Jph - Oncology (2)

Review of Oncologist Establishment October 2009 1. Introduction 1.1. There have been considerable personnel changes in the oncology workforce at the NNNUHFT over the last year, reflecting the increase in clinical activity and the complexity of oncological care. 1.2. 8 years ago, the service across the Norfolk and Waveney Cancer Network (NNUHFT and JPUHFT) was provided by 4 WTE consultant oncologists, who between them provided a total of 7.5 sessions of clinics and multi-disciplinary team cover for the JPUHFT 1.3. There are currently 10.5 WTE posts in clinical oncology and 1WTE medical oncologist at the NNUHFT. 1WTE medical oncologist was also appointed approximately 2 years ago to the JPUHFT. During this time there has been no increase in the number of hours of visiting consultants to the JPUHFT, in fact, some would argue that the visiting cover has diminished over time, in that: 1.3.1. There is no longer cover from the NNUHFT Staff Grade for visiting consultant absence – she has retired 1.3.2. Some of the visiting consultants are more junior and as such are able to see fewer patients in clinic 1.3.3. The number of sessions has reduced from 7.5 to 7 2. Current OP activity at the JPUHFT Three data sources have been used to estimate the current annual oncology OP activity: • • •

PAS (between January and June 2009), Data produced by Medical Oncologist Dr Dernedde, (between December 2008 and May 2009) The NNUHFT Oncology Notes system - verified by Dr Roques – Clinical Director, (between 1st January 2008 and 31st December 2008)

2.1. PAS – Jan to June 09 Consultant

Clinic Code

Dr Dernedde Dr Epurescu Dr Harnett Dr Wade Dr Martin Dr Martin Nurse led GI clinic

DERNJBR EPURJBR HARNJBR WADEJBR MARTJBR MARTJET NURSEGASJ Totals

New patients in 6 months 92* 50 87 78 46 2 1

Follow up patients in 6 months 317* 168 312 329 205 143 29

New patients / year 184 100 194 156 92 4 2 732

Follow up patients / year 634 336 624 658 410 286 58 3006

NB

*47 NP and 173 FU patients (UGI) seen on Mondays *45 NP and 144 FU patients (Lung) seen on Fridays

2.2. Data produced by Dr Dernedde’s data (Appendix A) Clinic

Cancer type

Mon am – Dr Dernedde Mon pm –Dr Epurescu

UGI LGI Ovarian Breast Urology Gynae Lung

Wed – Dr Harnett Wed – Dr Wade Fri – Dr Martin / Dr Dernedde

New patients in 6 months 43 39 14 114 57 28 69

Totals 2.3. The NNUHFT Oncology Notes System

Follow up patients in 6 months 205 121 45 340 257 127 397

New patients / year 86 78 28 228 114 56 138 728

Follow up patients / year 410 242 90 680 514 254 774 2964

2.3.1. Analysis of the Notes system, which collates data on patients attending both the NNUHFT and the JPUHFT, confirms that there were 3201 new patients registered, 3149 of which were seen (or had major annotations). Whilst this estimate can be challenged, with possible over estimates (due to registrations from telephone calls and ward referrals not seen in oncology) or under estimates (due to recurrences, 2nd primaries seen as New patients), the view of the Oncology Clinical Director is that this is an accurate assessment of New patient workload for the two Trusts. 2.3.2. A more detailed breakdown of these 3149 New Patients / year, across cancer body site and Consultant is shown in Appendix B 2.3.3. An estimate of the number of New patients for the JPUHFT has been calculated by dividing the total number of registered New patients on the Notes system by 3 (population served by the JPUHFT is 33% of the total served by both Trusts). An assumption has been made that the mix of cancer types will be consistent across the Network population. Cancer Type Head and Neck Lung Upper GI Brain Breast Skin Sarcoma Haem (including eye) Urological Lower GI Gynaecological Carcinoid Unknown

Numbers of New patients / year across both NNUHFT & JPUHFT 174 (includes Kings Lynn) 446 274 76 683 120 38 120 489 351 176 8 71

Estimated numbers of New Patients across the JPUHFT catchment 40 149 91 25 228 40 13 40 163 117 55 3 27

3. Oncology OP Capacity 3.1. The current clinic schedules and numbers of New patient / Follow Up Patients slots currently available are shown below. NB Some clinics have Staff Grade support.

Day

Session

Monday Wednesday Wednesday Friday - Weeks 1, 3, 4, 5 Friday - Weeks 1, 3, 4, 5 Friday - Week 2 Friday - Week 2 Friday

AM PM AM PM AM PM AM PM AM PM PM

Consultant Dr Dernedde Dr Epurescu Dr Harnett Dr Harnett Dr Wade Dr Wade Dr Martin Dr Martin Dr Martin Dr Martin Dr Dernedde Totals

New Slots 2 3 3 2 3 6 4 4 3 3 2 35

Follow Up Slots 8 6 9 3 9 16 18 18 13 13 8 121

3.2. The total capacity: 3.2.1. The theoretical capacity (based on 52 weeks / year) = 1820 New Patient slots / year and 6292 Follow Up slots / year 3.2.2. Being more realistic, assuming each consultant is operational for 42 weeks / year (based on 6 weeks Annual Leave + 4 weeks Study Leave), the actual total capacity available = 1470 New Patient slots and 5082 Follow Up slots / year. 3.2.3. Comparison of the OP activity presented in 2.1, 2.2 and 2.3.3 with the realistic capacity available (3.2.2) gives an appreciation of the level of mismatch between demand and capacity. The comparison is shown below Data source From PAS data From Dr Dernedde data From Oncology Notes data

New Patient slots required 732 728 991 Follow Up Patient slots required

From PAS data From Dr Dernedde data

3006 2964

New Patient slots available – based on 42 weeks / year 1470 1470 1470

Difference (+/-)

Follow Up Patient slots available – based on 42 weeks / year 5082 5082

Difference (+/-)

+738 +742 +479

+2076 +2118

3.3. Utilisation of New Patient and Follow Up Patient capacity. 3.3.1. Analysis of the PAS data allows us to determine how many of the New and Follow slots were used on each day. The results for each consultant are show in the dot plots below.

