Trust Board Meeting: Wednesday 12 November 2014
TB2014.125
Title
Review of Implementation of Expansion of Intensity
Modulated Radiotherapy
Status
For information
History
Presented to the Trust Management Executive – 13/2/14
Re-presented to the Trust Management Executive with the
addition of supplementary information – 9/10/14
Board Leads
Key purpose
Mr Paul Brennan, Director of Clinical Services
Strategy
Assurance
TB2014.125 - Review of Implementation of Expansion - IMRT
Policy
Performance
Page 1 of 15
Oxford University Hospitals
TB2014.125
Executive Summary
1. An implementation review has been undertaken for the Full Business Case for the
expansion of Intensity Modulated Radiotherapy. This development was approved by
the Trust Board on the 5/7/12.
2. The implementation review confirms that implementation has been fully and
successfully completed, delivering the benefits anticipated. A number of issues arose
in the in the course of implementation which affected the timescales and approach for
delivery e.g. delays in reaching agreement with PFI partners, and recruitment to certain
staff groups. These present opportunities for organisational learning and will inform the
future development and implementation of business cases.
3. Recommendation
The Trust Board is asked to note the contents of this report.
TB2014.125 Implementation Review - IMRT
Page 2 of 15
Oxford University Hospitals
TB2014.125
Implementation Review – Expansion of Intensity Modulated Radiotherapy
1.
Purpose
1.1. The Trust undertakes implementation reviews of approved business cases to :
•
Provide an assessment of the extent to which the objectives and benefits
of the case have been achieved within the agreed timescales and financial
envelope
•
Audit the operation of the business case process to ensure that clear
criterion for decision–making are explicit in the overall process
•
Provide assurance that decision making is underpinned by risk
assessments which appropriately address clinical, non-clinical and
financial risks at a strategic level
1.2. This paper presents an implementation review undertaken for the expansion in
the provision of intensity modulated radiotherapy. The business case for this
development was approved by the Trust Board on 5/7/12.
2.
Expansion of Intensity Modulated Radiotherapy
2.1. Intensity modulated radiotherapy (IMRT) is a form of conformal radiotherapy
that uses radiation beams of non-uniform intensity to conform dose to defined
tumour volumes, which allows improved targeting of the radiation dose.
2.2. The business case proposed expansion in the provision of IMRT at OUH to
ensure that all patients who would benefit from receiving this form of
radiotherapy could receive it locally. This would increase access from a level of
30 patients during 2011/12 to 750 patients per annum by 2013/14.
2.3. A phased implementation was proposed, with the sequential development of
protocols and implementation of IMRT by tumour site.
2.4. The expansion in the provision of IMRT would realise a number of benefits for
the radiotherapy services, namely :
•
•
•
•
•
3.
Ensure the Trust is providing a comprehensive radiotherapy service for
patients with cancer. The capacity to deliver IMRT including stereotactic
radiotherapy is a measure of clinical excellence.
Ensure that the treatment options available to patients minimise short and
long term risks to healthy tissue and support the delivery of optimal
outcomes.
To support the development and delivery of an ambitious programme of
cancer research. IMRT is a major focus of the NCRI Clinical and
Translational Radiotherapy Research Working Group and the Gray
Institute in Oxford.
The delivery of key national targets of a minimum of 30% of patients
treated with radical radiotherapy receiving inverse planned IMRT by end
2012.
Ensure that the Trust continues to remain competitive as a Cancer Centre.
Implementation Review
3.1. The implementation review (see Appendix 1) provides an assessment of
delivery against :
TB2014.125 - Review of Implementation of Expansion - IMRT
Page 3 of 15
Oxford University Hospitals
•
Agreed timescales
•
The planned manpower requirements
•
Revenue and capital allocations
•
Additional income targets
•
The anticipated benefits that would be realised
•
Risk management
TB2014.125
Any variances from plan are quantified and explained.
4.
Conclusions
4.1. The review has confirmed that the expansion in IMRT provision has been
successfully implemented, fully delivering the anticipated benefits.
