A case for improving cancer
services in London?
Healthcare for London cancer project
23 November 2009
Healthcare for London is part of Commissioning Support for London – an organisation providing clinical and business
support to London’s NHS
Welcome and objectives of
the day
Bill Gillespie
Chief Executive, Sutton and Merton PCT
Senior Responsible Officer, Healthcare for London cancer project
23 November 2009
Healthcare for London is part of Commissioning Support for London – an organisation providing clinical and business
support to London’s NHS
Introduction
Project aims:
• drive up quality across the whole patient
pathway and improve outcomes
• enable coherent developments in the
provider landscape in line with the
Healthcare for London vision
• ensure we pursue and realise all
opportunities to utilise resources efficiently
and improve productivity levels
A case for improving cancer
services in London?
Healthcare for London cancer project
23 November 2009
Healthcare for London is part of Commissioning Support for London – an organisation providing clinical and business
support to London’s NHS
Cancer in London:
A national perspective
Professor Mike Richards
November 2009
Cancer in London: A national perspective
Overview
• How does England compare with other
countries on cancer? How near are we to
“world-class”?
• How does London compare with the rest of
England?
• What are the key challenges for London cancer
services?
What would world-class look like? (1)
Primary outcomes
• Incidence
Low
• Mortality
Low
• Survival
High
• Health and well being of survivors
High
• Experience of care of cancer patients
High
What would world-class look like (2)
Secondary measures
• Healthy lifestyles (effective action on smoking, obesity etc.)
• Comprehensive screening services with high coverage
• Early diagnosis of symptomatic patients
• Well organised and coordinated services (e.g. MDTs)
• High quality treatment (surgery, radiotherapy, chemotherapy)
• Personalised information, support and rehabilitation
• High quality end of life care
• Cost-effective use of resources
Cancer survival in the 1990s
Where are we now? Primary outcomes
[1=best]
Incidence (2002)
Mortality (2004)
Survival (1995-9)
M
Better than average
5/15*
F
Worse than average
10/15*
M
Average
8/15*
F
Worse than average
11/15*
1 yr
Worse than average
17/23**
5/1 yr
Average
12/23**
* ‘Western’ countries and Japan
** Europe including Slovenia, Poland and the Czech Republic
Where are we now? Secondary measures (1)
1. “World-class” (but NB room for improvement)
• Tobacco strategy
• Screening services
• Establishment of MDTs
• Centralisation of complex cancer surgery
• Recruitment to clinical trials
Where are we now? Secondary measures (2)
2. “Solid progress”
•
Diagnostics
•
Cancer waits
•
Surgical training
•
Radiotherapy services
•
Chemotherapy services
•
Patient information
•
Communication skills training
•
Cancer intelligence (NCIN)
Where are we now? Secondary measures
3. “Early days”
•
Late diagnosis
•
Inequalities
•
Survivorship
•
Transforming inpatient care
Late diagnosis
• Almost certainly accounts for much of the gap in
survival between the UK and other Western countries
• 10,000 ‘avoidable deaths’ if England matched the best
in Europe
• One year survival rates poor (cf. Sweden) in almost all
PCTs in England
• Early diagnosis has to be a priority
How does London compare with the rest of England (1)
• London has a lower incidence of cancer, largely due
to a markedly lower age profile
• London has around
• 15% of the population
• 12% of new cancer cases
• 11% of cancer deaths
(7.5m/50m)
(27k/230k)
(13.6k/125k)
• London has a very high BME population
How does London compare with the rest of England (2)
• London has relatively more hospitals than other parts of
the country (therefore smaller average throughputs)
• Overall cancer mortality rates for Londoners are similar to
England as a whole
• However, there are marked inequalities in cancer
outcomes within London – from the best to the worst in
England
How does London compare on secondary measures (1)
• Screening coverage:
Very poor
• Late diagnosis of symptomatic patients:
• Poor one year survival rates cf. Europe
(but this is a widespread problem in England)
• MDT working:
? Analysis of peer review data
• Surgical volumes:
Generally low
How does London compare on secondary measures (2)
• Radiotherapy and chemotherapy:
Regrettably no
comparative data, as yet
• Participation in national clinical audits: Relatively poor
• Cancer bed utilisation:
Relatively high
• Patient experience:
Poor
• Place of death:
Hospital deaths high
Late diagnosis in 31 London PCTs
Lower (worse) Upper (better)
quartile
quartile
Cervical screening coverage
24
2
Breast screening coverage
27
0
2ww referrals/10k population
17
2
• Breast
15
2
• Colorectal
15
3
• Lung
3
15
One year survival
Bed utilisation in 31 London PCTs
Higher (worse) Lower (better)
quartile
quartile
Elective bed days
10
5
ALOS breast surgery
15
2
ALOS urological surgery
12
2
Emergency admissions
13
5
Emergency bed days
19
3
ALOS emergencies
16
1
Key challenges and questions for London on cancer (1)
1. Late diagnosis
•
If there are 10,000 avoidable cancer deaths pa in
England, at least 1000 of these relate to Londoners
•
Late diagnosis (screening and symptomatic) is almost
certainly the single largest factor. This requires action
at community and primary care levels
•
How might we best use polysystems?