E.g. there were 5 occasions in which 4 New patient slots were used and 8 occasions when 13 FU slots were used. NB The number of occasions in which no New or Follow Up slots were used confirms that in most cases Oncologists have provided cover for at least the assumed 42 weeks / year.

Numbers of Patients Attending Ne w & FU Clinics / Day- Jan to June 09

Dr Harnett - New

Dr Harnett - FU

0

3

6

9

12

15

18

21

Numbers of Patients Attending New & FU Clinics / Day - Jan to June 09

Dr Martin - New

Dr Martin - FU

0

6

12

18

24

30

36

42

Numbers of Patients Attending New & FU Clinics / Day - Jan to June 09

Dr Epurescu - New

Dr Epurescu - FU

0

2

4

6

8

10

12

Numbers of Patients Attending New & FU Clinics / Day - Jan to June 09

Dr Wade - New

Dr Wade - FU

0

3

6

9

12

15

18

Number of Patients Attending New and Follow Up Clinics / Day Jan to June 09

Dr Dernedde - NP

Dr Dernedde - FU

0

2

4

6 Data

8

10

12

4. Current Waiting Time Performance 4.1. Waits for New Patient appointments 4.1.1. The number of days wait between referral and initial OP appointment for each of the visiting consultant oncologists between January and June 09 are shown in the graphs below.

Days wait for Initial OP - Dr Harne tt 1

60 50 40 D aysW ait

UCL=35.20 30 20

_ X=13.03

10 0

LCL=-9.14

-10 1

11

21

31

41 51 61 Observation

71

81

91

Days Wait for Initial OP Appointme nt - Dr M artin 40

Days Wait for Initial OP Appointme nt - Dr Epure s cu

1

100 30

1

80

1

UCL=75.9

UCL=22.93 20

D aysW ait

60

10

0

_ X=8.52

40

6

11

16

_ X=25.4

20 LCL=-5.89

0 1

21 26 Observation

31

36

41

46

-20

LCL=-25.1

-40 1

6

11

16

21 26 31 Observation

36

41

46

Days Wait for Initial OP Appointme nt - Dr De rne dde 100

1 1

80 60 D a y sw a it

D a y sW a it

1

1

1

UCL=46.5

40 20

_ X=12.6

0 -20

LCL=-21.3 1

10

19

28

37 46 55 Observation

64

73

82

91

Days Wait for Initial OP Appointme nt - Dr Wade 1

40 1

UCL=32.95

D a y sW a it

30

20 _ X=10.36

10

0

-10

LCL=-12.23 1

9

17

25

33 41 49 Observation

57

65

73

4.1.2. Waiting times for New patient are seen as important by Oncologists – although there is no national target, the NNUHFT have set an internal target of <7 days between referral and appointment. 4.2. Waits for FU appointments Data is available to track the waiting time for follow up appointments but it is acknowledged that the data is of little value. It is important that patients have access to emergency advice on the same day and urgent advice within 7 days. Waiting time graphs are included in appendix D 5. Further potential demands on Oncologists Discussions with oncologists have identified a number of national and local initiatives / changes which need to be considered when planning future oncology establishments. These include: 5.1. Ensuring that patients are seen at the most appropriate hospital setting 5.1.1. Discussions with NNUHFT Clinical Director for Oncology confirm that it is appropriate for the JPUHFT in future to provide an out-patient oncology service (New and Follow up patients) for the majority of specific cancer types – there are a number of exceptions, those being: • • • • • • •

New Head and Neck cancer patients Head and Neck cancer patients in the 1st 6 months of follow up Brain cancer patients Skin Cancers – (although it is appropriate for BCC and SCC to be seen at JPUHFT) Patients with sarcoma Patients with carcinoid Patients with other rare cancers

5.1.2. With this in mind, if the New Patient activity associated with the cancer types referred to in 5.1 is deducted from the total estimate of 991 New patients cases, the remaining New Patient activity expected for the JPUHFT is in the order of 860 New cases / year. 5.1.3. The 131 New patients associated with the cancer types listed in 5.1.1 are already seen by Oncologists at the NNUHFT

5.1.4. The three data sources used to assess current OP activity have produced very similar estimates. For the purposes of future planning, the Oncology Notes system has been confirmed by the Oncology Clinical Director as the most reliable. 5.1.5. The analysis of the Oncology Notes System data does not extend to Follow Up activity so estimates of Follow Up activity associated with New Patient numbers have been prepared by two methods: 5.1.5.1.

Using New to Follow ratios provided by Dr Dernedde

5.1.5.2. Using a New to Follow ratio of 1:5 (It is estimated (from a Joint Collegiate Council for Oncology report – Dec 2000) that an average DGH population of 250,000 will have 1,000 new cancer registrations each year. If 75% of these were seen by an oncologist, there would be 750 new cancer patient consultations each year. The ratio of follow-up patients to new patients is found to be between 3 and 10:1 (Richards, MA and Parrott, JC, 1996) a ratio of say 5:1 would mean 3,750 follow-up consultations each year.)

Cancer type

UGI LGI / Ovarian Breast Uro / gynae Lung Skin / Haem Head & Neck Total

New Patient slots required

Conversion used – based on Dr Dernedde data

91 117 228 218 149 60

4.7 3.2 2.9 4.5 5.2 3

863

FU slots requiredbased on Dr Dernedde conversion 428 374 661 1071 775 180 Estimate 100 3489

FU slots required based on JCCO guidance 455 585 1140 1090 745 300 Estimate 100 4415

5.2. Rising incidence of Cancer 5.2.1. Future capacity planning should also take into account the increasing cancer incidence, estimated at approximately 8% every 5 years (NRAG – based on projections of the future changes to the population profile in terms of age and gender). With this in mind the following slots need to be available.

