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Mission (Almost) Impossible: Review of Breast Care Services in North Wales Rob Atenstaedt (Local Public Health Director, Conwy & Denbighshire LHBs) – lead Julia Williams (Associate Local Public Health Director, Conwy & Denbighshire LHBs) – support Andrew Jones, Regional Director of Public Health.

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Mission (Almost) Impossible:Review of Breast Care Services in North Wales Rob Atenstaedt (Local Public Health Director, Conwy & Denbighshire LHBs) – leadJulia Williams (Associate Local Public Health Director, Conwy & Denbighshire LHBs) – supportAndrew Jones, Regional Director of Public Health
  • Breast disease is major public health problem as signif cause of ill-health/death
  • Holcombe & Raynor Report (2007)
  • Burns Report (2007)
  • 20th March 2008 – Letter from the Minister: “the current breast care service should remain at Llandudno for the foreseeable future whilst further work and advice is provided on a model of breast care services in North Wales”
overall project
Overall Project
  • NW Cancer Network requested by Conwy LHB to lead project to develop model for breast care
  • NPHS asked to provide public health support and to lead on Phases 1 and 2a of project
your mission is
Your mission is:
  • As a public health consultant to review the current breast care service provided to North Wales residents and identify the option(s) for optimal configuration of breast care services to ensure that patients have the opportunity to access high quality breast care services.
  • You only have 10 days to do it (one day a week HSCQ time)…
  • You are a LPHD…
  • It’s the middle of the summer…
  • You cannot give to a trainee….
what did we do
What did we do?

1/Pull together a core project team

core team
Core Team
  • Small regional core team consisting

- Rob Atenstaedt (Lead)

- Julia Williams (Support)

- Andrew Jones (QA)

  • no central HSCQ domain support available except for QA purposes
what did we do1
What did we do?
  • 2/ Pull in external team support from the wider NPHS and beyond
other nphs teams involved
Other NPHS Teams involved
  • LKMS for literature review
  • HIAT for NHS activity data
wider nhs involvement
Wider NHS Involvement
  • WCISU for cancer data
  • NWCN for current service profiling
what did we do2
What did we do?

3/ Set clear objectives

  • 1/ To determine burden of breast disease in N Wales & need for breast care services
  • 2/ Review current service provided
  • 3/ To determine elements a high quality breast care service should provide & any gaps in current service
  • 4/ To describe options for new service model to facilitate NWCN to address delivery of preferred clinical model
what did we do3
What did we do?
  • 4/ Use a clear methodology
  • Methodology used was the NPHS methodology for performing service reviews/service modelling available on HSCQ domain website
nphs methodology
NPHS Methodology
  • Definition and scope of the service review/design

- Purpose of document

- How and why service needs to be reviewed/redesigned

- If concerns about quality or capacity of service, what evidence is there regarding the extent of the issue

  • Needs assessment

- State whose needs are being addressed

- Outline size i.e. numbers in the population / client group. Include trends and projections

- Outline extent of problems i.e. the “burden of disease”

- Provide comparative data

- Describe gaps in data

- Describe any caveats with data

nphs methodology1
NPHS Methodology
  • Service profile

- Structure of service

- Present activity

- Staffing complement and vacancies

  • Service model/option appraisal

- Describe recommended provision or “best practice”

