Acute Oncology in Welsh Hospitals Niladri Ghosal Tom Crosby Geraint Roberts Matt Makin

Cancer Reform Strategy 2007 The NCAG report 2009 NCEPOD report 2008

Use of chemotherapy (and its problems) are growing 60% increase in chemotherapy between (CRS) The 4 Cancer Centres Audit showed : Chemotherapy episodes doubled in colorectal cancer Breast and ovarian chemo increased by 40% 60% increase in chemotherapy between (CRS) The 4 Cancer Centres Audit showed : Chemotherapy episodes doubled in colorectal cancer Breast and ovarian chemo increased by 40% Availability of new drugs and longer durations Pts having more lines of chemo Wider range of cancer are treated with chemo Increasing neo- adjuvant and adjuvant indications

Confidential Enquiry into Patient Outcome and Death (NCEPOD) report between June – July ,050 systemic anti-cancer treatments were given 1044 (2%) died within 30 days. Of them: 35% received “Good” care 49% had “Room for Improvement” 8% received “Poor” care Safety of Patients receiving Systemic Anti- Cancer Treatment (SACT) was a concern

Factors affecting patient safety Lack of specialist oncology input Lack of continuity of care Sub-optimal communication between admitting teams and oncologists Inadequate and late discharge planning compromising future oncological interventions such as delay in chemotherapy cycles increased length of stay Unnecessary investigations and interventions Lack of “single point of contact” for oncological advice for medical and nursing staff Lack of oncology specific training among junior doctors and nurses

The financial impact of Cancer and SACT related illness are enormous

Approximately £4.35 billion was spent on cancer services in 2006/07, amounting to 5.2% of all NHS spending - DH programme budgeting data at Cancer Care is a major factor in Acute care: 273,000 emergency admissions a year with cancer ( ) Acute care takes 25-50% of NHS cancer spend 12% of all acute beds used for ‘cancer care’ Increase of 30% over 10 years Average DGH admissions ~5 pts a day with complications of treatment Average DGH admissions ~4 pts a week with cancer unknown (or undiagnosed) primary

NCAG report advised on 3 key areas Framework of planning and monitoring chemotherapy services Developing Acute Oncology Services The leadership, information systems, governance, monitoring, and commissioning of chemotherapy services.

The scope of Acute Oncology Service The scope of Acute Oncology Service Oncological emergencies, Chemotherapy complications Radiotherapy complications Education Liaison service Providing specialist input in day to day management Early discharge planning Co-ordinating care Continuity of care Other oncological problems CUP services CUP MDTs Streamlining pathways, Governance Rolling audits MSCC pathway management,

Day 1 - admitted PS-1 abdominal pain Day 2 & 3 - CT scan – liver metatasis Day 5 - Colonoscopy & Day 6- Endoscopy & Bone scan IF Acute oncology review Information Biopsy & urgent clinic Discharged Day 5-11 Await liver biopsy (bank holiday) Day 14 Discussed at MDT- refer oncology Day 15 Discharged – awaits clinic appointment Common Scenarios: Example 1

Day 1 Admitted PS-3 dementia Day 2 & 3 - CT scan & ascitic tap Day 5 - Diagnosis ovarian cancer IF Acute Oncology review PS = 3/4 Best supportive care decision day 2 Day 5-11 Await transfer ward ? for chemo Day 11 Seen by oncologist Not fit for chemo Day 13 Palliative care planning Got diarrhoea- missed consultant review Day 26- Nursing home Common Scenarios: Example 2

NCAT anticipates: AOS would reduce the Length of Stay (LOS) of Oncology In-patients by up to 1/3 rd (but this will depend on existing pathways) There will also be reduction in unnecessary investigations NCAT anticipates: AOS would reduce the Length of Stay (LOS) of Oncology In-patients by up to 1/3 rd (but this will depend on existing pathways) There will also be reduction in unnecessary investigations

An Illustration of how AOS can solve some of these issues in a peripheral DGH setting AOS in Wrexham Maelor Hospital (WMH)

Summary of oncological activity in WMH and SSU PARAMETER QUANTITY 1. Total number of care episodes (chemotherapy cycles) delivered in SSU per annum Number of care episodes per day20 (approx) 3. Number of oncology admissions per year300 (approx) 4. Number of new admissions per week Length of stay (LOS) for oncology in-patients7 days 6. Cost of oncology in-patient activity £200 /day*)£420, Projected savings of reducing mean LOS by 1 day£60,000 Data obtained from direct observation of activity in 2011 * = data obtained from work carried out in Velindre Cancer Centre,Cardiff

A&E MAU SAU Hospice GP Home Others Disease Specific Sub-groups, Consultants, Teams etc

A&E MAU SAU Hospice GP Home AOS 2012 Others Disease Specific Sub-groups, Consultants, Teams etc

Prospectively collected data for AOS Wrexham March – December 2011 Died in same Admission n230 Mean LOS8.2 days 7 days or less148 (64%)7 (4%) 14 days or less192 (83%)11 (5%) >14 days38 (17%)9 (24%)

Different Models…… NCAG Proposals: AOT would need minimum of: 1. Consultant Oncologist – 0.5 WTE (on site commitment to AOS from two oncologists) 2. Nurse Specialist for acute oncology service It is anticipated that the costs of recruitment of extra staff could be offset by reductions in inappropriate admissions and in lengths of stay, as well as reduced investigations and procedures performed.

Adapted from Dr Ernie Marshall’s presentation The Liverpool Model: St Helens and Knowlsey NHS Trust

Acute Oncology VCC- robust ‘Hub’ advise 24/7 –Consultant on-call –Acute oncology SpR –SHO –Nurse led chemo-pager –Palliative care CNS and Consultant 24/7 The Velindre Model: AOS at the “Hub”

Peripheral DGH Setting: The Wrexham Model Oncology service provided centrally from the North Wales Cancer Centre based in Glan Clwyd Hospital The frontline service is resourced by: 0.25 WTE on-site consultant support 1.0 FTE Advanced Nurse Practitioner 0.8 FTE Speciality Doctor The team closely links with the Specialist Palliative Care service. The on-site consultants also support the AOT whenever needed. The consultant support is due to increase.

National body of AOS should be developed to support Minimum data set Peer review the practice Ensure uniformity of service across Wales. National body of AOS should be developed to support Minimum data set Peer review the practice Ensure uniformity of service across Wales. The Future

1.AOS improves patient safety and saves NHS resources by streamlining patient pathways, reducing length of stay and reducing unnecessary investigations 2.The chosen model of AOS must adapt to local needs 3.Closer collaboration among the Wales Hospitals to develop the AOS must be encouraged 1.AOS improves patient safety and saves NHS resources by streamlining patient pathways, reducing length of stay and reducing unnecessary investigations 2.The chosen model of AOS must adapt to local needs 3.Closer collaboration among the Wales Hospitals to develop the AOS must be encouraged Conclusion