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Cancer Contributions to QIPP

Cancer Contributions to QIPP. Dr Janet Williamson National Director, NHS Improvement The Beeches Conference Centre, Birmingham 4 November 2010.

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Cancer Contributions to QIPP

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  1. Cancer Contributions to QIPP Dr Janet Williamson National Director, NHS Improvement The Beeches Conference Centre, Birmingham 4 November 2010

  2. “We must keep a relentless focus on improving quality and productivity. The QIPP programme and the need to achieve £15 - £20 Billion inefficiency savings by 20/03/14 are now more pressing than ever. We need to build on the excellent planning work you have all done”. Sir David Nicholson, NHS Chief Executive 2010

  3. Political Context for Cancer • Election Campaign (April 2010) – cancer featured prominently in Leader’s debate • Coalition Government agreement (May 2010) • White Paper: Equity and Excellence – Liberating the NHS (July 2010) • Announcement of Cancer Reform Strategy ‘Refresh’ • To be completed by Winter 2010 • Emphasis on improving outcomes

  4. Equity and Excellence: Liberating the NHS • Key messages • Information and choice: ‘No decision about me without me’ • Emphasis on outcome measures, not process targets • Commissioning: NHS Commission Board and GP consortia • Ring fenced public health budget

  5. Aims of ‘Refreshing’ the Cancer Reform Strategy To align cancer strategy with the White Paper To set the direction for the next 5 years – taking account of progress since 2007 To show how outcomes can be improved despite the cold financial climate

  6. Last 15 years: Huge investment in quality, equipment, manpower and redesign in cancer • Prevention: screening • Care: cancer waits, access, centralisation surgery new drugs • Clinical infrastructure – MDTs networks, clinical teams, facilities Mortality reduces by 2% pa under 75s

  7. Gap in service provision remains … • Early Diagnosis • 10,000 avoidable deaths p.a. • Survivorship • Over 3 million survivors • Service provision based in OPD • Inpatient – increasing emergency admissions (52%) • 14,000 occupied bed (60% non elective • Inequalities – variations UK wide

  8. Where the difference can be made • How many trips to the GP before diagnosis? • Why do 40% blood samples have defects? • Why does a woman needing breast surgery for cancer stay in hospital for 6 days when 23 hours is available? • Over 12 weeks from smear to result in hand for a test that takes 5 hours to process.

  9. Rationale • Patients do not wish to be in hospital more often or longer than necessary • Bed utilisation in England for cancer patients is higher than elsewhere • Inpatient care accounts for around half of all cancer expenditure • Inpatient bed utilisation varies widely between PCTs (even when cancer incidence has been accounted for) • We need to improve productivity if we are to introduce new life saving technologies

  10. If all cancer services adopted the winning principles &the key improvements this can save a million bed days

  11. Variation in mean LOS and activity by provider. Total excision of breast (B27) • Most providers have a mean LOS between 1 and 7 days. • Providers of few cases have been omitted.

