Inquiry into progress made to date on implementing the Welsh Government’s Cancer Delivery Plan and whether Wales is on course to achieve the outcomes and performance measures, as set out in the Cancer Delivery Plan, by 2016
Response from Velindre NHS Trust
Velindre NHS Trust comprises of 2 main operating Divisions namely:
Ø Velindre Cancer Centre, a specialist provider of non surgical cancer treatments
Ø Welsh Blood Services
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In addition Velindre NHS Trust is ‘Host’ to a number of external organisations:
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Velindre NHS Trust’s response to the ‘Inquiry into progress made to date on implementing WG’s Cancer Delivery plan’ will seek to provide comments under each of the headings as per the terms of reference of the Inquiry.
1. Is Wales on course to achieve the outcomes/performance measures as set out in the Cancer Delivery plan 2016
There has been good progress in some of the key areas within the Cancer Delivery plan. For example the Wales results from the recent Patient Experience Survey, run with the help of Macmillan, showed 89% patients rated their care as excellent or very good. In addition 88% of patients have been allocated a Clinical Nurse Specialist (CNS) and 86% patients said they had received the right amount of information. The Velindre results have been further analysed and show that they are very favourable in comparison to some of the best cancer centres in England and in fact in some domains Velindre’s scores exceeded those of English cancer centres. However it is recognised the results were variable by organisation and cancer site, thus the focus between now and 2016 is to address the variability and ensure consistency for patients irrespective of where they receive their care or which cancer they have.
Other examples of positive progress include:
· The introduction of peer review which is driving up standards,
· Good recruitment rates into clinical trials
· Clinical engagement, especially with work to review the patient pathways, with some very good examples at both the South Wales Cancer Network level but also within Velindre Cancer Centre e.g. work to reduce the pathway for head and neck patients receiving Radiotherapy with a reduction in waiting times from 28 to 14 days without any additional resources
· Increasing numbers of patients consenting to their tissue being collected for the Wales Cancer Bank
· Creation of specialised Multi Disciplinary Team meetings (MDT) for metastatic cancers for some cancer sites, thereby ensuring patients with metastatic disease or diagnosis of secondary cancers are given the same care as those with first diagnosis.
· An increasing focus across Wales on the “survivorship” agenda and ensuring patients are living well with their cancer
Some of the key remaining challenges are:
· Continue to manage demand with the increasing incidence and patients surviving longer with cancer
· Diagnosing patients earlier – as this takes time before long term benefits are seen
· Improving Cancer information systems to improve communications between providers of care, including primary care, and to ensure good quality data to measure the outcomes
2. Progress made in reducing the inequalities gap in cancer incidence and mortality rates
Reducing the inequalities will have a long term effect on survival and mortality. It is important that NHS works with the public to seek to change behaviours and reduce risk of incidence of cancer. There are clear roles for Public Health Wales and Primary care in leading work in this area. It may be worthwhile considering whether targets/outcome measures for these organisations would be helpful in the achievement of this by 2016.
It is essential that Wales keeps up with new treatment developments in order to ensure an equitable access to clinical trials for patients and to continue to ensure that Wales recruits and retains high calibre clinical staff. We welcome the WG review into Access of new Technologies.
We are aware that the IPFR process is currently under review and we welcome this, as the current process can cause stress for patients, their families and the clinical staff caring for the patients and to avoid any perceived inequity.
The results of the Patient Experience Survey showed some variations in access to Key workers and the provision of care plans and we believe it’d be helpful if Wales is to achieve progress in this area by 2016, if there was some policies/agreement around these topics.
3. The effectiveness of cancer screening services and the level of take-up across the population of Wales, particularly the harder to reach groups
In order to achieve the targets by 2016 there is need to continue to improve the national focus on prevention and we recognise the important role screening services play in prevention and early diagnosis.
Given the nature of the Trust screening service does not have a direct impact for the organisation. However VCC does recognise that it can, like all organisations, play a part in encouraging patients and their relatives to take up screening opportunities. The challenge is to reach the “harder to reach” communities.
VCC supports the “making every contact count” type initiative and would also welcome and support the development of some simple consistent messages for all to use.
4. Whether patients across Wales can access the care required (for example, access to diagnostic testing or out-of-hours care) in an appropriate setting and in a timely manner;
We recognise that reduced waiting times have a direct impact on outcomes and survival.
VCC has made significant progress over last few years in the reduction of waiting times for radiotherapy and chemotherapy treatments. For example in 2009 approximately 35% patients received radiotherapy within 28 days (with some patients waiting up to 11 weeks) and this is now 99%.
It is important that there is sufficient capacity in the future to maintain these waiting times – see later section re planning and funding.
The NHS is experiencing high demand for unscheduled care but the Acute Oncology Service (AOS) pilot between ABHB and Velindre Cancer Centre has proven a huge success and had an impact on patient’s ability to access the correct type of care in a timely manner.
For example prior to AOS only 16% of the patients received correct investigation for neutropenic Sepsis, but now with AOS in place this has risen to 86%. Similarly following introduction of AOS 85% of patients suspected metastatic spinal cord compression had an MRI within 24 hours, compared to previously only 61%, and the mean time to definitive therapy from MRI has reduced from 50 hours to 24 hours.
Similarly there has been some progress towards 7/7 working so patients have same level of service irrespective of the day but, as across many specialties in the NHS, further work is required in this area between now and 2016. Good examples of the shift towards 7/7 are demonstrated by the all Wales palliative care work which has resulted in 7/7 working in all organisations.