4.2. In the course of implementation, a number of issues did impact more adversely
than had been anticipated, namely the timeliness of agreeing the variation with
PFI partners and difficulties in recruiting to particular staff groups. The review
highlights the importance of early engagement with PFI partners where there is
a need to progress building works/equipment installation. Collaboration with the
university proved effective with some appointments proceeding on a joint basis
e.g. some medical appointments. Similarly appointments in “hard to appoint”
staff groups were addressed by making appointments at a lower grade than
originally planned and providing training. These issues will be used to inform the
future planning and implementation of schemes.
5.
Recommendation
5.1. The Trust Board is asked to note the contents of this report.
Mr Paul Brennan, Director of Clinical Services
October 2014
TB2014.125 Implementation Review - IMRT
Page 4 of 15
Oxford University Hospitals
TB2014.125
Appendix 1 Implementation Review – Expansion of Intensity Modulated
Radiotherapy
Business Case Reference
TB2012.079
Full Business Case for expansion of Intensity Modulated Radiotherapy
Date of Trust Board Approval
5/7/12
Implementation Plan
The business case proposed the following timescales for implementation. Please
comment on the delivery of these timelines.
Business Case approval
SOC approved by SPC
9/2/12
Achieved
Present Full Business Case to
Oncology Directorate/Clinical
Director
Business case to Surgery and
Oncology Division
Business case to Strategic
Planning Committee
Business case to Trust Board
Request formal variation
enquiry through INC (company
overseeing equipment
management in PFI), following
discussion with suppliers on
cost (suppliers have indicated
room for negotiation on price)
IMRT roll out
Pilot prostate intensity
modulated radiotherapy
(IMRT) completed and breast
forward planned IMRT routine
Prostate IMRT on-going
planning 2 patients per week
Gynae IMRT protocol
development. Work with
Ipswich
Start first treatments
May 2012
Achieved
13/6/12
Achieved
14/6/12
Achieved
28/6/12
No date
set in
business
case
Achieved on 5/7/12.
Variation enquiry request completed
by directorate Sept 2012.
Submitted to INC Jan 2013. Delay
due to negotiation on price and
submission of variation enquiry by
OUH team.
October
2011
Pilot prostate IMRT Oct 2010
achieved.
Breast forward planned IMRT – Oct
2011 achieved.
Achieved April 2012. Increased to
ALL prostate cancer Oct 2013.
Achieved.
Jan 2012
October
2011 –
March
2012
June 2012
Head and neck IMRT protocol
development. Work with
Ipswich
Oct 2011 –
July 2012
Start first treatment
July 2012
TB2014.125 Implementation Review - IMRT
Achieved June 2012 – endometrial
cancer.
More protracted – completed Jan
2013. IMRT lead (RM) appointed
Nov 2012 had big effect on roll out
thereafter.
Delayed - first patient treated Jan
Page 5 of 15
Oxford University Hospitals
TB2014.125
Implement pancreas IMRT
protocol
Staff recruitment process
following business case
approval
Start programme for protocol
development for other tumour
sites. (sarcoma, CNS multiple
fraction, lymphoma,
oesophagus, paeds)
June 2012
Staff appointed, increase to 4
patients per week
Programme to install RapidArc
on linac 4 (add OBI) then linac
2 (existing OBI)
October
2012
Oct 2012
Increase to 6 patients per
week
Jan 2013
July – Sept
2012
September
2012
TB2014.125 Implementation Review - IMRT
2013. ALL H+N patients treated
from April 2013.
Delayed due to focus on H+N IMRT
– first pancreas patient April 2013
See below. Recruitment extended
through to 2013.
Programme started and
implementation continues. New
new tumour sites started as below
with protocols in progress:
Oesophagus due Feb 2014. CNS
stereotactic due to start August
2014.
Started 4 pts per week Oct 2012.
April 2013 start. Delayed from 201213 due to delay in variation with PFI
being agreed.
So all installation moved to 2013-14
year. Installation completed Oct
2013. RapidArc commissioning
substantially complete (Dec 2013).
RapidArc treatment rolled out during
Jan – March 2014 to head and neck
and prostate cancer. Other tumour
sites to follow. The delay in
installation of RapidArc by 9
months, has meant that we have
had to implement fixed beam IMRT
to achieve the national target of
24% of all radical patients (including
all H+N cancer patients) by April
2013 which was later adjusted to
July 2013. We did achieve this
target in June 2013. However have
had to implement 16 hours weekend
working (Sat and sun am on 2
linacs) to achieve this during the
period of equipment upgrade where
1 machine has been constantly out
of action for 2013-14 year.