  12. Day Case/23 Hour Breast Surgical Pathway • Primary care – optimising pre- • operative health • Blood pressure • BMI, diabetes etc. • Lifestyle advice • Patient choice • Patient information • **Pre-operative surgical assessment • Full clinical & risk assessment eg thrombolysis prophylaxis • Default booking as day case – overnight booking as the exception not the rule • Specialist advice… anaesthetic/co-morbidity management • Check patient informed surgical consent • Inform patient of admission time, length of stay & discharge date • Patient education: self management e.g. arm mobility exercises - physiotherapist/nurse/DVD • Prosthesis advice/fitting • Prescribe TTO’s • Plan theatre scheduling and timing • Intra-operative • Drains the exception not the norm • Anaesthetics: short acting/ local anaesthetic • Analgesia: non steroidal/non opiate • Minimal intra operative fluids • *Sentinel node Biopsy • Surgical follow-up options • No follow up required • Patient activated e.g. telephone call/questionnaire • Pro-active follow up call • Outpatients appointment • GP follow-up • Open Access: seromas/drain management and complications • Joint clinic: e.g. • further treatment options: chemotherapy/radiotherapy • Palliative care 7/10/2010 • Continuing care for cancer patients • Continuing cancer care assessment care plan (including referral as appropriate to AHPs) • Education – self care management programme • Palliative care • Post-operative • Analgesia: avoid PCA/opiates • Provide nutrition and mobilise • Nurse led discharge • Patient discharge summary with 24/7 contact information and wound care advise • Discharge day case (85% of patients) • 23 hour discharge (1 night stay, 15% of patients) • GP discharge summary • Drain management information (if required) • Fitting permanent prosthesis • Dispense TTO’s • Admission (Day Unit, Treatment Centre, Surgical Ward) • Admit day of surgery • Starvation – the ‘2 and 6’ rule • fasting time 6 hours for food and • clear fluids 2 hours prior to surgery (consider carbohydrate drink) • No pre med • Pre-op analgesia (paracetamol/ • non steroidals) • Diagnosis(Triple Assessment Clinic) • Full clinical assessment • Mammogram/ultrasound/ +/-MRI +Chest X-ray • Core/fine needle biopsy • Bloods • Discuss informed consent • Pathology reporting • Outcomes • Discuss results • Involve patient in choice of treatments/trials/reconstruction • Obtain patient informed surgical consent • Confirm treatment/surgery date • ** Pre-operative assessment • Provide patient information prescription, hand held record/care plan/patient diary • Inform patient of next steps • Inform GP positive results within 24 hours/negative within 10 working days *Intra-operative - Sentinel Node Biopsy: In centres where adequate training has been provided. Extra theatre time e.g. 40mins is required for this procedure **Pre-operative - Surgical assessment at diagnosis clinic or minimum 7 days prior to surgery ‘Patient involvement & Choice Guarantee’ ‘Professional & Patient Outcome Audits’  Patient informed decision making

  13. Supporting Spread: www.improvement.nhs.uk

  14. Transferring the lessons from Birmingham An exemplar in improvement

  15. 13 National Clinical Spread Networks Lancashire & South Cumbria Humber & Yorkshire Merseyside & Cheshire Greater Manchester East Midlands Pan Birmingham Anglia Arden North London Three Counties Thames Valley ASW South West London

  16. Potential for Breast Day Case/23 Hour Model • National average Los 2.8 days (HES 09)= 95,200 bed days • Approx 34,000 new case registered per annum • 1 day stay = 34,000 bed days

  17. Cytology screening • 14 day standard delivery by end 2010 (baseline 12 weeks+) • Delivery of standard requires: • Understanding of process and redesign • First in, first out principles • Single queues • Small batches • Daily problem resolution

  18. The Result (QIPP) across 10 pilots • Q. 100% delivery of the 14 day standard • 80% in 7 days • I. New processes • P. £100K savings per site • 14% re-work eliminated • National impact £18million per annum

  19. Cytology : Phase 1 Turnaround position

  20. Sample taken in primary care Result received by patient Report issued from lab Processing and printing Laboratory Test Result issued by call/recall agency Time taken to reach laboratory Laboratory process- Liquid based cytology End to end TAT- 14 day max Training of smear takers Inconsistent use of NHS numbers Transport-delivery times/ routes Left at surgery Incorrect info/ demographics Illegible forms Missing/wrong smear taker codes 25% out of scope samples Skill mix/ staffing Processor down Data entry issues Over- printing labels Double look-up/ printing from open-exeter Matching forms/slides Writing on forms Excessive checks Backlogs Morale Sending out processing/screening Returned samples/cards Report running weekly Non-matches Enveloping- leaflets Postage ‘Abnormals’ sent out by GP Route to Colposcopy (direct referrals) Manual checking of electronic data Print jobs not believed Other IT issues Multiple results centres across PCT’s 5 hours 30 minutes value added time

  21. Innovation ‘The best way to improve services is through healthy plagiarism’. National Clinical Lead, Heart • Diffusion of innovation is critical • ‘Adaption’ not adoption is central • Open networks not closed alliances • No need to totally reinvent wheel • Define in terms of value added • Headspace for innovation • Defining ‘What to do’ and ‘How’

  22. The biggest enemies of improvement are: • ‘Not invented here’ • ‘We don’t work like that’ • ‘It’s easy for them. They have 6 nurse specialists and a couple of GPwSI.’ • ‘We can’t do more work without more staff/ equipment’ • ‘Jumping straight to solutions’ • ‘Not taking time to understand the process’ Source National Clinical Leads NHS Improvement

  23. The big opportunities • Early diagnosis and prevention • New models of care • Long term conditions • Self and supportive care • Transforming ‘inpatients’ • Diagnostics

  24. How quality can save money…… www.improvement.nhs.uk

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