Cancer type

UGI LGI / Ovarian Breast Uro / gynae

New Patient slots required (Additional 8%) 98 126 246 235

FU slots required (Additional 8%) Dr Dernedde conversion 462 404 714 1157

FU slots required (Additional 8%) JCCO conversion 490 630 1230 1175

Lung Skin / Haem Head & Neck Total

161 65

837 194 Estimate 110 3878

931 New Patient slots required 931

Follow Up Follow Up Patient Patient slots slots available – required – based on 42 (Dr Dernedde weeks / year conversion) 3878 5082

New Patient slots available – based on 42 weeks / year 1470 Diff (+/-)

Follow Up Patient slots required (JCCO conversion) 4765

+1204

805 325 Estimate 110 4765

Diff (+/-) +539 Follow Up Patient slots available – based on 42 weeks / year

Diff (+/-)

5082

+317

5.2.2. The Oncologists currently work within three teams: 5.2.2.1.

Team A specialising in Head & Neck, Lung, Upper GI and Brain

5.2.2.2.

Team B specialising in Breast, Skin, Sarcoma and Haematology

5.2.2.3.

Team C specialising in Urology, Lower GI, Gynaecology and Carcinoid

5.2.3. Assuming the Oncologists continue to work within this team structure then these slots need to be apportioned across the three teams as follows: Team

Number of New patient Slots required

A B C Total

259 311 361 931

Number of Follow Up Patient slots required Dr Dernedde JCCO conversion conversion 1409 * *1405 908 1555 1561 1805 3878 4765

* Includes an estimated 110 Head & Neck follow up appointments 5.2.4. Based on 42 available weeks the gap between slots available and slots required is:

Team Consultant A B C

New Patient Slots available Gap currently Dr Dernedde 168 Dr Martin 320 +229 Total Team A 488 Dr Harnett 210 -101 Total Team B 210 Dr Wade 378

Dr Epurescu Total Team C Team

Consultant

A

Dr Dernedde Dr Martin Total Team A Dr Harnett Total Team B Dr Wade Dr Epurescu Total Team C

B C

126 504

Follow Up Slots Available 672 1312 1984 504 504 1050 252 1302

+143 Gap (+ / -) – Dr Dernedde Conversion + 575

Gap (+ / -) – JCCO Conversion

- 404

- 1051

- 259

- 503

+ 579

5.3. The business case for Radiotherapy at JPUHFT 5.3.1. This business case has been presented to the JPUHFT Trust Board and Governors and is currently with local commissioners. A decision has yet to be made and recent guidance suggests that no decision will be made until waiting time targets for radiotherapy treatment have been reviewed nationally. The timescale for this is unknown. 5.3.2. It is worth remembering that the case does however include 2 WTE consultant oncologists and 1 WTE Consultant Radiographer. This should be considered alongside any proposed additions to the establishment. 5.3.3. Provides future scope for daily on-site presence of oncologists 5.4. Acute Oncology Service 5.4.1. The NCAG report mandates setting up of an acute oncology service in every hospital with an A&E department. The principle drive for this is to provide assessment and treatment of patients with complications of chemotherapy but the service is also expected to ensure the rapid and appropriate management of patients presenting with previously undiagnosed cancer. 5.4.2. At the NNUHFT, the expectation is that the acute oncology service will: 5.4.2.1.

Improve outcomes for patients with complications of cancer therapy

5.4.2.2.

More efficiently assess patients with complications of known cancer

5.4.2.3.

Assist in compliance with NICE metastatic spinal cord compression guidance

5.4.2.4.

Provide a more efficient palliative radiotherapy service

5.4.2.5.

Help provide better advice for patients with known cancer under other clinical teams

5.4.2.6. Reduce in-patient stay and compliance with NICE guidance for patients with cancer of unknown primary site

5.4.3. The proposal under discussion at the NNUHFT includes an additional 10 sessions of Consultant Oncologist time and 1 WTE Clinical Nurse Specialist covering the acute oncology service via a dedicated bleep 5.4.4. Discussions regarding an integrated approach to the development of the acute oncology service across both Trusts have just commenced. The Anglia Cancer Network is also now beginning to take a co-ordinating role 5.4.5. Arrangements for the JPUHFT are therefore unclear at this stage and may have some bearing on the JPUHFT oncology establishment later. 5.5. Review of patients on chemotherapy 5.5.1. It has been reported that due to lack of clinic capacity, breast cancer patients on chemotherapy are not being reviewed by the consultant oncologist, even patients with an urgent need for review. Waits of 2-3 months (previously even four months) to see a consultant are reportedly not uncommon, whereas all other patients have access to their consultant at the very next clinic, if problems arise. 5.5.2. There is a view that delays in review of patients present a clinical risk with potential for serious complaint. 5.5.3. A search of the “bookwise” electronic booking system in the Sandra Chapman Unit, between 1st June 08 and 31st May 09, identifies the need for approximately 320 additional follow up slots if the existing number of breast cancer patients are to be reviewed every third cycle of treatment. The data that supports this is available in appendix C 5.6. Leadership 5.6.1. Historically there have been excellent consultant links across the surgical and medical specialties between the JPUHFT and the NNUHFT. 5.6.2. Oncologists employed by the NNUHFT have provided on site services at the JPUHFT, covering OP clinics three days / week and MDT meetings by video link or on site. 5.6.3. The Medical Oncologist employed by the JPUHFT also has sessional commitments at the NNUHFT but is usually too busy to attend 5.6.4. There appears however to be confusion over oncology leadership at the JPUHFT – specifically who takes clinical responsibility for the services strategic development. There is a widely held view that this is a significant problem. 5.6.5. Oncologists have described a “walk in / walk out service” where they “don’t get known” at JPUHFT. They are keen to be more involved in teaching / giving presentations. There is also interest in supporting the case for development of Nuclear Medicine at the Trust. 5.7. Outreach services to Beccles 5.7.1. Outreach services were provided up until approximately 2 years ago, with twice monthly clinics scheduled immediately after the JPUHFT clinic and run by Dr Ostrowski. 5.7.2. It is reported that the Trust has some interest in re-initiating this service

