Early Awareness and Diagnosis

Roy McLachlan, NECN Director

May 2011

Structure

• Awareness and Earlier Diagnosis – the challenge

• Analysis of Significant Event Audits• National and Local Primary Care Audit• Using Lean Methodology Kaizen Events

– Kaizen events with General Practices– Kaizen event with City Hospitals Sunderland

• Questions

Improving outcomes: A strategy for Cancer

level of ambition

“Our aspiration is that England should achieve cancer outcomes which are comparable with the best in the world”

“ We believe that by 2014/15, 5000 additional lives can be saved each year. It is now for the NHS, working with PHE (Public Health England) to deliver this ambition”

Note: The “additional 5000 lives” will require England to match the European average. Approximately 10,000 additional lives would be saved if England was to match survival achieved in Sweden (and Australia and Canada)

From this….

Lancashire and South Cumbria

Greater Manchester & Cheshire

Merseyside & Cheshire

Yorkshire

Humber & Yorkshire Coast

North Trent

Pan Birmingham

Arden

Mount Vernon

North West London

North London

North East London

South East London

South West London

Peninsula

Dorset

Avon, Somerset & Wiltshire

3 Counties

Thames Valley

Central South Coast

Surrey, West Sussex & Hampshire

Sussex

Kent & Medway

Greater Midlands

North of England

Anglia

Essex

East Midlands

-20

-15

-10

-5

0

5

10

15

20

-10 -8 -6 -4 -2 0 2 4 6 8 10

Cancer networks with lower mortality (below England level)and large reduction in mortality (above England level ) since 1997

Larger % change

in mortality

rates (above

England level)

Low mortality (below England level)

High mortality (above England level)

Smaller%

change in

mortality rates

(below England

level)

Cancer networks with higher mortality (above England level)and smaller reduction in mortality (below England level ) since 1997

Relative change in mortality rates and the level of change in mortality rates since 1997 (compared to England level) by cancer network.3 year rolling age-standardised mortality rates (2007-2009) for all cancers for 0-74 years age group; % change in mortality rates since 1997

……to this

Relative change in mortality rates and the level of change in mortality rates since 1997 (compared to England level) by cancer network.

Predicted 3 Year Rolling Average (2012-14) - All Cancers - 0-74; % Change since 1995-97

-20

-15

-10

-5

0

5

10

15

20

-20.00% -15.00% -10.00% -5.00% 0.00% 5.00% 10.00% 15.00% 20.00%

Low Mortality - below England Level

High Mortality - above England Level

Lower % change

in rates - below

England Level

Higher %

change in rates - above

England Level

Analysis of Significant Event Audits for diagnosis of lung cancer &

cancers in young people Aim• The main aim of this study was to gain insights into the events that

surround the diagnosis for these two cancers• General Practices from the North East of England were invited to

participate, recruited by Local NHS cancer leads • The 92 practices  involved were invited to record clinical details on

the last patient diagnosed with lung cancer(132 SEA returned) and with cancer TYA, aged 15-25 with 35 SEA

• Participating practices were provided with electronic templates to record their SEA based on a structure recommended by the National Patient Safety Agency

Significant Event Audit continued

Key factors identified by GPs as essential to the process of recognition & referral:

– Having systems in place within the practice to deal with abnormal results

– Having continuity of care within the practice where possible– Having mechanisms in place to follow up, manage and refer

non-resolving symptoms– Considering negative/benign CXRs for the appearance in

context, as these do not exclude the possibility of lung cancer– Having an appropriate consulting style that allows young people

to feel comfortable enough to explain their symptoms

RCGP/NCAT Cancer Diagnosis Audit in Primary Care

• The audit tool was developed in response to the Cancer Reform Strategy and with support from the National Cancer Action Team. Those contributing to its development included primary care cancer leads and academic GPs who are researching issues of early diagnosis. The work was done under the aegis of the Royal College of General Practitioners

• Aims of using the audit tool – To identify any potential groups of patients or tumour types

which are particularly vulnerable to delay– To use the findings to plan interventions to improve early

diagnosis for cancer patients– Contribute to a national picture of causality of delays

National Cancer Audit in Primary Care

NECN aims in participating in the audit were:

– To identify any delays in patient pathways– To identify any potential groups of patients or tumour types

which are particularly vulnerable to delay– To use the findings to plan interventions to improve early

diagnosis for cancer patients across North of England Cancer Network

– To ensure that the findings inform commissioning intentions

NECN primary care audit findings

Issues• Repeat Chest x-ray for suspected lung cancer required further thought

and action • The 2 week wait referral criteria did not always fit a patient presentation • Co morbidity often masked underlying cancer • Negative investigation results delayed diagnosis

Learning • The 2 most important learning themes identified by almost all practices

were:• GP’s are required to be far more vigilant in their suspicions of

cancer even when clinical symptoms did not quite fit, the initial investigations were negative and/or the patient had co morbidities that might mask underlying cancer.

• Communication within the practice is vital.  In some cases referral was delayed as a result of a patient seeing several different GP’s within a practice over a period of time. 

Kaizen Events

A Kaizen event is:

• A rigorous two day event that eliminates waste and improves flow through the redesign of ineffective processes

• The team members and the home teams are empowered to make the changes that are needed

Kaizen events – 3 x Practices, Sunderland

Aim:

To reduce the Lead time from GP referral for chest x-ray to GP receipt of x-ray report. To improve communication. To reduce the number of process steps in the process

NHS South of Tyne and Wear Key FindingsNHS South of Tyne and Wear Key Findings

City Hospital Kaizen

Background:

• Kaizens in January/February 2010• Parking lot, including CXR reporting• Problems with current pathway and turnaround of radiological tests• June 2010 TITO – CXR reporting• Highlighted by GP survey, GP audit and current performance

Key changes and impact

• Remove dual paper and IT systems• Single level of referral for CXR• Consultant rota and reporting arrangements• Removal of backlog• Apply to all GP plain films not just CXR• Reports available on HISS• ICE and paper reports• Process and value stream maps

X-ray request to Report Value Stream Map Future State

CT

VA

NVA

%VA

CT

VA

NVA

%VA

CT

VA

NVA

%VA

CT

VA

NVA

%VA

CT

VA

NVA

%VA

CT

VA

NVA

%VA

CT

VA

NVA

%VA

CT

VA

NVA

%VA

GP request

(signed)

Pt attends

for x ray

CHS receives

paper work

Start dictation by Consultant

“Draft”

report on HISS)

“Signed” report on

HISS

Date report printed

Lead Time:

Report available to GP

1 1wd 1 0

3 days

EMIS, HISS and ICE

• Possible use of EMIS referral forms• Read coding for analysis and safety netting• Regular accessing of HISS• Programme to roll out ICE

Summary

• Solution generated by working together• Right people round the table• Extension to all plain films• Service improvement need not cost• Reports available on HISS• Methodology applicable across sectors

What’s coming up?…

• General Practice Profiles on Cancer• National support• Be Clear on Cancer Campaign• Partnership with Macmillan• Annual Conference

Be Clear on Cancer – national

materials

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