Key challenges and questions for London on cancer (2)
2. Service configuration
•
Are there too many small and unsustainable MDTs for
common cancers?
•
How can we provide good access to specialist assessment
across London?
• Outreach MDTs?
•
How can we ensure adequate critical mass for surgery?
• ?In reach surgery?
Key challenges and questions for London on cancer (3)
3. Quality and Productivity
•
•
•
•
Avoiding unnecessary admissions and shortening lengths
of stay is good for patients and for the NHS
Nationally, we aim to ‘save a million bed days’ (equivalent
to 2750 beds at 100% occupancy)
Maybe London should aim to save a 100,000 bed days
(equivalent to 275 beds)
How?
• Enhanced recovery: Elective surgery
• Ambulatory care services
• Acute oncology
Summary
• London could do a lot better on cancer
• Radical change will be needed to save 1000 lives and
100,000 bed days pa
• You have my full support
A case for improving cancer
services in London?
Healthcare for London cancer project
23 November 2009
Healthcare for London is part of Commissioning Support for London – an organisation providing clinical and business
support to London’s NHS
Case for change
Professor John Toy
Clinical Director
23 November 2009
Healthcare for London is part of Commissioning Support for London – an organisation providing clinical and business
support to London’s NHS
NHS cancer policy
• 1995 – Calman Hine report
• 1996 – NICE Improving Outcomes Guidance
• 2000 – NHS Cancer Plan
• 2007 – A Framework for Action
• 2007 – Cancer Reform Strategy
Cancer in the UK
Age standardised cause of death from malignant neoplasms in
comparable developed countries in Europe and the world 1993-2004
220
200
Deaths per 100,000 population
180
160
140
120
100
80
60
40
20
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Improving survival rates to European standards could translate to an
estimated 1,000 lives saved a year in London
0
Kensington & Chelsea
City of London
Harrow
City of Westminster
Barnet
Brent
Redbridge
Kingston upon Thames
Merton
Ealing
Bromley
Richmond upon Thames
London Average
Bexley
Sutton
Enfield
Croydon
Hillingdon
3-year standardised mortality rate
Hounslow
Camden
Haringey
Wandsworth
Havering
Waltham Forest
Hackney
Hammersmith & Fulham
Southwark
Lambeth
Newham
Barking & Dagenham
Greenwich
Islington
Lewisham
Tower Hamlets
per 100,000 age standard population
Cancer in London
Mortality for all malignant neoplasms in all London Boroughs – 2003-2005
England Average
250
225
200
175
150
125
100
75
50
25
Challenges in London
• Socioeconomic inequalities
• Population growth
• Differences in outcomes
• Patient experience
• Workforce
• Fragmentation of services
• Provision of specialist services
• Research
Cancer project structure
The governance arrangements for the cancer project are illustrated below:
Rarer
cancers
Clinical
Leadership
Group
London
Commissioning
Group
Cancer expert
reference panel
Cancer project
board
Patient panel
Project
team
Cancer
network
leads
Common
cancers
Early
diagnosis
Early diagnosis
Low public awareness
Late presentation to GPs
Delays in primary care
(awareness/attitude/access to
diagnostics)
Late referral to hospital
Delays in secondary care
More advanced disease at diagnosis
Poorer survival rates
Avoidable deaths
Early diagnosis
• Public awareness (NAEDI)
• Poor screening uptake rates
• Delays in presentation
• GPs see <10 new cancer patients a year
• GP access to diagnostics
Common cancers and general care
Types of cancers considered:
• breast cancer
• lung cancer
• colorectal cancer
• bladder and prostate cancer
• skin cancer (melanoma and nonmelanoma)
• haematology
Common cancers and general care
London’s relative survival rates for three common cancers (followed
until Dec 2004)
Breast
Colon
US average
Lung
87
EU average
79
England average
78
West London
62
54
81
North London
78
North East London
76
South East London
78
South West London
10
20
30
40
50
60
70
12
49
6
48
7
43
7
42
6
46
78
0
15
6
50
80
90
0
10
20
30
5-year survival rates (%)
40
50
7
60
70
0
10
20
Common cancers and general care
Delivery of services:
• best care as close to home as possible
• surgery
• systemic anti-cancer therapy (SACT)
• radiotherapy
• multi-disciplinary teams
• hospital bed days
• follow-up and support including rehabilitation
• supportive and palliative care
Rarer cancers and specialist care
Types of cancers considered:
• Upper gastrointestinal
• Rarer urological
• Head and neck and Endocrine
• Brain and CNS
• Gynaecological
• Sarcoma
How many providers?