5.8. Ratio of Medical to Clinical Oncologists 5.8.1. The Joint Collegiate Council for Oncology has recommended a ratio of 2 clinical oncologists to every 1 medical oncologist but also recognises the important contribution both specialties make towards comprehensive cancer care. The balance will also be influenced by the site-specialised interests of the oncologists and the tumour types for which the cancer unit is accredited. 5.8.2. With regard to OP clinic sessions, the ratio at the JPUHFT is 3 medical oncologist sessions to 6 clinical oncologist sessions. 5.9. The view is that the current establishment of oncologists makes it impossible to cover consultant absence. If the consultant is absent for any reason then clinics are cancelled. This reportedly is the norm across the Trust. 5.10. Even without cover, the consultant oncologists provide a service with comparatively short waits for New Patient clinic slots. These waits do however exceed the local target of < 7 days set at the NNUHFT. See section 4.1 5.11. During these discussions there have been “requests” to have cover arrangements for Lower GI and Urology as well as Breast appointments. 5.12. Suggestions have also included Nurse / Radiographer led Follow up for Breast patients – with there being potential for approximately 400 slots / year to be seen by a Nurse 5.13. There is a view is that the workload for Breast cancer is sufficiently high to warrant input from a 2nd Consultant, either running clinics side by side with the existing clinic or on another day. Input to the MDT could be actual or via video link 5.14.

Potential for Oncology Clinics alongside other cancer clinics

5.14.1. The Wednesday pm Breast clinic currently runs alongside the surgical Breast clinic – new patients can then if required be referred from the surgeons for an oncological opinion. 5.14.2. There is enthusiasm to run a joint Gynae-oncology clinic between Dr Wade and Mr Nieto 5.15.

MDT cover

5.15.1. The importance of oncologist input to MDTs has long been recognised and is a key recommendation of the Calman Hine Cancer Report. 5.15.2. The table below provides a picture of the MDTs established and the contribution made to them by Oncologists. This contribution can be from either Trust (video links) and is not constrained to those visiting the JPUHFT Cancer Body Site

Day / Time

Type of MDT

Consultant

Breast Lung

Wed Tues (12-1)

On site – JPH Video linked with NNUH

Dr Harnett Dr Martin / Dr

Comment Suggestions have been made regarding the need for an additional MDT / week at JPUHFT Covered by NNUHFT team in absence of Dr Martin

Colorectal

Monday Lunchtime

On site – JPH

Dernedde Dr Epurescu

Upper GI

Friday lunchtime

Video linked with NNUH

Dr Dernedde

Urology

Wed morning

On site – JPH

Gynaecology

Thur lunchtime

Video linked with NNUH

Dr Wade Dr Epurescu / Dr Wade

Radiotherapy patients seen at NNUH Radiotherapy patients referred to NNUH. TWR from NNUH also attends. Radiotherapy referrals made by UD to TWR No oncologist present at MDT even though Dr Wade is at the JPUHFT on Wednesdays. Specialised urology (penis / testis) seen at NNUH

(Thyroid)

Wed morning Mon lunchtime (fortnightly

Lymphoma

Tues morning

Brain

None

Joint MDT with NNUH Video linked with NNUH Video linked with NNUH No link with NNUH or Cambridge

Skin

Mon morning

Video linked with NNUH

Dr Harnett

Dr Biswas also from NNUHFT New patients seen at NNUH Dr Roques / Martin from NNUHFT Dr Roques / Martin from NNUHFT All new patients seen at NNUH ANH and HMS from NNUHFT All new patients seen at NNUH Video links needs to be established with Addenbrookes There is a JPUHFT MDT on Friday pm with no Oncology input – noted at Peer Review

Informal – developing

Video links with NNUH / supraregional in development

Dr Stebbings

Takes place every two weeks on a Friday – HMS

Head & Neck

Sarcoma

Dr Martin Dr Martin

5.15.3. Gaps highlighted through discussion are: 5.15.3.1. Colorectal MDT is attended by a Medical Oncologist only; as such there is no specific radiotherapy input to the discussion from a clinical oncologist. 5.15.3.2.

The JPUHFT Urology MDT meets without input from any Oncology expertise

5.15.3.3.

There is no Oncology input to the JPUHFT Skin MDT

5.15.3.4. There are no video links from Addenbrookes to JPUHFT and NNUHFT so although local patients are “managed very competently by the Addenbrookes team”, local clinicians do not have the opportunity to be involved in Brain MDT’s 5.15.3.5. The potential need for a second weekly Breast MDT – a counter argument exists for expansion of the existing weekly MDT or a more efficient MDT. 5.15.4. Standards for MDT’s NICE has published Improving Outcomes Guidance for many tumour types which specifies oncology input to local MDT’s:

5.15.4.1

IOG Skin (p45) – Local skin MDT – Not every local Skin MDT will have a clinical or medical oncologist available but if local circumstances allow they should part of the local Skin MDT arrangements

5.15.4.2

IOG Colorectal (p45) – Whenever elective surgery is considered for patients with rectal cancer, a clinical oncologist should be involved in discussion about each patient before surgery is scheduled. In view of the current shortage of clinical oncologists in the NHS, teleconferencing may be appropriate to enable this discussion to be held. A medical oncologist may also be included in the MDT if available

5.15.4.3

IOG Breast (p77) – Oncologists should devote at least 3 sessions / week to breast oncology. Newly appointed oncologists should have at least one years experience in an established breast unit. Where the oncologist is a medical oncologist, a firm link must be established between the core team and the clinical oncologist from the centre to which patients are referred for radiotherapy.

