Achievement of Cancer Waiting Times Standards
1.
Introduction
This paper sets-out the issues that have been identified in meeting the current cancer waiting
times standards, and what actions are being taken to ensure compliance with these standards is
maintained. The paper also details the actions being taken to implement the new cancer waiting
times described in the Cancer Reform Strategy as part of “Going further on Cancer Waits”, and the
recently announced adjustments to the way cancer waiting times will be measured in the future.
2.
Background
The NHS Cancer Plan published in September 2000 first introduced three specific cancer waiting
times standards. This commenced with the Two week wait for GP referral for specialist opinion for
a suspected cancer, moving through both diagnostic and treatment pathways with the 62-day
urgent GP to first treatment, and the 31-day decision to treat to first treatment standards.
In December 2007 the Cancer Reform Strategy was published which mandated a series of
extensions to these existing waiting times standards including:
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A maximum two month wait from referral from a cancer screening service to first
treatment for all cancers (December 2008)
A maximum two month wait from a consultants decision to upgrade the urgency of a
patient they suspect to have cancer to first treatment for all cancers (December 2008)
A maximum one month wait for all subsequent treatments for new cases of a primary and
recurrent where an anti-cancer drug regimen or surgery is the chosen treatment modality
(December 2008)
A maximum two week wait from referral for general breast symptoms (where cancer is not
suspected) to date first seen (December 2009)
A maximum one month wait for all subsequent treatments for new cases of a primary and
recurrent where radiotherapy is the chosen treatment modality (December 2010)
A maximum one month wait for all subsequent treatments for new cases of a primary and
recurrent for all treatment modalities (December 2010)
The definitions for the measurement of these new standards were received at the end of
September 2008. In addition to these, adjustments were announced at the same time, as to the
way existing cancer waiting times are measured, to bring these in line with the national rules for
18-week Referral to Treatment time measurement.
3.
Operational challenges
An action plan has been developed to address the three key areas of focus: a) achievement of
existing targets; b) implementation of the new cancer standards; c) addressing pathway problems
resulting from changes to the measurement rules. The following sections outline the challenges
identified and conclude with an overview of the actions being taken to address these issues.
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a)
Achievement of existing targets
During recent months the performance against both the 31 and 62-day target has fallen below the
national thresholds. At the end of September (most recently reported month), year-to-date
performance against the 31-day target was 97.2%, and the 62-day target 93.1%. Performance
against the 31-day standard has improved, with draft figures for both October and November
being at the required 98% standard. But challenges remain in achieving the 62-day target.
A review of the breaches of standard has demonstrated that problems exist in a relatively small
number of tumour sites, but also that the majority of breaches fall into three main types. These
are summarised as follows:
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b)
Surgical delays – due to a lack of theatre capacity, inability to utilise theatre capacity due to
bed related cancellations and the prioritisation of urgent cases from other trusts
Diagnostic Delay – Long delay for PET scans across the network (prior to contract being
agreed for the mobile scanner sited at the Trust)
Delayed Tertiary referrals – patients referred greater than day 41 in the pathway (allowing
less than three weeks for in many cases both diagnostics and treatment)
Implementation of new waiting times standards
As noted in the background the first of the expanded cancer waiting times targets will come into
effect from the end of December 2008. Whilst the standards were outlined in the Cancer Reform
Strategy back in December 2007, the operational definitions and dataset were not published until
the end of September and thus work undertaken to identify the impact of the new standards
undertaken prior to this take had to be based on “guestimates”.
The implementation of the extended targets will not only be challenging in those areas who are
already experiencing significant capacity issues (colorectal and thoracic as an example), but also in
those areas for which the impact analysis has demonstrated a high level of demand from
recurrence, such as in skin cancer, bladder cancer and hepato-biliary (HPB) tumours.
c)
Changes to the measurement rules
Included in the new cancer waiting times dataset are changes to the ‘adjustment’ rules to align
these with the rule-set for measurement of 18-week Referral to Treatment Times. This rule change
was announced at the end of September and will have a significant impact on the Trust
performance against all current, as well as new, targets. It is acknowledged by the Department of
Health that there will be a negative impact on achievement of waiting times, and it has been
indicated as a result the thresholds for existing target achievement will be reduced. But, the new
thresholds will not be known before the go live date for the new rule changes come into effect on
the 1st January 2009. It has been indicated therefore that these will be set (retrospectively)
following the submission of three months of data from all organisations. Broad indications have
however been given that the same thresholds for achievement as for the 18-week wait will be
applied (i.e. 90% for admitted and 95% for non-admitted pathways).
