Agenda item 11.4 - Appendix 1
Business Case for a full-time
Consultant in Clinical Oncology
1. Strategic case – The Strategic Fit
Business Need
1.1 This proposal is for a whole time equivalent (10PA’s) Consultant
Clinical Oncologist. The post-holder will provide a major site service for
patients with lung and colorectal cancer and, at least initially, as a minor
site, head and neck cancer.
Strategic Overview
1.2 The oncology service is currently provided at the Royal United
Hospital in Bath by 6 oncologists [approximately 3.5 WTEs] [4 clinical
oncologists, 2 medical oncologists], four of which have a substantial [more
than 50%] time commitment at Bath.
1.3 For a catchment population of the RUH both the NHS Cancer Plan
and Royal College of Radiologist calculations would recommend 8 WTE
Consultant Oncologist.
1.4 The proposed appointments job plan will support the RUH lung,
colorectal and head and neck cancer teams and will in turn support
compliance with National Cancer Waiting Time targets, National Peer
Review measures and NICE Improving Outcomes Guidance (IOG).
1.5 In 2003 the PCTs supported a programme of investment in oncology
and the first additional consultant Clinical Oncologist was appointed in
2006. It was anticipated that following this appointment, there would be
a further program of investment in oncology. Medical staffing would be
developed, to support an additional 3WTE consultant oncologists over
three years. Unfortunately, financial constraints and prioritization of
Author: John Travers, Divisional Manager
Date: September 2008
Public Trust Board
3 September 2008
Page 1 of 9
Agenda item 11.4 - Appendix 1
financial balance throughout the South West and the NHS as a whole
meant that further consultant expansion was halted.
1.6 An Oncology review paper has recently been presented to PCTs in
the BCAP health economy outlining the need for a major investment of
c£2.5 million to expand the current oncology service. Whilst part of the
£2.5 million will almost certainly come from income the paper is still
currently under discussion.
1.7 Only BaNES PCT has made a firm commitment to any additional
funding, £75,000, in this financial year.
1.8 The RUH oncology team provides a comprehensive service for the
Bath, Somerset and Wiltshire Local Health Community offering all
conventional treatment options for the management of cancer on a single
integrated site. There is very close working between the cancer site
specific teams supporting an efficient, streamlined, high quality service for
patients. The RUH oncology service is very closely linked with the Bristol
Haematology & Oncology Centre (BHOC). Some complex radiotherapy
planning is undertaken in Bristol but most radiotherapy is delivered in
Bath. Some of the current Consultant Clinical Oncologists work across the
two trusts to facilitate an efficient service. The members of the Bath
Oncology team are engaged in the development of Avon Somerset and
Wiltshire cancer network (ASWCS) wide protocols for the best clinical
management. Colleagues from the BHOC may also be called upon for
second opinions
1.9 The oncology services within the RUH have historically been
generously supported by charitable donations predominately from the
Bath Cancer Unit Support Group who have invested nearly three million
pounds since 1985 in equipment and facilities.
Rational for the proposed development
1.10 The provision of surgical and non-surgical oncology at the RUH is
pivotal to providing the complete spectrum of cancer care at the RUH, a
key RUH objective.
1.11 Securing additional oncology support is supported by all the cancer
site specific multidisciplinary teams as a high priority.
1.12 Nationally one in three people will develop cancer at some time in
their life and one in four will die from it. The approximate number of
people currently within the UK who have a diagnosis of cancer is 1.2
Author: John Travers, Divisional Manager
Date: September 2008
Public Trust Board
3 September 2008
Page 2 of 9
Agenda item 11.4 - Appendix 1
million. The number of cases diagnosed annually is set to increase with
some experts predicting that the number could treble by 2025 due to an
aging population. The predicted expansion in the number of patients
undergoing treatment and those living with cancer will consequently
increase the demand for cancer services.
1.13 The RUH does not have sufficient oncology input to adequately
support all the cancer activities at the RUH, for example, outpatient and
inpatient care, radiotherapy, chemotherapy, MDT attendance and
participation in clinical trials. In addition the main oncology ward William
Budd, is dependent upon consultant staff for ward cover with very limited
input from middle grade staff making out of hours and weekend oncology
medical cover a significant issue. Medical cover however is supported by
the high level of expertise of the nursing staff on William Budd ward.
1.14 The demand for Consultant Oncologist expertise has never been so
great, as highlighted in the National Cancer Reform Strategy (CRS)
published December 2007. The CRS builds on progress made since the
publication of the NHS Cancer Plan, recognising the key challenges and
opportunities for improving outcomes. The CRS also sets out a clear
direction for the next 5 years showing how we will deliver cancer
outcomes which are amongst the best in the world.
1.15 There are 6 key areas for action within the CRS and 4 key drivers
for delivery outlined below;Areas for action
1.
2.
3.
4.
5.
6.
Prevention
Diagnosing cancer earlier
Ensuring better treatment
Living with and beyond cancer
Reducing cancer inequalities
Delivering care in the most appropriate setting
Drivers for delivery
1.
2.
3.
4.
Using information to drive quality and choice
Stronger commissioning
Funding world class cancer care
Planning for the future
Author: John Travers, Divisional Manager
Date: September 2008
Public Trust Board
3 September 2008
Page 3 of 9
Agenda item 11.4 - Appendix 1
1.16 The CRS states that there will be major investment in staff and
facilities to deliver world class radiotherapy services, encouraging an
urgent expansion of local capacity of radiotherapy to support the growing
demand.
1.17 Drug treatments have also increased greatly over the last twenty
years (in 2006 nationally £729m was spend on drug treatment for
cancer). There are a number of drugs licensed for use in different cancer
and drug combinations which are shown to be active against cancers
which where previously resistant. It is also important that patients have
access to clinical trials. All of these activities cannot take place without
adequate support from Clinical Oncologists.
The consequence of
improved outcomes and increased number of treatment possibilities mean
that patients are living longer and require ongoing oncology support.
1.18 The CRS goes further on cancer waiting times extending the current
31 day target to 31 days for all treatment lines not just first definitive
treatment which will further increase the oncologists workload to ensure
patients are treated within target.
1.19 The combination of the increase in the number of new cancers
detected each year plus an increase in the number of possible treatment
regimes, lines of treatment, the extension of the national cancer waiting
targets and patient’s expectation means that the demand for clinical
oncologist time has never been so great.
1.20 The majority of Consultant Clinical Oncologists employed within the
ASWCS cancer network are employed by a single trust but have sessions
in multiple hospital locations. This facilitates a basic coverage of all cancer
sites across the ASWCS 2 million population however the actual session
time within each location is limited due to traveling, and afternoon clinics
are frequently delayed due to previous clinical commitments.
1.21 Not having a core clinical oncologist team at the RUH causes
unnecessary delays. The plan is to work towards a 5 year expansion of
both Medical and Clinical Consultant Oncologist numbers.
Benefits of this development
1.22 The benefits of this appointment include:

Compliance with national cancer waiting times targets including
the revised targets in the CRS
Author: John Travers, Divisional Manager
Date: September 2008
Public Trust Board
3 September 2008
Page 4 of 9
Agenda item 11.4 - Appendix 1




Increased oncology out-patient capacity including on-treatment
reviews
Multidisciplinary team coverage of colorectal, head & neck and
Lung MDT (national peer review standard)
Establishment of parallel lung cancer clinic with respiratory
physicians to fast track patients in line with national targets and
cancer standards.
More timely in-patient reviews
Key risks – Consequences of do nothing option
1.23 The key risk is continued lack of capacity in the Oncology service
resulting in:





Failure to comply with national cancer waiting time targets to
first definitive treatment – particularly the 62 day target for Lung
cancer and new 31 day targets for all lines of treatment
Repeated double-booking (and therefore overrunning) of outpatient clinics.
Poor clinic letter turnaround times due to overbooking and extra
dictation.
Poor response times to “pink slip” intra-hospital referrals from
other teams.
Considerable pressures on Oncology Consultants to cross cover
Consultants who are only at the RUH for a limited number of
sessions – particularly on treatment review for radiotherapy
patients.
Critical Success Factors
1.24 The critical success factors include:




Compliance with national cancer targets monitored with
monthly key performance indicators
Reduced double booking and overrunning of clinics measured
by audit
Meet Trust target of correspondence with GPs measured by
audit of clinic letter turnaround times
Better response times to “pink slip” referrals measured by
audit
Main Stakeholders
Author: John Travers, Divisional Manager
Date: September 2008
Public Trust Board
3 September 2008
Page 5 of 9
Agenda item 11.4 - Appendix 1
1.25 The main stakeholders are:




2
Patients
Primary Care Trusts – mainly Wiltshire, BaNES, Somerset. All
Primary care Trusts appear to support the oncology expansion
in principle however only BaNES PCT have committed funding,
£75k, to date. A case has been made for investment of c
£2.5m in Oncology services, some of which will be by
increased income.
General Practitioners
Oncology Medical, nursing and support staff
Options appraisal: the economic case
Collaboration
2.1 The Oncology department already work collaboratively with BHOC
and the wider cancer network. There is little scope to expand this further
with the current consultant establishment.
Service reconfiguration
2.2 Pharmacist led and nurse led prescribing has also been introduced in
order to take some of the pressure of the existing consultant workforce.
This in turn has increased pressure on the pharmacy and nursing
establishment in Oncology as this was introduced without backfilling the
existing pharmacy and nursing posts.
2.3 Nurse-led outpatient clinics are also in place and have relieved some
of the pressure on existing outpatient clinics however consultant clinics
remain over booked and continually overrun.
2.4 Whilst the above measures have generally improved patient care
and are service improvements which are likely to expand in the future,
there remains a need to significantly expand the consultant workforce.
Reducing the service
2.5 An alternative option to expanding the medical staff establishment is
to reduce the service. This does not appear to be a viable option as local
providers do not have the capacity to absorb additional activity and it does
not comply with either the Cancer Reform Strategy or RUH key objectives.
Author: John Travers, Divisional Manager
Date: September 2008
Public Trust Board
3 September 2008
Page 6 of 9
Agenda item 11.4 - Appendix 1
3
Commercial aspects – the financial case
3.1 Recruitment to this post will be by normal RUH recruitment process
and therefore poses little risk.
3.2
4
This post should have no financial or service impact on other
departments.
Affordability – the financial case
4.1 It is proposed that until full funding becomes available that this
business case is taken forward in two stages:


Stage 1 – recruit to consultant post only
Stage 2 – recruit the necessary support staff when full funding
identified
I
COST FYE 2008/9
Stage 1
Description
Gross
Cost
Consultant
Removal Expenses
Travel & Training
Advertising / Set up
Total Cost
No. WTE Recurrent
of
PA’s
£
1
102,668
Non
Recurrent
£
Total
8,000
1,500
104,168
2,000
10,000
114,168
COST FYE 2008/9
Stage 2
Description
Gross
Cost
Radiographer – band 6
Nursing support
A&C 3 Secretary
Total Cost
No. WTE Recurrent
of
PA’s
£
1
35,222
0.5
20,004
0.5
9,603
64,829
Author: John Travers, Divisional Manager
Non
Recurrent
£
64,829
Date: September 2008
Public Trust Board
3 September 2008
Page 7 of 9
Total
Agenda item 11.4 - Appendix 1
4.2 An oncology review paper has been presented to PCTs for discussion
explaining the rational for increased investment in Oncology services. The
stated investment need is c£2.6 million of which some c£0.45million is
likely to be increased income.
4.3 Work is also ongoing to understand the block contract income for
Chemotherapy and Radiotherapy and there is an assumption that the RUH
is currently underfunded for these services.
4.4 BaNES PCT have made a firm offer of £75,000 for the 208/09
financial year. It is anticipated that there will be further funding available
in this financial year and next from both Wiltshire and Somerset PCTs.
4.5 It is proposed that the current locum consultant post (without the
support staff costed above) is made substantive. The Clinical Specialty
and Support Services Division will fund the balance between the £75,000
offered and the cost of the substantive post, until such time as full funding
becomes available.
4.6
Once full finding is available the support staff will also be required
SIGN OFF
Board Manager
John Travers
Date
15/08/08
Board
Accountant
Sara Wellings
Date
15/08/08
Board Chair
Lindsay Grant
Date
15/08/08
Lead Clinician
Chris Knechtli
Date
15/08/08
Other Managers/Clinicians (as applicable – e.g. Support Services, Pharmacy - as implicated
in service proposal)
Service/Department
Date
Date
Author: John Travers, Divisional Manager
Date: September 2008
Public Trust Board
3 September 2008
Page 8 of 9
Agenda item 11.4 - Appendix 1
Finance Director
Date
Author: John Travers, Divisional Manager
Date: September 2008
Public Trust Board
3 September 2008
Page 9 of 9