5.15.4.4

IOG Urology (p27) – Oncologist with expertise in radiotherapy and chemotherapy for patients with urological cancers. The oncologist, who is likely to be a member of the specialist urological cancer team from a linked cancer centre, should cooperate with other specialist oncologists in the network

5.15.5

Peer Review

A peer review team visited the JPUHFT on 22/09/09 and reviewed gynaecological diagnostic services and skin LMDT. For the skin team they verbally raised a concern regarding the lack of oncologist attendance at the LMDT held here at the Trust. Whilst there was some disagreement locally about the need for oncologist input for the type of patients discussed, the peer review team upheld the measure. No formal documentation available until the report is finally issued in December 09. 6. Conclusions 6.1. The PAS and Dr Dernedde data sources provide comparable estimates of current OP activity. The estimates they give though are slightly lower than that obtained from analysis of the NNUHFT Oncology Notes system. 6.2. It is also possible that a proportion of OP activity has been omitted from the PAS totals presented in section 2.1, with a number of New Patients and Follow Up patient slots being provided in “review clinic” templates. 6.3. Based on JCCO estimates, where they estimate that a population of 250,000 would see approximately 1000 new cancer cases / year, the NNUHFT Oncology Notes system provides a reliable data set and has been proposed as the preferred “planning tool.” 6.4. There is significant variation in the numbers of New and Follow Up slots available to consultants in their clinic templates. (Refer to section 3.1) The number of New Patient slots can vary from 2 to 6 per clinic and the number of Follow Up slots can vary from 3 to 18 slots per clinic.

6.5. The data presented in 3.2.3 shows that the current total allocation of New and Follow Up slots in clinics is in excess of what is required for the current demand. Even with the highest estimate of New patient demand (991 patients from the Oncology Notes System source) there is an excess of nearly 480 New patients slots (and at least 2000 Follow Up slots) across all consultant clinics – based on 42 operational weeks / year. 6.6. This excess of New and Follow Up slots should not however automatically be assumed to be slots that are available to be used within the time constraints of the clinics. It is obvious from discussion that clinics often “run over time” even though slots are not utilised. This implies that clinic slots are too short. 6.7. Section 3.3 provides useful information on how the allocation of New and Follow Up slots has been used. If we discount 0 entries (clinic not open) and look by consultant at the most common number of New patients and Follow Up patients seen / day (or ½ day) alongside the range, then the results are; 6.7.1. Dr Harnett most commonly sees 4 New patients / day (range 1-8) and 13 Follow Up patients / day (range 8 - 21) 6.7.2. Dr Martin most commonly sees 1, 2 or 3 New Patients / day (range 1-6) and 10 Follow Up patients / day (range 3 - 44) 6.7.3. Dr Epurescu most commonly sees 2 New Patients / ½ day (range 1-5) and 8 Follow Up patients / ½ day (range 6 -12) 6.7.4. Dr Wade most commonly sees either 3 or 6 New Patients / day (range 1 – 7) and either 14 or 18 Follow Up patients / day (range 9 – 20) 6.7.5. Dr Dernedde most commonly sees 2 New patients / ½ day (range 1-4) and 7 Follow Up patients / ½ day (range 2-13) 6.8. On a daily basis there is a relatively high level of consistency across consultants in the numbers of New and Follow Up patients actually seen in clinics. Dr Harnett sees slightly fewer Follow Ups / day than his colleagues (because he does not review breast chemotherapy patients) and Dr Martin tends to see slightly fewer New and Follow Up patients / day than his colleagues. Dr Martin has the greatest level of variation in his Follow Up numbers – with 4 occasions in which over 30 patients were seen, once as many as 44 patients. 6.9. Waiting times performance data shown in section 3 ranges between 8.5 and 25 days for New Patient appointments and between 24 and 149 days for Follow Up appointments. (NB – a high proportion of 0 days waits for Dr Dernedde skews the lower value of 24 days). Whilst not a national target, there is an internal target at the NNUHFT to see New Patients within 7 days of referral (unless there are clinical reasons for a longer delay or the patient wishes to defer an appointment) and there is a view that this should be the aim across both Trusts. 6.10 Discussions with the Oncology Clinical Director regarding which cancer patients should be seen at the JPUHFT suggest that approximately 87% of New Patients should be seen at their local Trust with the remaining 130 New patients being seen at the NNUHFT. There appears to be no formal agreement between the two Trusts that work should be distributed in this way. 6.11 Assuming agreement is reached and that cancer incidence rises by 8% over the next 5 years, the minimum activity that should be used for service planning is 930 New Patients and 3800 Follow

Up patient slots (based on Dr Dernedde’s conversion factor.) On these numbers, and assuming 42 operational weeks / year the total number of slots currently available is actually in excess of what is required – with approx 540 more New Patients slots and 1204 Follow Up slots available than required. See 6.6. 6.12 There is strong support from the oncologists for the current arrangement of working in three teams to continue. Although 5.11 suggests that the slot capacity available exceeds that required, it does not mean that the capacity is in the right place as far as the teams are concerned. Some adjustments are required, based on the data available: 6.12.1 Team A could theoretically reduce its New slots by 230 / year and its Follow Up by 575 / year. What is clear from the data in section 2.1 to 2.2 is that Dr Dernedde is seeing a greater proportion of the patients seen collectively by team A and yet has approximately 30% of the total New patient and Follow up slot capacity. Either New / FU slot capacity needs to be redistributed from Dr Martin to Dr Dernedde or the patient workload needs to be more fairly distributed. Because of the “frailty of Dr Dernedde’s patients, there is a need to have sufficient OP slots available for patients to be seen quickly rather than defer them to the Sandra Chapman Clinic – as is currently the case.” 6.12.2 Team B needs to increase its New slots by 100 / year and its Follow up by 400 / year 6.12.3 Team C could decrease its New slots by 140 / year and needs to increase its Follow Up by 260 / year. 6.13

If the JCCO advice from Dec 2000 is accepted, then the number of Follow Up slots that should be available for a population of 250,000 is 4650 (using a conservative New to Follow Up ratio of 5:1.)