RapidArc roll out on Varian 2 and 4
started Feb 2014.
Achieved. 29 patients started IMRT
in Jan 2013. See graph below.
Page 6 of 15
Oxford University Hospitals
Start rollout of other tumour
sites treatment gradual
increase in new starters
TB2014.125
April 2013
Install ExacTrac/RapidArc/On
April 2013
board imaging (OBI) on linac 6
– installation was completed
on linac 5
Roll out all additional tumour
sites (anus, stereotactic single
fraction CNS, rectum)
May 2013
– April
2014
14 patients per week, all
tumour sites implemented
April 2014
New tumour sites started Inverse
IMRT: Breast ca Dec 2012.
Lymphoma included in H+N protocol
Feb 2013.
Unusual sites Sept 13.
In addition. We started stereotactic
ablative radiotherapy (SABR) stereotactic lung RT (Dec 2012) and
stereotactic liver RT (Feb 2013).
This was not included in the IMRT
business case, but involved
considerable technical input.
Delay due to moving all of RapidArc
and cone beam computed
tomography (CBCT) installation into
2013-14. So this machine was put
later in programme. OBI and
RapidArc installed August 2013.
ExacTrac installation completed Feb
2014. But not accepted until 22 May
2014 due to issues around whether
OBI link to ExacTrac was included in
order or not. (The link was not
available when the equipment was
ordered).
Varian 5 RapidArc commissioning
was completed 1 July 2014. Go live
for RapidArc on Varian 5 - 7 July
2014.
Achieved early: Anal cancer Feb
2013
Rectal ca protocol approved Oct
2013. To start clinical in 2014 with
RapidArc. Stereotactic radiosurgery
(SRS) August 2014 as outlined
above.
140 patients started IMRT
treatments Aug – Oct 2013. A rate
of 11-12 per week. See graph
below. Approximately 50 patients
per month are now starting IMRT.
(35% of all radical patients)
Recruitment
The business case described the requirement for the additional staff listed below
to support IMRT activity and service growth respectively. The case proposed that
TB2014.125 Implementation Review - IMRT
Page 7 of 15
Oxford University Hospitals
TB2014.125
appointments to the IMRT posts would start in 2012/13 and for growth in
2013/14. Please explain any variances from this plan.
Note that the project benefited a lot from the support of university employed staff
including Dr Tim Maughan, (Clinical Director) who supported and contributed to
the business case and Dr Maria Hawkins (started Nov 2012 as Technical
Radiotherapy lead) who contributed to the protocol and technique development
within the GI tumour sites.
IMRT
10PA Consultant Clinical Oncologist
5PA in 2012-13:
sessions
3PA from Nov 2012 : part funded
University appointment: RM LGI cancer
Oxford
2PA from Nov 2012 : part funded
University appointment: SM UGI Oxford
5PA in 2013-14:
1PA from Jan 13 IMRT Lead, RM – early
start due to RT Innovation funding.
1PA from Apr13 : Prostate cancer, AS
0.5PA from Apr13 : UGI Cancer: SM
0.5PA from Apr 13 : Lung cancer: NP
1PA from July 13 : Lung and urology: RS
new post.
0.5PA to CB (CNS SRT) start August 2014
0.5PA to NW(CNS SRT) start August 2014
1PA Consultant radiology sessions
0.5PA started Jan 2013 (NT) Head and
Neck cancer radiology.
0.5PA to start in August 2014 with the
Stereotactic Cranial RT service (PP).
0.5WTE Band 8C Physicist –
FvdH appointed in 2013. Started Feb
Development Lead (plus 0.5WTE
2014. Joint post with university.
University of Oxford)
2.0WTE Band 8A Physicist (1.0
2012/13: HW and CH appointed to posts
appointed in 2012/13 and 1.0
in conjunction with 0.5 brachytherapy
appointed in 2013/14)
post. total 1.5 WTE. Started Jan 2013.