- Describe shortfall in provision

- Describe implications of any gaps in the provision

- Describe option(s) for a new service model

  • Conclusion and summary
  • Recommendations where applicable
what did we do4
What did we do?
  • 5/ Be clear on project limitations
  • Pragmatic approach
  • Rapid review building on data presented in the previous report into breast surgery
  • Data limited to 2006
  • Not possible to carry out a rigorous systematic review or to review all literature in relation to key areas.
  • For healthcare needs assessment, only epidemiological, rather than corporate and comparative methods, utilised.
what did we do5
What did we do?
  • 6/ Be clear on specific roles/responsibilities within project
core team roles responsibilities
Core Team: Roles/Responsibilities
  • Rob: needs assessment of breast disease in North Wales and literature review of what constitutes high quality breast care services
  • Julia: review of current breast care service in North Wales
  • Rob/Julia: identify gaps in current service
  • Rob: options for a new breast care service for North Wales residents
  • Rob: pull report together/ prepare powerpoint
  • Andrew: QA and exec summary
LKMS support
  • Developing a search strategy
  • Defining and scoping the search questions
  • Undertaking a series of searches with a high level of specificity
  • Screening and filtering of results
  • Providing document delivery of selected articles
  • Writing up the search methodology
  • Assisting with citations
  • Compiling reference list for the final report
questions looked at in the literature review included
Questions looked at in the literature review included
  • What is epidemiology of breast disease (breast cancer and benign breast conditions) ? [1996-]
  • What are elements of high quality breast care services? [1996-]
  • What breast care models are currently in operation in the UK/ Europe/ Developed World? [1996-]
  • To locate general review papers on aetiology, prevention and management of breast diseases [1994-]
  • Is there evidence that surgery for breast cancer can be done as a day case procedure? [1996-]
  • Is there any guidance on how the following services should be organised: [1996-]
    • Oncoplastic breast surgery
    • Localisation biopsy/guide wire breast excision


hiat support
HIAT Support
  • Admission rates
  • Rates of bed use
  • Average length of stay
  • Benign and malignant breast conditions
wcisu support
WCISU Support
  • Incidence data
  • Mortality data
  • Survival data
  • Breast Cancer predictions
  • Maps and tables
north wales cancer network
North Wales Cancer Network
  • Help with data gathering and checking of key messages
what did we do6
What did we do?
  • 7/ Have a robust QA process
qa process
QA Process
  • Consultant/regional director QA – Peter Stevenson/ Andrew Jones
  • HCW QA – Hugo Van Woerden
  • Academic QA – Iain Robbé
  • Comms Team QA – Chris Lines
how long did it take
How long did it take?
  • Rob: needs assessment of breast disease & lit. review of what constitutes high quality breast care services: 30
  • Julia: review of current breast care service: 10
  • Rob/Julia: identify gaps in current service: 2
  • Rob: options for new breast care service: 2
  • Rob: pulling report together and preparing powerpoint: 5
  • Andrew: QA and exec summary: 8
  • LKMS: 16 sessions
  • HIAT: 2.5 sessions (estimate)
  • WCISU: 4 sessions
  • External QA: 5.5 sessions
  • Meetings: 5 sessions
  • TOTAL =90 (conservative estimate)
what went well not so well
What went well/not so well?
  • Well:

- Project deadline met (just!)

- good response so far to review from stakeholders

- good communication with Breast DON

  • Not So Well:

-Communication issue with NWCN

what are next steps
What are next Steps?
  • Presented findings at:

- North Wales Breast DON

- Conwy CHC meeting

  • Presentation at Llandudno Hospital Action Group 27 October
  • Continued NPHS support for Phase 3 of overall project
what were our recommendations
What were our recommendations?
  • 1/ Detailed option appraisal for delivery of breast care services based on findings & options identified. Should have regard to appropriate criteria (including specific needs of national breast screening programme delivered by BTW) & wider consideration of general health care services across N Wales. Criteria could include:

- Accessibility

- GP Practice Opinion

- User opinion

- Ease of staffing

- Ease of management

- Capacity

- Quality of environment

- Time to implement

what were our recommendations1
What were our recommendations?
  • 2/ As part of process, existing gaps in service provision should be considered including:

a) need for introduction of on-site breast reconstruction / oncoplastic service in N Wales.

b) introduction of ambulatory breast surgery

  • 3/ N Wales health community, with its partners, should seek to:

a) maximise appropriate uptake of screening

b) actively promote prevention of breast cancer by working in collaboration to address lifestyle/ risk behaviour, and tackle inequalities in N Wales