6.14

If we use this JCCO guidance on New to Follow up ratio then:

6.14.1 Team A would need 1405 Follow Up slots / year (580 less than it currently has) – includes 110 Follow Up slots for Head & Neck appointments. (Refer also to 6.12.1) 6.14.2 Team B would need 1555 Follow Up slots / year (1050 more than it currently has) 6.14.3 Team C would need 1805 Follow Up slots / year (500 more than it currently has) 6.15

The business case for radiotherapy which includes 2 WTE Clinical Oncologists, presents a great future opportunity for a 5 days / week oncology presence at the JPUHFT. Success in the radiotherapy case will undoubtedly influence the outcome of this work but at this point in time, the two cases need to remain separate.

6.16

The number of visiting consultant sessions at the JPUHFT has not increased within the last 8 years

6.17

Plans for the Acute Oncology Service have clearly been discussed separately at each Trust. Opportunities to integrate these plans are at a very early stage of discussion.

6.18

There is serious concern that Breast cancer patients undergoing chemotherapy are not being reviewed as per protocol by an oncologist. (Oncologists at both Trusts are committed to working to common agreed protocols – including FU frequency, but current staffing does not support this). This reportedly presents a significant clinical risk with a serious risk of

complaint which it appears could be reduced substantially by providing a minimum of 320 additional follow up slots. 6.19

There are no clinical leadership arrangements obvious to all those involved in delivering the service. If this continues then it is unlikely that the Trust will develop and implement an oncology strategy for the Trust which aligns with that of its “oncology partner” at the NNUHFT. The absence of an aligned strategy is likely to lead to fragmentation of oncology services across the Trusts. There is interest from within the Oncology Service to provide these clinical leadership arrangements.

6.20

The value of providing outreach services to Beccles is questionable. Although it is a very “patient centred” option, it appears that the service was previously withdrawn because the number of patients attending was small. It is unlikely to be an efficient way of using consultant oncologist time in future.

6.21

Based on current working patterns of 6 sessions of clinical oncologist time and 1 session visiting + 2 resident medical oncologist, the JPUHFT complies with the JCCO recommended ratio of clinical to medical oncologists. The reality is that any shortfall in OP capacity could be addressed by employing either medical or clinical oncologists (or even nurse / radiographers for Follow Up). Given the interest in providing a radiotherapy service in future, it maybe more sensible to employ additional clinical oncologist sessions.

6.22

The data presented in section 3.3.1 confirms that there were very few occasions in which weekly OP clinics did not take place. One consultant was available for 46 weeks and the remaining consultants were available for between 40 and 42 weeks of the year. Ideally, all consultant absences should be covered by a colleague with the same team, but this has certainly been impractical in the past. With waiting time performance for New Patients between 8.5 and 25 days across all consultants, and therefore exceeding the desired target of seeing New Patients within 7 days, the case for additional consultant cover is strong.

6.23

The advantages (to patients and clinical staff) of running Oncology clinics alongside surgical clinics have been proposed by at least two of the oncologists. The principle is a good one although there may be practical difficulties in aligning schedules of the relevant surgeons and oncologists. If this can be achieved without loss of clinic capacity then it makes sense to do so. There appears to be particular value in joint clinics for Head & Neck (already taking place), Skin and Gynaecological cancers.

6.24

The absence of a clinical oncologist opinion at the colorectal MDT and any oncologist opinion at the urology and Skin MDT’s weakens the MDT discussion. Whilst involvement of a medical oncologist in the colorectal MDT is valued, he can only contribute to chemotherapy treatment discussions. The fact that an oncologist specialising in urology work is present at the JPUHFT on the same day as the urology MDT, but doesn’t attend, is surprising. (refer to section 5.15.4)

6.25

Any case for a 2nd breast MDT needs to be driven by the Lead Clinician for Breast at the JPUHFT. Even if the principle is accepted there will be practical difficulties in releasing time for all specialties to attend. Interestingly, the NNUHFT has 1 x Breast MDT / week, serving a population twice that served by JPUHFT.

7

Recommendations

7.1 For planning purposes, the Oncology Notes System with JCCO conversion and with 8% uplift for rising cancer incidence, is used. This means that the JPUHFT should be planning on a New Patient demand of 930 patients and a Follow Up demand of 4765 patients / year. 7.2 Current clinic templates are replaced with templates that provide capacity for the anticipated demand of New and Follow Up Patients. The actual slots required are: 7.2.1

For Team A – 260 New Patient slots and 1405 Follow Up slots / year – appropriately aligned to the relative caseloads of Dr Dernedde and Dr Martin. There is scope for Dr Dernedde to provide OP consultation alongside Dr Martin on Friday pm using the existing Op nursing / admin support.

7.2.2

For Team B – 310 New Patient Slots and 1555 Follow Up slots / year

7.2.3

For Team C – 360 New patient Slots and 1805 Follow Up slots

7.3 The time allocated for New and Follow Up slots is standardised at 30 mins / New patient and 15 mins / Follow Up patient. (This would then be consistent with the standard at the NNUHFT) 7.3.1

This means that the OP time required for the teams is: Team

A Dr Martin Dr Dernedde B Dr Harnett C Dr Wade Dr Epurescu 7.3.2

New Patient hrs required 3.1

Follow Up Patient hrs required 8.4

Total OP hrs required 11.5

New Patient slots (30 mins) required 6

Follow Up slots (15 mins) required 34

3.7

9.25

12.95

7

37

4.3

10.75

15.05

9

43

Limit the total time for OP clinics to 6 to 6.5 hours / day – allowing 1 to 1.5 hours / day for associated administrative work.

7.4 Accommodate these OP hours required by: 7.4.1

Maintaining the current number of clinic days for team A, re-aligning OP slots appropriately to the caseload of Dr Dernedde and Dr Martin – and review capacity in 6 months

7.4.2

Providing an additional full days clinic / week (additional 2 x Clinics) for team B

7.4.3

Providing an additional full days clinic / week (additional 2 x clinics) for team C

7.4.4

Uplifting the visiting JPUHFT oncology establishment by 20% to ensure that OP clinics are always covered during annual and study leave absences and that the New Patient target of being seen within 7 days is maintained.

7.5 Whilst there may be benefits of using Tuesdays or Thursdays for these additional clinics, any days where clinic resources are available can theoretically be used.