2013/14: SP appointed initially to band 7
May 2013 while gaining experience he
moved to the full SRT Band 8A post 1st
Dec 2013
2.0WTE Band 7 Physicists
Unable to recruit registered clinical
scientists due to national shortage. JL in
post Nov 2013 as Band 6 and moved to
registration and Band 7 post in April
2014. EI in post March 2013 as Band 6
and should move to registration and Band
7 post in Dec 2014
1.0WTE Band 6 Dosimetrist
A O’N in post Jan 2013
1.0WTE Band 7 Radiographer (CNS
Divided into 2 posts jointly with band 7
TB2014.125 Implementation Review - IMRT
Page 8 of 15
Oxford University Hospitals
SRT and H and N specialist)
TB2014.125
existing post funding.
SD appointed H+N specialist radiographer
– started June 2013.
CNS SRT specialist radiographer RW
started April 2014.
1.0WTE Band
1.0WTE Band
Growth
1.0WTE Band
2.0WTE Band
3 Radiographer helper
4 Clinical Secretary
GB started May 2013
CC appointed Sept 2012.
7 Radiographer
6 Radiographer
Recruited. During 2013-14
Recruited. During 2013-14
Finance (IMRT and Growth)
Revenue
The business case proposed
additional pay costs of £165k in
2012/13, increasing to £623k for
2013/14 and annually thereafter.
Please confirm the additional pay
costs for 2012/13 and the
additional pay costs for 2013/14.
Please comment on any variance
from plan.
Please confirm budgets for
2014/15.
The business case proposed
additional non-pay costs of £69k
(capital charges) in 2012/13,
increasing to £347k in 2013/14.
Please confirm the non-pay costs
incurred in 2012/13 and the nonpay costs for 2013/14. Please
explain any variance from plan.
Please confirm the budget for
2014/15.
The business case anticipated
additional income, over and above
the 2011/12 baseline of £31k, of
£675k in 2012/13, increasing to
£1,649k in 2013/14. Please confirm
the additional income delivered in
2012/13 and the additional income
for 2013/14.
TB2014.125 Implementation Review - IMRT
2012/13 – £115k - £50k lower than planned
due to some delays in appointments
2013/14 - £523k - £100k lower than planned
due to some delays in appointments. In
particular the band 8C physics joint
university post started Feb 2014.
Budget for 2014/15 is £623k.
2012/13 – no capital charges as equipment
installation occurred 2013/14
2013/14 non pay costs:
£413k capital charge and depreciation.
Mistake in business case. Capital charges on
expenditure of £1,555k were included rather
than £2,600k.
Budget for 2014/15: £413k capital charge.
2012:13 additional income. We planned to
deliver 196 courses, and actually delivered
147 courses of IMRT.
2013:14
We planned to deliver 485 courses of IMRT
during 2013/14. In fact 463 were delivered.
Page 9 of 15
Oxford University Hospitals
Please explain any variance from
plan.
Please confirm budgets for
2014/15.
TB2014.125
The additional income was £1,887k. (cf
£1,649k in business case) This is related to
the higher than expected income for IMRT
planning. (£864k due to growth and £1,023k
due to delivery of IMRT).
Budget for 2014/15 £2,600k looks
achievable.
Other Revenue Cost Consequences
Have any other costs been incurred No
as a result of this business case?
Capital and Space Requirements
Additional capital expenditure of
No non-pay expenditure was incurred in
£2,651k was approved, with
2012/13. The £69k purchase of QA
expenditure of £1,096k planned for equipment was delayed (agreed with Paul
2012/13 and £1,555k expenditure
Brennan) from 2012/2013 to match the
planned for 2013/14. What
delay of the linac upgrades, (more delays
expenditure was incurred in
than anticipated occurred in the
2012/13 and 2013/14 respectively? procurement process).
Please explain any variances from
plan.
Non-pay Expenditure : 2013-14
£2,134 k to OCHRE. (NO VAT paid)
£84.3k for QA equipment – includes VAT.
Total: £2,218k
The variation from the total expected
expenditure of £2,651k is due to the fact
that 20% VAT was assumed in the business
case, but was not in fact payable.
Saving approx. £450k cf business case
Have any other capital costs been
incurred as a result of this business
case?
