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QA Director’s Update & NHS reforms

QA Director’s Update & NHS reforms. Dr Linda Garvican QA Director, Cancer Screening Programmes, NHS South East Coast. NHS. Cancer Screening Programmes. Screening and NHS reforms. National Screening Programme Teams  Public Health England Julietta Patnick, Director of Cancer Screening

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QA Director’s Update & NHS reforms

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  1. QA Director’s Update &NHS reforms Dr Linda Garvican QA Director, Cancer Screening Programmes, NHS South East Coast NHS Cancer Screening Programmes

  2. Screening and NHS reforms • National Screening Programme Teams  Public Health England • Julietta Patnick, Director of Cancer Screening • Anne Mackie, Director of UK National Screening Committee [all non-cancer screening programmes, and screening policy] • Roles and responsibilities • Quality assurance and standards • New programme implementation • Service specifications • Commissioning Screening Programmes • Established programmes: National Commissioning Board • New programmes: Public Health England NHS Cancer Screening Programmes

  3. Local Public Health involvement in screening • No Regional Director of Public Health • Director of Public Health in local authority/PHE • No longer in NHS • Health and Wellbeing Boards • Need for some local public health leadership • Practical local implementation issues • Serious incidents • Cancer screening QARC • Funded by PHE or fully integrated?

  4. Cervical screening 1 14 day turnaround • Sample taking in primary care to result letter posted first class on day 13 • 98% target set out in Improving Outcomes – a Strategy for Cancer • Sustainability in smaller labs… • Sussex Pathology Network: centralised hub in Haywards Heath? • West Surrey Pathology Network: Merger of ASPH pathology service and Partnership Pathology? • Even more laboratory consolidation in Kent and Medway?

  5. Achievement of 14 day turnaround

  6. How sustainable?

  7. Cervical screening 2 Introduction of HPV Testing • Triage of low grade abnormalities, from 2011/12 • ‘Test of cure’ for treated women from 2012/13 • Several automated technologies, using the LBC sample • Sentinel sites used Hybrid Capture 2 • High volume throughput required for cost effective use of controls

  8. Triage All borderline or mild Result within 14-day turnaround HPV +ve Straight to colposcopy HPV –ve Routine recall in 3/5 years Test of cure Cytology 6/12 post treatment HPV +ve Straight back to colposcopy HPV –ve Routine recall in 3 years No annual follow- up for 10 years Implications

  9. Commissioning HPV testing • Announced 15 December 2010 in NHS Operating Framework 2011/12, and in Improving Outcomes: a Strategy for Cancer in January 2011 • No details on costs or rules of engagement available • Still PCT responsibility to commission screening for 2011/12 • No new money… • Deadline for PCT’s operating plans for 2011/12 in early January  • Missed the boat for new financial year… But • There is national funding for 2 years from April 2011: • Year 1 - £2 per sample screened • Year 2 - £1 per sample screened • All within programme samples: GP & community, clinic, hospital, GUM – not just HPV tested ones, not under 25s and not non NHS • Pro-rata from start date • Includes costs of testing and additional colposcopy

  10. NAT COLP QA • Workload changes in Colposcopy After HPV • Units seeing pts – 2 mild / 3 borderline • = 120 extra colp / 10000 screened • Units seeing – 1 mild / 3 borderline • = 64 extra colp / 10000 screened • Test of cure – expect 20- 26 % HPV +ve at 6/12 • Extra 12% workload due to cyto –ve/HPV +ve

  11. Criteria to bid for national funding • Laboratory must have a minimum workload of 35000 • The programme must continue to comply with 14 day turnaround • Colposcopy capacity must be sufficient and sustainable • HPV testing must be subject to QA and EQA • There must be a Pathway Manager – one lead person for each programme with whom National Office and other parties will liaise • Sign off will be by QA and the PCT(s) (not SHA) • National Office will contract with each laboratory for HPV testing through an SLA. Labs will be expected to sub-contract for additional services such as colposcopy and virology and pass on the appropriate portion of funding to those services

  12. National ‘to do’ list • Evaluation Report, & Advice to the NHS – from DH in May 2011 • Implementation Guide • Primary Care Pack • Patient materials – letters & leaflets • Revised NHSCSP guidelines – ABC, Colposcopy & Histopathology • Evaluation of different technologies • NHS Supply Chain Framework Agreement (Procurement must be subject to the European Procurement Tendering Process)