As outlined earlier in this response Wales is reviewing the system of access of new technologies with the aim of ensuring that appropriate, clinically proven treatments/technologies are available to patients in Wales in a timely manner for the population .We welcome this review as we believe it is important for patients to have access to the most appropriate, clinically effective treatments.
With regard to the introduction of new drugs AWMSG have made improvements in their systems which have resulted in a reduction in the average time for an assessment to announcement. However further improvements to the system, including a system for orphan drugs, or drugs for rarer cancers is we believe essential to ensure equity for all patients.
Access to treatment i.e. waiting times are important and VCC welcomes the review of the 31/62 day targets, with the shift to more clinically determined targets. However it is important that the implications of the changes to the target are worked through prior to any formal changes.
Finally with regard to access to care in timely manner the IPFR process has some issues – but as outlined earlier it is under review with the aim of addressing and improving the process and we welcome this review.
5. The level of collaborative working across sectors, especially between the NHS and third sector, to ensure patients receive effective person-centred care from multi-disciplinary teams.
There remains a very good level of collaboration across NHS organisations and with the Third Sector in the provision of cancer services. Examples include:
The Acute Oncology Service (AOS) pilot between VCC and ABHB has shown excellent results due to the high level of collaborative working. It has been shortlisted in NHS Wales Awards under the category of working across organisations.
There are projects funded by Macmillan which involve piloting electronic health needs assessments (e-hna) for patients and the development of care plans and key workers. These type of projects are great examples of work seeking to ensure ‘Person centred care’ is delivered by the MDT. Similarly Velindre Cancer Centre is working closely with Maggies in the development of a Maggies’ centre for patients in south east Wales – again an environment to deliver person centred care.
As outlined earlier in the response the All Wales Palliative care project provides another excellent example of collaborative working between the Third sector and NHS organisations for end of life care.
Recent events run by the South Wales Cancer Network to review lung cancer and colorectal pathways were only successful due to the close working of the organisations involved in delivering care. This type of work now needs to be rolled out across other cancer sites.
With regard to R&D the fact that in Wales research and treatment are delivered as part of a spectrum of care is a strength. Wales has improved access to trials as per the requirement of the cancer Delivery plan but if Wales is to maintain this level of access it requires organisations to continue to improve the way they work together in respect of the timeliness of start up, delivery and application of research. To support this increase in access it is important that there is a clear strategic drive and funding strategy to ensure that ALL patients have access to speedy delivery of research in line with the delivery plan.
6. Whether the current level of funding for cancer services is appropriate, used effectively and provides value for money
In the absence of comparative data it is challenging to comment on whether the current level of funding is appropriate, thus our response to this section will instead focus on the process for allocation of the funding, rather than the amount/level of funds.
In today’s financial climate the challenge for NHS Wales is to cope with the increasing demands for cancer services as more patients are diagnosed, more treatments are available and patients are surviving longer with their disease. Linking this to Prudent healthcare providers of cancer services need over coming years to consider potentially ineffective treatments/interventions and the impact on investment decisions. For example the provision of CNS and good palliative care has been demonstrated to improve the patient experience and in some studies to increase survival and quality of life compared to high cost drug treatments. VCC has a system in place to review deaths of patients within 30 days of SACT /chemotherapy treatments to ensure the clinical appropriateness of potentially high cost drugs, especially at end of life. All organisations should be encouraged to undertake similar reviews and VCC plans to roll it out to Radiotherapy between now and 2016.
Thus when considering investments Radiotherapy and Clinical Nurse Specialist (CNS) may prove more cost effective compared to some end of life medicines – but in Wales there isn’t a process currently for the comparative assessments to be undertaken.
Similarly as patients live longer organisations need to develop new models of follow up so patients are less dependant .These models could include more focus on holistic needs through provision of support and rehabilitation.
The Acute Oncology Service (AOS) pilot has shown a reduction in length of stay and unnecessary investigations and hence a cost effective development.
Improved appraisal mechanisms for non drugs and technological interventions are vital to assist in decisions to invest in effective services that provide VFM. As outlined earlier there is currently a review in Wales into this area and we welcome that.
The Cancer Delivery Plan mentions the Health Boards should plan radiotherapy services through the Networks. There is we believe a need to strengthen the commissioning/planning arrangements between HBs and the Trust and that needs to be a focus for all organisations over coming years in order to prevent Wales falling behind other UK and European countries with regard to the development of radiotherapy techniques and capacity.
Developments in stratified medicine means there is a need, we believe, for a policy for the infrastructure of stratified medicine so patients can be selected for treatments on basis that they are more likely to benefit – thus for other patients this may avoid unnecessary treatment or fewer side effects.
With the Cancer Delivery Plan focus on R&D it is, we believe, vital all aspects of R&D funding are reviewed to ensure it is not having a detrimental affect on R&D in cancer services with a complex portfolio of funding streams which are a mixture of recurring and non-recurring.
Finally, it is our belief that the strategic planning of all cancer services could benefit from strengthening, through excellent clinical engagement and a cancer specific focus. As previously outlined there is a need for long term strategic capital planning, especially for radiotherapy equipment, so that Wales doesn’t lag behind. Recent decisions e.g. to support development of SBRT/SRS services in Wales are a welcome step forward.