of all urgent referrals

Examples of good practice from Cancer Service Improvement Programme include electronic/faxed referral to a single point, referral to a service not a consultant, direct referral to specialist service from diagnostics, no vetting or, as a minimum, daily team vetting of all referrals

Rapid Assessment and diagnosis

Ensure mechanisms established to process urgent referrals within appropriate timescales

Examples of good practice from Cancer Service Improvement Programme include single route of referral and access for endoscopy services, prebooking/scheduling of investigations and appointments, dedicated fast track clinics with rapid reporting, reduce consultant vetting of investigation requests, telephone consultation/communication of results, specialist nurse led clinics, reduce follow up appointments at outpatient clinics

MDT

Ensure Multidisciplinary Team Meetings in place for all cancers to support clinical management decision making and data capture

Examples of good practice from Cancer Service Improvement Programme include clear responsibility for coordination of MDT to ensure all necessary information is available at MDT fro treatment decision making, MDT used to refer on for treatment, timely communication with MDT of GP decision, video conferencing/telemedicine lines to be used where attendance is limited

First Treatment

Reduce delays in first treatment for all urgent referrals through optimal capacity, demand management and scheduling

Examples of good practice from Cancer Service Improvement Programme include coordination of treatment processes across network to ensure optimum use of capacity e.g. theatre time, planned management of annual leave and public holidays, streamlining of booking processes for chemotherapy and radiotherapy, efficient system for appropriate referral to palliative care

Across total care pathway

Information


Redesign


Ensure systems in place across NHSScotland to track all urgent referrals through diagnosis to treatment and produce monthly monitoring information

Ensure changes are implemented to address bottlenecks, reducing time for each step of the pathway within overall target

Clinical Strategies: Cancer
June 2005

EMAIL FROM THE SCOTTISH EXECUTIVE TO THE CLERK 29 AUGUST 2005

Dear Shelagh

Further to your e-mail of 4 August regarding information about the remaining outstanding issues from the Audit Committee's Bowel Cancer inquiry.

(1) QUALITY OF CARE

Explanatory notes and the data presented at the Bowel Cancer Network workshop on Friday 13 May are attached.

(2) CLINICAL NURSE SPECIALIST ROLE

SEHD has recently appointed a Nurse Consultant in Cancer to work within the Clinical Strategies – Cancer Team in collaboration with the Nursing Directorate. The remit of this post is to assist in the development of cancer services of which one task will be to consider with NHS Board Cancer and service leads how this action can  best be achieved building on existing models of practice and the role development framework which was launched in July 2005. In addition for the first time Student Nurse Intake Planning exercise is asking NHS Boards to forecast their growth of clinical nurse specialists over the next five years. This forward planning approach will assist the review of the role and remit of specialist nurses in cancer. Agenda for Change has distinct job profiles and Knowledge and Skills Framework outlines for a clinical nurse specialist, which will also support a review of such roles.

(3) DEVELOPING THE ENDOSCOPY WORKFORCE IN SCOTLAND

The SE has supported the development of the business case for the enhancement of endoscopy services and in addition £741, 775 is being provided.  NHS Education for Scotland (NES) will progress this and develop a project plan for:-

Medical Endoscopists: training for 50 "train the trainer" courses and 100 short skills courses .  These courses are available now and it is anticipated that  up to 30 places will be allocated in 2005 in order to ensure proper support is in place to non-medical endoscopists emerging from training in 2006.  A further 20 medical trainees to be trained in 2006.

Non-Medical Trainees: training through Glasgow Caledonian University for up to 25 nurse (non-doctor) endoscopists with an emphasis on expanding numbers significantly in January 2006.  This course runs bi-yearly in September and January and is ready to accommodate significant expansion from January 2006.

I hope this information is helpful for the Audit Committee.

KEVIN WOODS
Head of Health Department

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OTHER WRITTEN EVIDENCE

The following evidence was received by the Committee but is not reproduced in this report:

Top 20 Actions for Change, “Making it Happen”, Cancer Service Improvement Programme, Scottish Executive, 2005. [http://www.cci.scot.nhs.uk/cci/files/CSIP%20Top%2020%20Actions%20for%20Change%20FINAL.pdf.] Accessed September 2005.

Trends in Cancer Survival in Scotland, 1977 – 2001. ISD, National Services Scotland August 2004. [http://www.isdscotland.org/isd/info3.jsp?pContentID=338&p_applic=CCC&p_service=Content.show&] Accessed September 2005.

New ‘Delivery Group’ to scrutinise NHS performance. Scottish Executive press release, 29 July 2005. [http://www.scotland.gov.uk/News/Releases/2005/07/29100522] Accessed September 2005.

National eHealth/IM&T Strategy, 2004-2008, NHS Scotland, April 2004. [http://www.show.scot.nhs.uk/imt/WordDocs/National%20eHealth%20IMT%20Strategy%20April%2004%20final%20draft.doc] Accessed September 2005.


Footnotes:

1 AGS report “A review of bowel cancer services”, (“AGS report”), AGS/2005/2, page, 8, para 27

2 WOSCAN (West of Scotland Cancer Network), NOSCAN (North of Scotland Cancer Network) and SCAN (South East of Scotland Cancer Network)

3 AGS report page 3, para 6

4  AGS report, page 17 (good practice example 1), page 20 (good practice example 2), page 27 (good practice examples 3 and 4), page 42 (good practice example 6)

5 AGS report, page 13, Exhibit 7

6 Cancer in Scotland; Action for Change, SEHD (2001), Edinburgh: The Scottish Executive

7 AGS report, page 11, paras 44-51

8 Data presented at the Bowel Cancer Network workshop on 13 May 2005, e-mail from Dr Kevin Woods 29 August 2005

9 Letter from Dr Kevin Woods, 10 June 2005, Annex E

10 Top 20 Actions for Change, “ Making it Happen”, Cancer Service Improvement Programme, Scottish Executive, 2005

11 AGS report page 13, paras 54-56

12 “New Delivery Group to Scrutinise NHS Performance”, Scottish Executive news release, 29 July 2005

13 Letter from Dr Kevin Woods, 10 June 2005, Annex E

14 AGS report, page 25, para 96

15 Letter from Dr Kevin Woods, 10 June 2005, Annex E,

16 Letter from Dr Kevin Woods, 10 June 2005, Annex E, page 7, and E-mail from Dr Kevin Woods 29 August 2005

17 AGS report, page 27 (good practice example 3)

18 Scottish Executive Health Department, Cancer Waiting Times: National Delivery Plan, June 2005

19 AGS report, page 44, para 180, page 46 and 48, paras 192 - 201

20 Col 1140 – 1144, letter from Dr Kevin Woods, 10 June 2005 Annex F, Submission from Dr Woods, 21 June 2005, E-mail from Dr Woods 29 August 2005

21 AGS report, page 3, para 6

22 Letter from Dr Kevin Woods, 10 June 2005, Annex D, Executive Response to the Committee’s 5th Report “Overview of the Financial Performance of the NHS in Scotland 2003/04”, point 11 page 4, point 31, page 13

23 Letter from Dr Kevin Woods, 10 June 2005, Annex D

24 Audit Committee 5th Report, page 6, paras 36 and 37

25 AGS report, Key Messages Summary, para 8

26 AGS report, page 10, para 37

27 AGS report, page 9 and page 10, para 36