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A case for improving cancer services in London?

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  1. A case for improving cancer services in London? Healthcare for London cancer project 23 November 2009

  2. Welcome and objectives of the day Bill Gillespie Chief Executive, Sutton and Merton PCT Senior Responsible Officer, Healthcare for London cancer project 23 November 2009

  3. Introduction Project aims: • drive up quality across the whole patient pathway and improve outcomes • enable coherent developments in the provider landscape in line with the Healthcare for London vision • ensure we pursue and realise all opportunities to utilise resources efficiently and improve productivity levels

  4. A case for improving cancer services in London? Healthcare for London cancer project 23 November 2009

  5. Cancer in London:A national perspective Professor Mike Richards November 2009

  6. Cancer in London: A national perspective Overview • How does England compare with other countries on cancer? How near are we to “world-class”? • How does London compare with the rest of England? • What are the key challenges for London cancer services?

  7. What would world-class look like? (1) Primary outcomes • Incidence Low • Mortality Low • Survival High • Health and well being of survivors High • Experience of care of cancer patients High

  8. What would world-class look like (2) Secondary measures • Healthy lifestyles (effective action on smoking, obesity etc.) • Comprehensive screening services with high coverage • Early diagnosis of symptomatic patients • Well organised and coordinated services (e.g. MDTs) • High quality treatment (surgery, radiotherapy, chemotherapy) • Personalised information, support and rehabilitation • High quality end of life care • Cost-effective use of resources

  9. Cancer survival in the 1990s

  10. Where are we now? Primary outcomes

  11. Where are we now? Secondary measures (1) • “World-class” (but NB room for improvement) • Tobacco strategy • Screening services • Establishment of MDTs • Centralisation of complex cancer surgery • Recruitment to clinical trials

  12. Where are we now? Secondary measures (2) • “Solid progress” • Diagnostics • Cancer waits • Surgical training • Radiotherapy services • Chemotherapy services • Patient information • Communication skills training • Cancer intelligence (NCIN)

  13. Where are we now? Secondary measures • “Early days” • Late diagnosis • Inequalities • Survivorship • Transforming inpatient care

  14. Late diagnosis • Almost certainly accounts for much of the gap in survival between the UK and other Western countries • 10,000 ‘avoidable deaths’ if England matched the best in Europe • One year survival rates poor (cf. Sweden) in almost all PCTs in England • Early diagnosis has to be a priority

  15. How does London compare with the rest of England (1) • London has a lower incidence of cancer, largely due to a markedly lower age profile • London has around • 15% of the population (7.5m/50m) • 12% of new cancer cases (27k/230k) • 11% of cancer deaths (13.6k/125k) • London has a very high BME population

  16. How does London compare with the rest of England (2) • London has relatively more hospitals than other parts of the country (therefore smaller average throughputs) • Overall cancer mortality rates for Londoners are similar to England as a whole • However, there are marked inequalities in cancer outcomes within London – from the best to the worst in England

  17. How does London compare on secondary measures (1) • Screening coverage: Very poor • Late diagnosis of symptomatic patients: • Poor one year survival rates cf. Europe(but this is a widespread problem in England) • MDT working: ? Analysis of peer review data • Surgical volumes: Generally low

  18. How does London compare on secondary measures (2) • Radiotherapy and chemotherapy: Regrettably no comparative data, as yet • Participation in national clinical audits: Relatively poor • Cancer bed utilisation: Relatively high • Patient experience: Poor • Place of death: Hospital deaths high

  19. Late diagnosis in 31 London PCTs

  20. Bed utilisation in 31 London PCTs

  21. Key challenges and questions for London on cancer (1) • Late diagnosis • If there are 10,000 avoidable cancer deaths pa in England, at least 1000 of these relate to Londoners • Late diagnosis (screening and symptomatic) is almost certainly the single largest factor. This requires action at community and primary care levels • How might we best use polysystems?

  22. Key challenges and questions for London on cancer (2) • Service configuration • Are there too many small and unsustainable MDTs for common cancers? • How can we provide good access to specialist assessment across London? • Outreach MDTs? • How can we ensure adequate critical mass for surgery? • ?In reach surgery?