  13. What we need to do in next few months • Formally merge laboratories to reach >35,000… • Develop bids • Consider technology platforms (but prices won’t be available until September) • Address colposcopy capacity issues • Re-write local protocols • Adopt national template leaflets • Educate primary care/sample takers • Identify a Pathway Manager in each laboratory • Amend laboratory systems to cater for new result & action codes

  14. New DH standard Acute Contract from April 2011- implications for cancer screening • Cancer waiting times • 62 day target for screen detected cancers must be met in 90% of cases, cf 85% for symptomatic 2WW • 31 day targets for • First definitive treatment (96%) • Second and subsequent treatments • Surgery (94%) and drugs (98%) • Radiotherapy live from 1 January 2011 (94%) • Breaches of all cancer waits will incur below target levels will incur fine to Trust of 2% of ‘Actual Outturn Value of service line revenue’ • Staging data: • Mandatory inclusion in dataset sent to Cancer Registry • Need to ensure recorded at gynae MDM

  15. Training sample takers • New training scheme organised by SECQARC • Quality-accredited by Universities of Brighton & Surrey • More course planned for 2011 • On-line update scheme • Takes about 1 hour • Updates on changes to programme and what to tell women • Uptake of e-learning high in Kent & Medway but more work needed to raise awareness in Surrey & Sussex • Content reviewed annually - will now need to include HPV testing • BMJ Learning: 6 free CPD modules on cancer screening http://learning.bmj.com/learning/modules.html?action=listLatestModules

  16. No news on… • Revised protocol for invasive cancer audit • Audit of experiences of young women (<30) with cervical cancer • Next QADs meeting 5 May

  17. NHSCSP Audit of Invasive Cervical Cancer, National Report, 2007-2010 DRAFT • 6,173 cases of cervical cancer and 21,481 controls, • 90% overlap with cancer registry data • Approximately 80% of all cases within screening age-range (25-64). Peak number in women aged 35-39 • 23% of cases had no stage recorded in audit • 45% of cases in women aged 25-64 are diagnosed with FIGO Stage 1A and 73% of these are treated by cone biopsy. • 60% of women > 65 with cervical cancer are FIGO Stage 2 or worse. • About three quarters of cervical cancers are of squamous histology.

  18. Attempt to classify women’s screening histories • 28% of cases with invasive cervical cancer stage 1A and 28% of those with stage 1B or worse occurred despite apparent adherence to screening guidelines (i.e. their screening history is up to date). • Much higher proportion of population controls complied with the screening guidelines (60%) than cases (28%). They were also more likely to have been screened (13% of controls had no screening history compared to 17% of cancers stage 1A and 23% of those stage 1B+).

  19. Colposcopy in ICA • Colposcopy data ‘particularly challenging to collect and the variability in the quality of the data included in this Audit has made its interpretation challenging’ • Colposcopy data is of particular interest in women who had a cytology test indicating referral to colposcopy more than 4 months before diagnosis, because it suggests a recurrence of a previously treated cervical abnormality or delay in the diagnostic procedure. • While 69% of all cervical cancers in the Audit had cytology with an action code of suspend, only in 21% (1290 cases) of them was the cytology taken more than 4 months before diagnosis. Complete colposcopy data on this subset of casesis essential to evaluate colposcopy management as part of the Audit.

  20. Trent Cancer Registry / NCIN / NHSCSP publication • Incidence has halved and mortality decreased by 2/3 in 20 years • Incidence reduction has levelled off in recent years • North/south divide in both incidence and mortality by SHA and cancer network • Poorer incidence and mortality associated with deprivation in PCT of residence • Some improvement in survival from mid 1980s • 82% 86% at 1 yr • 62-68% at 5 yrs

  21. Map of incidence by cancer network, 2004-8

  22. Mortality by cancer network, 2004-8

  23. Young women • Incidence in women aged 25-29 increased by 77% between 1998 and 2008 • Incidence in women aged 30-34 increased by 29%... • Mortality in these age groups stabilised… • Relative survival much worse in older women: • 1 year: 96% at 15-39 cf 52% aged >80 • 5 year: 86% at 15-39 cf 27% aged >80

  24. Mortality by age

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