7.6 Scope for Nurse / Radiographer led Breast Follow Up should be investigated alongside the proposed expansion of Team B clinics (7.4.2). In the long term, the Nurse / Radiographer can then provide cover for Breast Follow up. (Until the case for radiotherapy at JPUHFT is approved, this cover should be provided by Nursing) 7.7 Scope for Nurse led follow up for Urology should also be investigated alongside the proposed expansion of Team C clinics (7.4.3). 7.8 Nursing and Administrative support to the additional clinics needs to be reviewed and increased if required. 7.9 The demands on Oncologist time associated with in-patient care are unlikely to change in the short term. No additional resource associated with in-patient care is proposed at this time. 7.10 Responsibility for the oncology teams’ workload should lie with the team rather than individual consultants. The recommendation is that secretaries will continue to be book patients into a specific consultant slots but that unused clinic capacity is at least offered to another consultant within the team to use where possible. 7.11 If an oncology team is unable to use any of its teams’ unused capacity then this capacity should at least be offered to the other oncology teams. It is acknowledged that it will only rarely be possible for a consultant from another team to use this capacity to see other cancer types. 7.12 The Trust monitors utilisation of clinic slots for each consultant to ensure that slots are used efficiently and that templates are appropriate. 7.13

The Trust continues to collect data on waiting time performance (particularly for New Patients) and analysis is carried out as required. A target of <7 days between referral and New Patient appointment should be maintained in line with performance at the NNUHFT.

7.14

Clinical leadership of the Oncology service across both Trusts should lie with the NNUHFT Oncology Clinical Director. The Clinical Director should be allocated 1 PA for his/ her JPUHFT contribution and this should be reflected in his / her job plan.

7.15

The Oncology Clinical Director should work closely with the Medical Oncologist at the JPUHFT but should take overall responsibility for:

7.15.1 Distribution of relevant cancer work to the NNUHFT, making provision at the NNUHFT for the additional 130 New Patients and their corresponding Follow Up appointments. NB – the distribution of cancer work between the two Trusts should be formally agreed by the appropriate Trust Executives. 7.15.2 Integration of a plan for Acute Oncology Services across the two Trusts. Potential resource requirements are likely to be known soon. 7.15.3 Assisting in developing the relationships between the service and other specialties within the JPUHFT 7.16

Team A continues to take responsibility for Follow up of the Head & Neck cancer patients to be seen at the JPUHFT (estimated at 110 patients / year)

7.17

Team B takes responsibility for the Skin (BCC and SCC) and Haematology cancers to be seen at the JPUHFT

7.18

The Trust does not wait until the outcome of the business case for radiotherapy is known before taking action on Oncology capacity. The shortfall can be addressed now and then the oncology establishment reviewed again in line with the requirements for radiotherapy.

7.19

Follow up of Breast cancer patients on chemotherapy is maintained according to protocol within the additional Follow Up capacity proposed.

7.20

No outreach services to Beccles are provided unless the numbers increase significantly, in which case the situation should be reviewed.

7.21

Support the wish of oncologists to run oncology clinics alongside surgical oncology clinics if it is practical to do so and out patient capacity is not lost as a result.

7.22

Input to JPUHFT MDT meetings is accommodated within the new schedules proposed in 7.4

7.23

A number of shortfalls associated with MDT’s need to be addressed as follows:

7.23.1 A clinical oncologist from Team C should provide input to the Lower GI MDT. If the additional 1 day clinic for team C took place on a Monday then it is possible that a clinical oncologist could attend. If this is not possible then attendance through video link from NNUHFT is a realistic compromise. 7.23.2 A second oncologist involved in the additional Breast clinic for Team B should link into the existing Breast MDT and possibly a second Breast MDT if that was to be developed. This could either be by direct attendance or through video link. 7.23.3 An oncologist from Team C to attend the JPUHFT Urology MDT on Wednesday. 7.23.4 If there is a need for a separate Skin MDT on Friday, (rather than a common Skin MDT across the Trusts) then an oncologist from Team B should participate. 7.24

The full cost implications of these recommendations should be considered by the JPUHFT Medical Division / Finance team. In summary they are:

7.24.1 2 x additional days of Oncology clinics (4 x clinics) – with associated oncologist, nursing and administrative costs (potentially including secretarial costs within that) – based on NNUHFT Job Plans, 4 additional clinics equates to 6 PA’s. 7.24.2 Cover for the equivalent of 20% of clinics (based on 10 / 52 weeks / year absence) = 2 PA’s 7.24.3 Nursing costs to support 400 Breast Cancer Follow Up slots / year – approximately 1 clinic / week. Potentially Urology Cancer Follow Up could also be included. 7.24.4 1 x PA for clinical leadership 7.24.5 Costs associated with JPUHFT element of the integrated plan for Acute Oncology Service – as yet unknown (potentially this could include additional medical / nurse specialist resource)

7.24.6 Costs associated with any referral of the 130 New cancer patients (Head and Neck, Skin, Brain, Sarcoma, Sarcoid and other rare cancers) to NNNUHFT 7.24.7 1 x MDT session for Clinical Oncologist input to Lower GI MDT 7.24.8 Possibly 1 x MDT session for Clinical Oncologist input to Skin MDT

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Appendix A

JPUH – Oncology patient numbers according to clinic statistics (based on IPM data December 08 – May 09) Upper gastro-intestinal cancer (Monday morning clinic, U Dernedde) Seen in last Extrapolated figures for 6 months 1 year New patients 43 86 Follow up pat. 205 410 (Follow-up in this (173 + 32) clinic + follow-up in nurse-led clinic) Ratio New/FU 1 : 4.7

Patient numbers per clinic 1.6 7.8

Lower gastro-intestinal and ovarian cancer (Monday afternoon clinic, D Epurescu) Seen in last Extrapolated figures for Patient numbers per 6 months 1 year clinic New patients 54 108 2.0 Follow up pat. 166 332 6.3 Ratio New/FU 1 : 3.2 Breast cancer (Wednesday all day, A Harnett) Seen in last 6 months New patients 114 Follow up pat. 340

