Cancer Care Review - East Midlands Clinical Senate

Cancer Care Review: a proposed model for London
29th October 2015
Welcome
Teresa Moss, Director
Transforming Cancer Services Team for London
Cancer Care Review: a proposed model for London
Agenda
13:45
Welcome & Introduction: Teresa Moss, Director of Transforming Cancer Services Team for
London
13:55
Living with and Beyond Cancer: a patient perspective: Chris Lewis
14:25
Cancer as a Long Term Condition: a model for London: Liz Price, Senior Strategy Lead for
Living with and beyond cancer, Transforming Cancer Services Team for London
Proposed Cancer Care Review Model:
Bonnie Green, co-Chair Pan London Cancer User Partnership Group and member of pan
London Cancer Commissioning Board and Living with and beyond Cancer Board
15.00
Dr Afsana Safa, Associate GP for Transforming Cancer Services Team for London and
Macmillan Cancer Lead GP for Central London CCG
Q&A with panel
15.15
15:25
Refreshments break
Table discussion: Consultation on CCR proposal
16:25
Feedback from table discussion
17.00
Closing Remarks, next steps and follow up
2
Cancer Care Review: a proposed model for London
Living with and Beyond Cancer: a patient perspective
Chris Lewis
Patient and Founder of Chris's Cancer Community
www.chris-cancercommunity.com
3
Cancer as a long term condition
A model for London
Liz Price
Senior Strategy Lead (living with and
beyond cancer)
29 October 2015
Introduction
• In the UK, cancer remains the leading cause of mortality (NHSE). It
is a top priority nationally and in London.
• 1 in 2 people will get cancer sometime in their life (CRUK).
• There are over 2m people living with and beyond cancer in the UK
and that this number is set to double by 2030 (Macmillan).
• In London, we expect there to be around 387,000 people by 2030.
• In 2010, there were 186,600 Londoners who were living with or
beyond cancer (diagnosed in the last 20 years). This is enough to
fill Wembley stadium, twice!
• Five year survival rates by CCG is not yet published, however the
London area rate is 48% (compared to England rate of 48%).
• 70% of people who have cancer, have at least one other long term
condition (Macmillan).
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Policy drivers
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Prevention
The prevention agenda for cancer relates to both new primary cancers as well as recurrence. Smoking cessation, healthy diet and physical
activity are key interventions for improving survival rates and quality of life. We can reduce the current rate of 1 in 2 expecting to be
diagnosed with cancer with healthier lifestyles.
•
More than 4 in 10 cases of cancer are caused by
aspects of our lifestyles which we have the ability to
change. Tobacco remains the main risk factor,
followed by obesity
•
We need to continue to raise awareness of the
impact risk factors have on our health, especially in
vulnerable populations, and support people to make
changes
•
Efforts to tackle smoking rates should continue at
pace, with the ultimate aim of reaching less than 5%
prevalence in adults by 2035
•
Vaccination and chemo-prevention will play an
increasing role
•
With increasing numbers of people surviving their
primary cancer, we need a stronger focus on
preventing secondary cancers.
•
Evidence from the United States shows that exercise
following a cancer diagnosis can prevent recurrence
of cancer by 40% - this is more cost effective than
chemotherapy and much greater reduction in
patients developing consequences of cancer
treatment.
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http://www.cancerresearchuk.org/sites/default/files/achieving_world-class_cancer_outcomes_-_a_strategy_for_england_2015-2020.pdf
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NHS West London CCG
NHS West Essex CCG
NHS Wandsworth CCG
NHS Waltham Forest CCG
NHS Tower Hamlets CCG
NHS Sutton CCG
NHS Southwark CCG
NHS Richmond CCG
NHS Redbridge CCG
NHS Newham CCG
NHS Merton CCG
NHS Lewisham CCG
NHS Lambeth CCG
NHS Kingston CCG
NHS Islington CCG
NHS Hounslow CCG
NHS Hillingdon CCG
NHS Havering CCG
NHS Haringey CCG
NHS Hammersmith and…
NHS Greenwich CCG
NHS Enfield CCG
NHS Ealing CCG
NHS Croydon CCG
NHS City and Hackney CCG
NHS Central London…
NHS Camden CCG
NHS Bromley CCG
NHS Brent CCG
NHS Bexley CCG
NHS Barnsley CCG
NHS Barnet CCG
NHS Barking and Dagenham…
London prevalence of common cancers
55% of Londoners who are living with and beyond cancer (diagnosed within the last 20
years) have/had prostate, breast or colorectal cancer.