The non-pay upgrade of the linacs has now
been completed.
No
Activity
The case anticipated the delivery of the total levels of activity for 2012/13 and
2013/14. Demand for treatment is expected to increase year on year. Please
comment on its achievement in 2012/13 and the position for 2013/14.
Please confirm the plan for 2014/15.
2012/13
Plan
Actual
2013/14
Variance
TB2014.125 Implementation Review - IMRT
Plan
Actual
Variance
2014/15
Plan
Page 10 of 15
Oxford University Hospitals
Fractions
SC22,23,
SC41Z
1,500
(69005400)
??
IMRT
Planning
SC40Z,
SC41Z
Growth
Fractions
196
151
44,934
IMRT
and Non
IMRT
Planning
3,715
TB2014.125
6,456
(16056
-9600)
Unable
to
estimate
This figure was
overestimated
13880 (2488011000)
45
485
490
+5
750
45,270
-336
49,440
48,298
-1,142
50,000
3049
666
3,805
3427
-378
3700
Benefits Realisation
The business case proposed the realisation of the following benefits, please
comment on their delivery.
Benefit
Target
Timeline
Delivery
Value
Increase portfolio 30% of
Due End
Oct 2013 – 38.6% of patients
of treatment
patients to
2012.
starting radical RT started inverse
options to include receive IMRT Likely to
planned IMRT treatments. See
IMRT, thus
achieve
graph demonstrating that this
meeting NRAG
end 2013.
delivery has been sustained
target
Reduce irradiation 26%
End 2013
This is a long term aim. We have
of healthy tissues reduction in
audited our outcomes in anal
and long-term
late toxicity
cancer pre IMRT and will
morbidity
as shown in
compare post IMRT.
clinical trials
Increase number
4
End 2013
4 Trials open using IMRT: Arc 2,
of IMRT clinical
(more in
Import High, Neoscope, BR14.
trials
later years)
Financial and
Margin of
2014-2015 Stereotactic RT to be
Operational
43% in
financial
implemented in 2014-15. Will
viability in the
2013/14 and year
increase numbers further 50 SRS
long-term
57% in
and 35 multiple fraction SRT.
2014/15
Risks
The case identified a number of risks to implementation namely :
• Downtime in 2012 and 2013 to allow installation and commissioning of
additional equipment for RapidArc and ExacTrac hardware/software
• Additional staffing not approved
• Additional staffing not available to recruit
• Forward projection of patient and fraction numbers are too low. Hit capacity
TB2014.125 Implementation Review - IMRT
Page 11 of 15
Oxford University Hospitals
TB2014.125
earlier than envisaged
• Forward projection of patient and fraction numbers are too high or
commissioners do not commission the actual numbers delivered
Of the risks identified,
Yes, the delay in installation of RA by 6 months, against
did any of them impact our plan. Firstly, the department was unable to start any
more significantly than
work on RapidArc until the anaesthetic gas pipe work
had been anticipated?
had been completed in Dec 2012 and then there was a
delay in submitting and agreeing variation with INC until
Jan 2013 with a start date put back from Oct 2012 to
April 213.
This has meant that we have had to implement fixed
beam IMRT to try and achieve the national target of
24% of all radical patients (including all H+N cancer
patients) by April 2013. We did achieve this target in
June 2013 and have done since. However have had to
implement 16 hours weekend working (Sat and Sun AM
on 2 linacs) to achieve this during the period of
equipment upgrade where 1 machine has been
constantly out of action for 2013-14 year.
Additional staffing were approved in a timely manner.
Delay in recruiting both physicist and radiographer staff.
This is due to nationally recognised shortages in these
staff groups. Necessitating appointing 3 of the physics
posts below grade and providing training. Clinician
appointment did not present any issues due to
University joint appointments.
Commissioners have funded our planned and actual
numbers because RT is now specialist commissioned
and funded by case based tariff.