Extrapolated figures for 1 year 228 680

Patient numbers per clinic 4.3 13

Urology and gynaecology. cancer (Wednesday all day, R Wade) Seen in last Extrapolated figures for 6 months 1 year New patients 85 170 Follow up pat. 384 778 Ratio New/FU 1 : 4.5

Patient numbers per clinic 3.2 14.9

Lung clinic (Friday all day, C Martin / U Dernedde) Seen in last 6 months New patients 138* Follow up pat. 730* Ratio New/FU 1 : 5.2

Patient numbers per clinic 2.6 14.8

Ratio New/FU

1 : 2.9

Extrapolated figures for 1 year 138 774

(* corrected IPM figures, because some patients were seen as new patients by one consultant are booked as new patients twice when referred for radiotherapy)

Total number of new cancer patients seen in oncology clinics: 730 per yeari

Appendix B

Estimate of activity in oncology for 1/1/08-31/12/08 1. Oncology Notes Registrations 1/1/08-31/12/08 3201 NPs registered 52 never seen (very brief MDT notes etc – all excluded) 3149 seen (or major annotation on Notes) Coding Approx 60% had ICD-10 code on Notes – assumed correct Approx 25% had diagnosis on Notes – retrospectively coded without reference to main Notes entry TWR May09 Approx 15% had no diagnosis – Notes reviewed and retrospectively coded TWR May 09 Possible errors Over-estimates – other brief MDT notes, registrations from phone calls and ward referrals not seen in oncology Under-estimates – recurrences, 2nd primaries seen as NPs? Either – incorrect data entry Summary TWRf

WMCM

97 121 42 67

77 229

1 2

2 9

H&Na Lung Upper GI Brain Breast Skin Sarcomab Haemc inc eye GU Lower GI Gynae Carcinoid Unknownd Benigne Total

MRDf

ANH

HMS

42 53

1 2

1 34 1

370 4 2 23

57 100 33 95

1

82

1

275

2 0

1

RJWg

GKh

56

MJOi

22

1 146

1 3 1

1 1

1 6

ASB

UD 52 65 3 4 2

EDE

Total 174 446 274 76

2 101

683 120 38 120

1 1

1 140

103 86

98

25 1 11

1

1 122 61

489 351 176 8

11

6

71 123

138

294

8 10 7 348

2 4 326

5 0 100

5 0 489

10 111 449

1 0 377

8 0 296

10 0 267

3 1 65

3149

Notes: a) H&N patients all seen in joint clinic NNUH – some registered only at MDT but this figure seem right b) Sarcoma all seen in joint clinic c) Haem now all (myeloma?) seen in joint clinic w haem NNUH

d) these are true unknown primary cancers e) Majority are benign soft tissue disease managed by HMS in sarcoma MDT f) includes 20 patients registered under AB and HBJ (CNS tumours) g) started May 08 h) started March 08 i) retired May 08. Figures seem low – what was happening to his JPUH patients?

Appendix C

Breast cancer treatment figures obtained from the “Bookwise” electronic booking system in the Sandra Chapman Unit Search

criteria: any patients under Dr.Harnett seen between 01.06.08 and 31.05.09

Results: 979 visits in total 823 visits for breast cancer specific treatment (=chemotherapy / bisphosphonates / Herceptin) 123 patients (breast cancer patients only) Number of treatments and number of necessary clinic appointments as per departmental protocols (e.g. patients on adjuvant treatment to be seen after every third cycle etc.ii) Treatment regime

Number of treatments

AC Capecitabine Carbo/Gemcitabine CMF Doxorubicin Epirubicin FEC Herceptin Taxanes Taxol weekly Vinorelbine Zometa

38 188 27 57 8 36 198 117 38 17 43 56

Ass. Number of clinic appointment as per departmental protocol 19 63 14 18 4 12 66 30 19 3 22 19 ∑ 289

Minimum amount of follow-up consultant-led clinics would be 289/year. In addition, patients with problems (disease progression etc.) should be able to seen in a consultant-led clinic at the nearest available clinic slot (usually next upcoming clinic). This is at least an extra ~ 30 patients/year. So the total number of clinic slots required for these treatment patients is ~320/year.  Assuming there are 45 clinics per year, this would be 7 follow-up patients per week (again: absolute minimum! In other UK hospitals, these patients are seen more frequently).

Appendix D FU Waiting Times Data Days Wait for FU Op Appointme nt - Dr Harne tt 1

400

1

11

UCL=365.1

D aysW ait

300

200

_ X=148.7

100

0 LCL=-67.7 1

32

63

94

125 156 187 Observation

218

249

280

311

Days Wait for FU OP Appointme nt - Dr Epure s cu UCL=317.9

300

D aysW ait

200 _ X=125.7 100

0 LCL=-66.4 -100 1

18

35

52

69 86 103 Observation

120

137

154

Days Wait for FU OP Appointme nt - Dr M artin 1

400

1

1

UCL=376.7

D aysW ait

300

200 _ X=128.1

100

0

-100

LCL=-120.6 1

36

71

106

141 176 211 Observation

246

281

316

Days Wait for FU Op Appointme nt - Dr Wade 400

1

1

11

1

1

UCL=322.9

D aysW ait

300

200 _ X=117.7

100

0 LCL=-87.5

-100 1

34

67

100

133 166 199 Observation

232

265

298

Days wait for Follow Up Op Appointme nt - Dr De rne dde 200

1 1 1

150 1

D aysw ait

1 1 1 1 1

1

1 1

100

1

1

1 1 1 11 11 1 1 11 11 1 11 1 11 11 1 1 1 1

UCL=74.7

50 _ X=24.2 0 LCL=-26.4 1

32

63

94

125 156 187 Observation

218

249

280

i

Not included are approximately 10-20 new cancer patients seen in the monthly joint head and neck clinic of Craig Martin ii Compared with other UK hospitals, these figures represent an absolute minimum of care!