  23. Key challenges and questions for London on cancer (3) • Quality and Productivity • Avoiding unnecessary admissions and shortening lengths of stay is good for patients and for the NHS • Nationally, we aim to ‘save a million bed days’ (equivalent to 2750 beds at 100% occupancy) • Maybe London should aim to save a 100,000 bed days (equivalent to 275 beds) • How? • Enhanced recovery: Elective surgery • Ambulatory care services • Acute oncology

  24. Summary • London could do a lot better on cancer • Radical change will be needed to save 1000 lives and 100,000 bed days pa • You have my full support

  25. A case for improving cancer services in London? Healthcare for London cancer project 23 November 2009

  26. Case for change Professor John Toy Clinical Director 23 November 2009

  27. NHS cancer policy • 1995 – Calman Hine report • 1996 – NICE Improving Outcomes Guidance • 2000 – NHS Cancer Plan • 2007 – A Framework for Action • 2007 – Cancer Reform Strategy

  28. Cancer in the UK Age standardised cause of death from malignant neoplasms in comparable developed countries in Europe and the world 1993-2004 Improving survival rates to European standards could translate to an estimated 1,000 lives saved a year in London

  29. Cancer in London Mortality for all malignant neoplasms in all London Boroughs – 2003-2005

  30. Challenges in London • Socioeconomic inequalities • Population growth • Differences in outcomes • Patient experience • Workforce • Fragmentation of services • Provision of specialist services • Research

  31. Cancer project structure The governance arrangements for the cancer project are illustrated below: Clinical Leadership Group London Commissioning Group Cancer expert reference panel Cancer project board Patient panel Rarer cancers Common cancers Early diagnosis Project team Cancer network leads

  32. Early diagnosis

  33. Early diagnosis Public awareness (NAEDI) Poor screening uptake rates Delays in presentation GPs see <10 new cancer patients a year GP access to diagnostics

  34. Common cancers and general care Types of cancers considered: • breast cancer • lung cancer • colorectal cancer • bladder and prostate cancer • skin cancer (melanoma and non-melanoma) • haematology

  35. Common cancers and general care London’s relative survival rates for three common cancers (followed until Dec 2004)

  36. Common cancers and general care Delivery of services: best care as close to home as possible surgery systemic anti-cancer therapy (SACT) radiotherapy multi-disciplinary teams hospital bed days follow-up and support including rehabilitation supportive and palliative care

  37. Rarer cancers and specialist care Types of cancers considered: • Upper gastrointestinal • Rarer urological • Head and neck and Endocrine • Brain and CNS • Gynaecological • Sarcoma

  38. How many providers? There is evidence that worse clinical outcomes are associated with low surgical volumes Achieving minimum IOG volumes is deemed insufficient Concentration of cases can achieve a critical mass of expertise and financial sustainability

  39. Rarer cancers and specialist care Haematopoietic progenitor cell transplantation (HPCT) Molecular diagnostics Specialist Imaging Specialist radiotherapy Specialist care includes:

  40. How many providers? Specialist treatments, technologies and techniques are demanding of scarce resource and expertise Four out of nine adult HPCT units in London are not JACIE accredited High expense requires cost-effective spending

  41. How many cancer networks? Yorkshire – one network Population served = 2.6 million Geographical area = 783 sq/m One cancer centre London – Five networks Population(s) served = 7.8(1.5 -1.8) million Geographical area = 607 sq/m Five (joint) cancer centres

  42. Yorkshire and London

  43. Next challenge Translate the case for change into a clinically robust and affordable new model of care on behalf of London’s patients in a bold and ambitious fashion

  44. A case for improving cancer services in London? Healthcare for London cancer project 23 November 2009

  45. Cancer model of care Professor John Toy Clinical Director 23 November 2009

  46. Themes from the case for change General themes London characteristics Strong commissioning needed based on best practice and latest research Barriers to improvement Early diagnosis Need to diagnose cancer earlier Delay is associated with public behaviour clinical practice infrastructure

  47. Themes from the case for change Common cancers and general care Variation in the services offered to patients Implementation of existing recommendations Localise where possible, centralise where necessary Multi-disciplinary teams can operate more efficiently and effectively Some follow-up is unnecessary Supportive care and palliation services must improve

  48. Themes from the case for change Rarer cancers and specialist care Benefits of centralisation for patients and healthcare system Some rarer services should be centralised Some services are appropriately configured but some improvements remain to be made Specific arrangements necessary for highly specialist services

  49. The current context Healthcare for London: A Framework for Action The Cancer Reform Strategy NICE Improving Outcomes Guidance Productivity and the financial climate The NHS Improvement Plan Fostering innovation and research Academic Health Science Centres

  50. The way forward – emerging ideas There are areas of excellence in London, but not everywhere Treatment and care should be standardised for all patients Learning and best practice should be openly shared Stronger commissioning of high-quality services Organisational boundaries should not create barriers Specialist surgery should be centralised Common treatments and surgery should be localised where possible Locally delivered services should be centrally managed