Number of people living with and beyond cancer in 2010
(who were diagnosed in the last 20 years)
6000
5000
4000
3000
2000
1000
Prostate
Breast
Colorectal
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The Cancer Patient Experience Survey
The 2014 CPES tells us that there is a marked difference between patient satisfaction of their stay in hospital
compared to that of the support provided by primary and community care. Patient satisfaction with support following
discharge is even worse.
SPG
CCG
Patient`s rating of
care excellent/
very good (Q70)
Satisfaction with
support from GPs
and practice nurses
(Q64)
Satisfaction with support
from health and social
services post discharge
(Q56)
Best in England
-
96.9%
83.3%
85.3%
England average
All England CCGs
88.5%
66.6%
58.3%
London average
All London CCGs
84.7%
60.3%
48.1%
North Central
London
Barnet
85.3%
66.8%
41.5%
Enfield
79.3%
55.4%
44.6%
Haringey
83.0%
61.3%
44.1%
Camden
88.6%
61.2%
39.3%
Islington
86.5%
63.0%
55.6%
City & Hackney
75.8%
53.0%
40.0%
Tower Hamlets
85.8%
60.5%
39.6%
Newham
82.3%
62.6%
40.3%
Waltham Forest
78.9%
57.1%
42.5%
Redbridge
83.6%
53.5%
47.1%
Barking &
Dagenham
83.5%
58.3%
43.3%
Havering
87.0%
57.2%
52.4%
East London
Source: National Cancer Patient Experience Survey (2014)
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SPG
CCG
South East London
South West
London
North West London
Patient`s rating of
care excellent/ very
good (Q70)
Satisfaction with
support from GPs and
practice nurses (Q64)
Satisfaction with support
from health and social
services post discharge
(Q56)
Lambeth
84.3%
58.3%
41.4%
Southwark
85.9%
62.9%
59.7%
Lewisham
88.7%
59.3%
41.4%
Greenwich
89.8%
52.7%
42.7%
Bexley
88.1%
54.2%
43.0%
Bromley
85.1%
60.5%
63.5%
Wandsworth
87.8%
65.6%
59.4%
Richmond
90.3%
68.4%
57.6%
Kingston
85.4%
61.5%
63.6%
Merton
86.7%
53.7%
45.3%
Sutton
91.1%
65.4%
58.8%
Croydon
87.4%
59.4%
56.3%
Central London
81.7%
71.2%
46.63%
West London
81.6%
65.8%
52.9%
H’smith & Fulham
81.7%
56.1%
31.3%
Brent
81.3%
65.3%
48.2%
Ealing
81.2%
62.9%
47.1%
Hounslow
82.1%
56.4%
38.0%
Harrow
83.1%
55.3%
51.3%
Hillingdon
88.3%
63.6%
61.3%
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Source: National Cancer Patient Experience Survey (2014)
CPES 2014/15 - Question 19
The consequences of treatment that are prioritised in the London cancer commissioning strategy are: lymphoedema,
bladder and bowel dysfunction, sexual dysfunction, fertility and emotional + psychological effects. Side effects of
cancer treatment can :
a)
Have a short, medium and long term effect on the person’s quality of life
b)
Appear immediately after treatment or can start many years after treatment
Whit
W Middx
UCH
RNOH
RMH
NW Hosp
Hilling
St G
R Free
RBH
N Middx
Lew&Gr
Kingston
Kings
ICHT
Homerton
GSTT
ESTH
Ealing
Croydon
Chelwest
Barts
Barnet
100
90
80
70
60
50
40
30
20
10
0
BHF
Q19 Patient definitely told about treatment side effects that could affect them in the future
Trust
National
Highest in
England
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Why should we consider cancer as a long term condition?
There are specific issues for patients with cancer that would benefit from a holistic, long term conditions approach:
•
94% of people with cancer experience physical health problems in their first year after treatment
•
70% of people who live with and beyond cancer have at least one other long term condition
•
A Nuffield Trust evaluation (2014) showed that 15 months after diagnosis, people with cancer had 60%
more A&E attendances, 97% more emergency admissions and 50% more primary care contacts
compared to a population of the same age/gender.
•
64% of people living with cancer have practical or personal support needs, and 78% have emotional
support needs; the majority (75%) of which say that these needs are caused by their cancer or cancer
treatment. Yet many do not get the support they need to live as well as possible in their homes.
•
Of those who receive social care support, more people receive this 18 months after their cancer diagnosis.
Social care use for those with cancer is less than for those with other chronic diseases.