• There is evidence that worse clinical
outcomes are associated with low surgical
volumes
• Achieving minimum IOG volumes is
deemed insufficient
• Concentration of cases can achieve a
critical mass of expertise and financial
sustainability
Rarer cancers and specialist care
Specialist care includes:
• Haematopoietic progenitor cell
transplantation (HPCT)
• Molecular diagnostics
• Specialist Imaging
• Specialist radiotherapy
How many providers?
• Specialist treatments, technologies and
techniques are demanding of scarce
resource and expertise
• Four out of nine adult HPCT units in
London are not JACIE accredited
• High expense requires cost-effective
spending
How many cancer networks?
Yorkshire – one network
• Population served = 2.6 million
• Geographical area = 783 sq/m
• One cancer centre
London – Five networks
• Population(s) served = 7.8(1.5 -1.8) million
• Geographical area = 607 sq/m
• Five (joint) cancer centres
Yorkshire and London
Incidence
1 year survival
(2000 – 2004)
(ASR/100,000, 2005)
Yorks 386 (378.9 - 393.1)
66.5 (66.0 - 66.9)
West L
351 (342.0 - 359.9)
<
69.0 (68.3 - 69.6)
>
North L
347 (335.8 - 357.7) <
67.3 (66.6 - 68.0)
~
NEast L 333 (323.4 - 342.6) <
63.0 (62.3 - 63.7)
<
SEast L 373 (362.9 – 383.0) ~
65.9 (65.3 - 66.6)
~
SWest L 374 (363.0 - 384.5) ~
70.7 (70.0 - 71.3)
>
Next challenge
Translate the case for change into a
clinically robust and affordable new model of
care on behalf of London’s patients in a bold
and ambitious fashion
A case for improving cancer
services in London?
Healthcare for London cancer project
23 November 2009
Healthcare for London is part of Commissioning Support for London – an organisation providing clinical and business
support to London’s NHS
Cancer model of care
Professor John Toy
Clinical Director
23 November 2009
Healthcare for London is part of Commissioning Support for London – an organisation providing clinical and business
support to London’s NHS
Themes from the case for change
General themes
• London characteristics
• Strong commissioning needed based on best practice
and latest research
• Barriers to improvement
Early diagnosis
• Need to diagnose cancer earlier
• Delay is associated with
– public behaviour
– clinical practice
– infrastructure
Themes from the case for change
Common cancers and general care
• Variation in the services offered to patients
• Implementation of existing recommendations
• Localise where possible, centralise where necessary
• Multi-disciplinary teams can operate more efficiently and
effectively
• Some follow-up is unnecessary
• Supportive care and palliation services must improve
Themes from the case for change
Rarer cancers and specialist care
• Benefits of centralisation for patients and healthcare
system
• Some rarer services should be centralised
• Some services are appropriately configured but some
improvements remain to be made
• Specific arrangements necessary for highly specialist
services
The current context
• Healthcare for London: A Framework for Action
• The Cancer Reform Strategy
• NICE Improving Outcomes Guidance
• Productivity and the financial climate
• The NHS Improvement Plan
• Fostering innovation and research
• Academic Health Science Centres
The way forward – emerging ideas
• There are areas of excellence in London, but not
everywhere
• Treatment and care should be standardised for all
patients
• Learning and best practice should be openly shared
• Stronger commissioning of high-quality services
• Organisational boundaries should not create barriers
• Specialist surgery should be centralised
• Common treatments and surgery should be localised
where possible
• Locally delivered services should be centrally managed
Possible ways forward
• Transparent performance metrics through the London
Quality Observatory
• Accreditation processes, peer review led
• Hub and spoke provider networks
• Remove organisational boundaries as far as possible
• Governed partnerships between providers
What are the best models of care?
• An emerging idea is of a limited number of provider
networks
• Services commissioned on the basis of pathways
• Expert commissioning advice from existing network teams
• These are only emerging ideas. Other options have not
been ruled out.
Questions:
• What do you think the model of care should be?
• Do you agree with our emerging ideas?
• What examples of good practice do you know?
• What are the barriers to change and what are the
enablers to bring change about?