As part of the new rule-set, adjustments will no longer be able to be made for patients rescheduling appointments or diagnostic tests. In addition, waiting times cannot be adjusted if a
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patient is not fit for the intended medical treatment, for example when a patient has a comorbidity and treatment cannot progress until a patient has been treated for their underlying
condition. Adjustments to waiting times will now only be able to be made if the:
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patient does not attend (DNA) there first two-week wait appointment
patient chooses to delay their treatment but only if being delivered in the inpatient setting
(i.e. is an admission)
The following table summarises the impact the adjustments will have on our current trust
performance.
2ww
31 day
62 day
Current Threshold
98%
98%
95%
Current Performance
98.9%
95.5%
91.8%
New adjusted Performance
90.3%
91.6%
75.3%
(N.B. Current performance varies from those figures noted earlier in the document as for these calculations were
performed prior to September’s data being finalised and submitted to the Department of Health)
4.
Action Plan
It is clear from the above summary of information we have some significant challenges ahead to
ensure performance against existing standards is restored, and the new cancer standards are
achieved. The following actions have been taken and will be taken under the following workstreams:
Performance management
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Cancer Implementation Group to meet weekly, to monitor performance, review breach
reports and confirm agreed actions have been taken (complete)
Weekly reports to be produced detailing current and projected performance (complete)
High risk patients to be monitored via weekly Divisional Primary Targeting List (PTL)
meetings (complete)
Implement joint PTL review with member of clinical team for high risk areas (complete)
Breach reports to be completed on a weekly basis by each Divisional lead, using the new
breach report template (complete/continuing)
Breach reports for patients referred by other trusts to be copied to the referring provider
(December)
Awareness and engagement
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Implications of new targets to be discussed at all Divisional Boards, professional
committees and the Trust Executive Group (continuing)
Training sessions to be held for clinical and non-clinical staff (continuing)
Standard presentation on the cancer standards and changes to measurement rules to be
made available to all staff (complete)
Data Capture
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Confirm and implement the process by which Multi-Disciplinary Team (MDT) co-ordinators
capture and record information within cancer register on subsequent cancer treatments
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Validate ‘old’ data held on the cancer register for patients who were treated, or pathways
commenced, in 2008
Implement the software enhancements to the cancer register once these have been
released (expected December)
Provide each MDT with a “how to capture” guide for using the cancer register (November)
Implement ‘live’ data collection, via the cancer register, across all MDTs (December)
Capacity planning / pathway improvements
 Identify ongoing capacity requirements for challenged specialities e.g. Thoracic surgery –
Lung (continuing)
 Identify capacity required for high risk areas for new targets (i.e. Skin, Urology, HPB)
(continuing)
 Agree plans for increasing in capacity for above specialities (to be confirmed)
 Re-map the Lung Cancer Pathway against the agreed network pathway to ensure clear
internal processes (November)
 Fully implement the pathway reporting system by reporting timelines against the agreed
network pathways (December)
 Review all pathways to ensure they cover further treatments / follow up plans (continuing)
5.
Recommendation
Achievement of the existing cancer standards has in part been impacted by a number of different
factors, including the difficulties faced by increasing levels of elective and non-elective demand
over the last year. Challenges also remain in the achievement of the new cancer standards, and
the implementation of the new measurement rules. The Trust Board are asked to note the actions
being taken and support the work in progress.
Prepared by: Teresa Levy (Cancer Service Manager)
Xanthe Whittaker (Head of Performance Improvement)
Presented by: Irene Scott (Chief Operating Officer)
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