•
Late effects of radiotherapy and chemotherapy can lead to a raised risk of new primary cancers, heart
disease, diabetes, osteoporosis, cognitive dysfunction/dementia, hypothyroidism.
•
58% of people feel their emotional needs are not looked after as much as their physical needs.
•
At diagnosis, half of all patients experience anxiety and depression sufficient to impair their quality of life.
One quarter will have ongoing symptoms for the next six months. Psychological morbidity impacts upon
not just quality of life, but survival.
•
There is increasing evidence of the importance of diet and physical activity to: reduce likelihood of new
primary cancers, reduce rates of cancer recurring, manage the physical and psychological effects of
treatment.
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Managing cancer as a long term condition
This model is holistic and personalised
Primary care support (NEW)
* Automatic contact immediately following diagnosis with
offer of an appointment (ph/f2f).
* Patient added to CCG cancer register.
* Holistic cancer care review by GP/practice within xx weeks
of end of treatment.
* Annual birthday LTC review by GP/practice nurse (part of
co/multi-morbidity LTC management)
* All cancer patients flagged on GP system to ensure GP
continuity of care
* Carer support
* Primary care led follow up pathways eg prostate cancer
(GP or practice nurse led)
Acute care
* CNS/AHP key worker as first point of contact
* Holistic care planning throughout patient journey (for patient and
carer, shared with primary care)
* Schemes to increase physical activity and healthy living - health &
wellbeing events
* End of Treatment clinic with the patient within 6 weeks after end of
treatment (and Treatment Summary shared with patient GP within
48hrs of that clinic)
* Stratified follow up pathways (supported self management pathways)
– for breast, colorectal and prostate as a minimum. Includes remote
monitoring and rapid access back to specialist services if needed.
* Specialist support for reducing risk/managing consequences of
lymphoedema, bladder and bowel dysfunction, sexual dysfunction and
others
* Rehabilitation pathways (National Cancer Action Team guidance)
Person affected by cancer
Mental health and social care
* Access to psychological support (patient and ?carer) during
treatment phase - Level 2 CNS, Level 3/4 psychiatric liaison
services
* Access to psychological support post treatment (patient and
carer) – IAPT (self/GP referral).
* Provision of aids/services to support people living at home
– mobility (eg getting in and out of bed, leaving the house),
practical tasks (eg cooking, housework, grocery shopping)
and personal care (eg washing and dressing, going to the
toilet), financial (eg benefits advice).
* Formal Carer’s assessments conducted by the local
authority
Community based services (NHS and third sector)
* Support for reducing risk/managing consequences of
treatment eg community nursing and AHP services
* Rehabilitation pathways (National Cancer Action Team
guidance)
* Schemes to increase physical activity and healthy living health & wellbeing events, exercise prescriptions etc
* Support to return to work or study, volunteering
opportunities
* Financial advice and support
* Patient and carer support networks
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Other aspects to “living with and beyond cancer” that is
personalised and holistic
Hospital services need to implement the priorities from the NCSI
Routine use of the ‘recovery package’
A combination of different interventions
(shown in the image below), which when
delivered together, greatly improves the
outcomes and coordination of care for
people living with and beyond cancer.
Implement stratified pathways of care
The clinical team and the person living with cancer
make a joint decision about the best form of aftercare
based on:
•
their knowledge of the disease (what type of
cancer and what is likely to happen next)
•
the treatment (what the effects or consequences
may be both in the short term and long term)
•
the person (whether they have other illnesses or
conditions, and how much support that they feel
they need).
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Other aspects to “living with and beyond cancer” that is
personalised and holistic
Hospital, community, mental health, primary care, social services and the third sector need to work
together to better diagnose and manage the consequences of treatment for the long term needs of
people who have or have had cancer.
Consequences of treatment (short term and late
effects):
•
Lymphoedema
•
Pelvic radiation disease
•
Sexual dysfunction (men and women)
•
Psychological support
•
Hormone symptoms
Long term conditions framework
“The House of Care takes a whole system approach
to LTC management. It makes the person central to
care. It is about aligning levers, drivers, evidence and
assets to enhance the quality of life for people with
long term conditions no matter what or how many
conditions they have.” Tools include: interactive
toolkit, an information dashboard and a diagnostic
tool.
Pre/rehabilitation from point of diagnosis
•
Physical activity
•
Vocational rehabilitation
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Take home messages
There were 186,600 people living with and beyond cancer in London in 2010. It is estimated that there
will be 4 million in the UK by 2030 (366,000 in London).
We expect new cancer diagnoses to increase - to cope with that rise, we need to implement stratified
follow up pathways across all acute providers (breast, prostate and colorectal particularly). This will
stratify patients into complex case management, shared care and supported self management.