Were there any
National target 24% to receive IMRT by April 2013 was
unanticipated issues
introduced in Dec 2012. We met this by June 2013 and
that impacted adversely have exceeded this month on month. While the year on
on implementation?
year increase in demand for radiotherapy was
anticipated and planned for, the Milton Keynes patient
transfer to OUH during 2013-14, and completely from
April 2014 could not have been anticipated. This has
meant the requirement for an increase in capacity of an
additional 8000 fractions per year more. This has had a
significant impact on the delivery of cancer targets. As
IMRT ultimately enables patients to be treated more
quickly, its implementation has played a key role in the
plans to return performance to the required standards
(this is especially so for the 31 day target for
radiotherapy). Separate business case approved TME 25
June 2014 to expand staff to continue to open 2
machines weekends and run 6th linac full time. Steps
have been made to minimise the downtime due to
maintenance and QA e.g. maintenance largely
TB2014.125 Implementation Review - IMRT
Page 12 of 15
Oxford University Hospitals
TB2014.125
supported in-house with QA taking place at week-ends.
This allows optimal use to be made of all machines
within the limitations of the PFI MES contract (linac
hours/year).
Learning points
Please describe any learning points from the implementation of your business case
which can be shared with others.
Once the business case has been approved. Ensure that the OUH estates team
engage with the PFI partners rapidly to ensure that the variation enquiry is
approved rapidly so that work can be undertaken. Our project was 7 months
behind schedule due to this and the delay in completing anaesthetic gas pipes
repair work, and had to employ staff to work weekend overtime for 9 months to
compensate for this. But still met the national target of 24% IMRT treatments by
June 2013 (target was imposed in December 2012 to start April 2013).
With regard to the MES, it is very important to ensure that the clinical teams are
rigorous in their evaluation of equipment, particularly where the technology is new
to the department. This will ensure that the needs of the service are optimally
met.
Author:
Date:
Claire Blesing – Clinical Director Oncology and Haematology
1 December 2013, updated 4 September 2014 following
ExacTrac acceptance.
Implementation of IMRT
The following graph and table demonstrates the increasing levels of cancer treatment that
have been delivered by IMRT :
% IMRT/ radical for treatments started each month
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Note: National target from April 2013: 24% of radical cases to receive IMRT
TB2014.125 Implementation Review - IMRT
Page 13 of 15
Oxford University Hospitals
Actual
IMRT
% IMRT/
Radical
TB2014.125
Number of
Radical Cases
New Tumour Sites
Jan-12
2
1%
148
Feb-12
7
6%
127
Mar-12
8
6%
130
Apr-12
7
5%
149
May-12
5
4%
139
Jun-12
2
2%
126
Jul-12
10
7%
148
Aug-12
2
2%
136
Sep-12
7
6%
118
Oct-12
18
11%
172
Nov-12
15
10%
147
Dec-12
14
11%
125
Jan-13
29
15%
188
Head and neck cancer
Feb-13
19
15%
123
Anal cancer
Mar-13
23
17%
134
Apr-13
28
21%
135
May-13
29
22%
131
Jun-13
33
25%
134
Jul-13
50
29%
171
Aug-13
35
22%
157
Sep-13
44
28%
159
Oct-13
61
39%
158
Nov-13
47
33%
141
Dec-13
41
137
Jan-14
Feb-14
Mar-14
Apr-14
May-14
45
55
64
40
30%
28%
33%
35%
39%
26%
Jun-14
63
40%
50
Prostate cancer (started as pilot 2010)
Endometrial cancer (post op)
All prostate cancers
Pancreas cancer
Rapid Arc signed off V2 and V 4
160
Rapid Arc started for prostate cancer
155 Rapid Arc started for Head and Neck ca
163
151
Rapid Arc go live Varian 5 machine ,
159 ExacTrac signed off
153
Acronyms and Abbreviations
CNS - Central nervous system
CBCT – Cone beam computed tomography
IGRT - Image guided radiotherapy, use of on board imaging or portal imaging to verify
patient position and guide treatment.
IMRT - Intensity modulated radiotherapy
Linac - linear accelerator – used to deliver external beam radiotherapy treatment
TB2014.125 Implementation Review - IMRT
Page 14 of 15
Oxford University Hospitals
TB2014.125
OBI - On Board Imaging (kilovoltage and cone beam CT imaging integrated with
treatment unit)
SABR – Stereotactic ablative radiotherapy
TB2014.125 Implementation Review - IMRT
Page 15 of 15