To get the full benefits of stratified follow up, all patients should have a holistic needs assessment
(which includes a care plan) devised. This is done at the point of diagnosis and at other key parts in
their cancer journey through to long term conditions management and end of life. It will be done in
acute and primary care.
At the end of active treatment, all patients should receive a treatment summary, which is also shared
with their GP.
All patients should have access to a health & wellbeing event (in the community or at their local
hospital) which includes the importance of healthy lifestyles, physical activity, signs and symptoms to
watch out for, signposting to local services.
All patients should have a holistic cancer care review in primary care, ideally after the end of active
treatment.
Patients are then offered an annual long term conditions review with their GP practice particularly
if they have multi-morbidities (conducted by their GP, practice nurse, AHP). All of their long term
conditions needs may be taken into account in one appointment.
Consequences of treatment (immediate, short and late term effects) should be discussed at the
point of diagnosis to make informed choices on cancer treatment options. They should also be
discussed at other key points so that symptoms can be managed promptly and effectively.
We need to improve cancer rehabilitation – this includes supporting the physical,
emotional/psychological, social, vocational needs of people and the consequences of having cancer
and its treatment. We also need to think about rehabilitation starting from when someone is first told
that they have cancer.
The holistic needs of carers should also be taken into account.
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Cancer Care Review:
the proposed model for London
Bonnie Green
co-Chair Pan London Cancer User Partnership Group and member of pan
London Cancer Commissioning Board and the Living with and beyond Cancer
Board
Cancer Care Review:
The proposed model for London
Dr Afsana Safa
Associate Lead GP
Transforming Cancer Services Team for London
18
Purpose of the Cancer Care Review
•
Increasing survivors
•
Complex treatment
•
Ongoing physical and psychological needs
•
Cancer as a long term condition
•
The role of the GP
19
Current Practice
• The CCR was included in QoF in 2012:
The percentage of patients with cancer, diagnosed within the preceding 15 months,
who have a patient review recorded as occurring within 6 months of the date of
diagnosis
• Significant variation in understanding, content, duration, clinician
20
21
Case for Change
• Patient voice
• Cancer Patient Experience Survey
• The recovery package
• GP satisfaction
• Healthcare contacts post diagnosis and treatment
22
Other models
•
Macmillan Cancer Care Review, 2010
•
CORD, 2013
•
Wandsworth PACT 2014
•
Time to talk, City & Hackney 2015
•
Prostate cancer primary care led follow up, Croydon 2013-15
•
London Cancer/Macmillan, supporting GP practices 2015
23
Template for a CCR
• Diagnosis
• Treatment Summary
• Current monitoring
• Medication review
• Physical effects
• Psychological effects
• Lifestyle
• Social support
24
The 4 Point Model
1. Patient added to the cancer register (is an SEA
required?)
2. Patient contact at point of diagnosis – telephone
and letter
3. CCR – established trigger points. Extended
consultation. Inclusion of HNA and TS information
4. Cancer included as part of annual LTC review
where appropriate
25
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Thank you for listening
Q& A for the panel
27
Table discussion
Questions for Table Discussion: 1 hour
Q1. How would you improve the 4 point model?
Q2. What are the barriers to implementation of this?
Q3. How would the model / notion of a holistic cancer care review impact you as a
patient, GP, primary care nurse or a Commissioner and what else could we be doing
in primary care for patients after treatment of cancer?
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Next steps…
TCST Project Team
Pan London Consultation event
29th October 2015 (this event)
TCST Project Team
CCR event (29th October) delegates
10th November (1st draft)
Living with & Beyond Board
17th November (final report)
Liz Price – Senior Strategy Lead
Cancer Programme Executive
24th November (final report)
Liz Price – Senior Strategy Lead
Cancer Commissioning Board
15th December (final report)
Liz Price – Senior Strategy Lead
Afsana Safa – Lead GP
Cancer Clinical Leads Advisory
Group
7th January (final report)
Sarita Yaganti – Project Lead
Afsana Safa – Lead GP
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The Transforming Cancer Services team would like to
thank you all for attending this consultation event.
If you have any further questions or queries, please contact us on:
Sarita Yaganti – Project Lead:
TCST Team
s.yaganti@nhs.net or telephone: 020 3049 4359
SECSU.tcstlondon@nhs.net or telephone: 020 3049 4331
Transforming Cancer Services Team for London
TCST is part of the Healthy London Partnership, a collaboration between all London CCGs
and NHS England London region to support the delivery of better health in London
@tcst_london
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