Dr Jaimin Patel Macmillan GP- Croydon GP Appraiser and Referral triager, Prostate Cancer Project lead GP

Macmillan’s Inspiring Millions Vision

Registration and light lunch 14.05 - 14.20 Welcome Time Subject Speaker 13.30 - 14.00 Registration and light lunch   14.05 - 14.20 Welcome Setting the scene-Macmillan Resources, Croydon Priorities Dr Jaimin Patel, Croydon Macmillan GP 14.20 - 14.55 Early Detection of Cancer- NICE NG12 Changes in Suspected Cancer : recognition and referral, Pan London Strategy Dr Ishani Patel Transforming Cancer Services Team, Healthy London Partnership Early Diagnosis of Cancer and Quality Improvement 14.55- 15.25 Acute Oncology Services at CUH with Q&A Dr Tuck-Kay Loke Clinical Head of Service for Cancer & Dr Nicola Beech Acute Oncology Service at CHS NHS Trust 15.25 - 15.40 COFFEE 15.40 – 16.25 Colorectal - New Nice Update on Lower G.I. and direct access proctology Q&A Mr Muti Abulafi Lead Colorectal Surgeon at CHS 16.25 – 16.50 Urology- NICE changes & and local pathway update- PSA & Haematuria Mr Babbin John Urologist at CHS 16:50-17.00 Electronic referral update Omar Ali & Jill Anderson CHS

FACTS 2 million people living in the UK with cancer, this number will double by 2030 Around 25% people in the UK face poor health or disability after cancer treatment Half of people diagnosed with cancer now survive their disease for at least 10 years These figures highlight the importance of primary care health care professionals being equipped to support these groups As of the end of 2010, around 9,100 people in Croydon CCG were living with and beyond cancer up to 20 years after diagnosis. This could rise to an estimated 17,700 by 2030

The Importance of early Detection of Cancer and Screening Why is Improving Cancer Survival Important? •Cancer is leading cause of premature mortality for many CCGs •Under 75 mortality for all cancers part of CCG Indicator Pack • 1 year survival included in CCG 2015/16 Delivery Dashboard -QUIPP • As people living longer the proportion of people getting cancer is increasing •Emergency presentations costly & poorer outcomes •Improve Patient Experience ) “

Safety Netting The government has set a target for saving 5,000 lives a year through earlier diagnosis of cancer by 2014. Diagnosis of cancer in primary care is beset by three interrelated challenges – the relative infrequency of cancer, initial non-specific presentation of symptoms which occur relatively commonly, and variable time course of evolution of clinical features. Safety netting is one of the most important “tools” that GPs and their practices can use for patients whose presentation is not initially recognised as cancer, ensuring that they are re-evaluated in a timely and appropriate manner.  

Cancer Strategy Development and Implementation Group Quality Premium: For 2015/16 the CCG  agreed a local Quality Premium relating to increasing the % of cancers detected at stages 1 and 2. The data available at the time showed the following performance of the CCG against national performance The earlier detection of cancers improves the outcomes for patients in terms of treatments that can be provided at early stages so increasing positive outcomes for patients in success of treatment outcomes and increased levels of survivorship so decreasing the levels of mortality. Cancer Strategy Development and Implementation Group In place for Croydon CCG - CHS, TCST, Croydon CCG, Macmillan GP , CRUK , Public Health. Key Areas defined in the strategy are : Early Detection Prevention Cancer Screening Reducing Inequalities and variations Patient Experience Living with and beyond cancer End of life care   CCG          National 2012 Performance 31.6% (HSCIC : CCG Indicator:1.18) 41.6% (HSCIC: CCG Indicator 1.18)                                                                                                          

Early stage cancer treatment significantly less expensive Treatment Costs Stage 1 Stage 4 Colon Cancer £3,372 £12,519 Rectal Cancer £4,449 £11,815 Lung Cancer £7,952 £13,078 Ovarian Cancer £5,328 £15,081 One of the key strengths of Mac GPs is that they are ordinary GPs most of the time. They understand the coal-face and can help improve outcomes for cancer at a local level Macmillan GPs influence change rather than provide a service, and they do this working across geographical boundaries, often bringing new learning and practical solutions from other areas of the country. Macmillan GPs influence change rather than provide a ‘cancer service’

5.6 Cancer 5.6.1 Prevalence and incidence Indicator MDY TNH WSS NAS   5.6.1 Prevalence and incidence Indicator MDY TNH WSS NAS PRY ECR Cro Lon Eng Target N Ad Sels Cancer diagnosed (since 1st April 2003) (all ages) 1.26% 1.46% 1.62% 1.95% 2.21% 1.34% 2.10% 1.12% 2.56% New cancer cases (incidence per 1,000) 2.77 2.96 4.19 5.22 5.06 3.47 3.89 3.28 4.90 4.98 5.38 5.6.2 Cancer screening The targets shown are the national targets for coverage. Cervical screening coverage (last 5 yrs) (ages 25-64) 73.3% 77.5% 79.1% 79.3% 80.6% 73.2% 76.7% n/a 80 77.7% 80.4% Cervical screening coverage (excl exceptions) (CS002) 78.9% 80.0% 80.9% 84.8% 83.8% 79.2% 81.0% 80.1% 81.9% 80.7% 87.7% Breast screening coverage (last 3 years) (age 50-70) 59.3% 59.8% 63.8% 67.4% 68.2% 60.3% 63.4% 64.1% 72.1% 59.2% 71.4% Bowel screening coverage (last 2.5 years) (age 60-69) 43.7% 43.9% 54.0% 55.5% 58.9% 45.7% 51.2% 49.5% 58.8% 39.9% 62.1% 5.6.3 Cancer waiting times 5.6.3.1 Two-week wait (TWW) referrals The rates are not age standardised, and are per 1,000 population per year. Total two-week wait referrals (per 1,000) 13.7 18.1 23.2 22.8 16.0 18.3 17.0 21.7 16.8 28.0 Referrals with suspected breast cancer 1.8 3.1 2.7 3.4 3.5 2.4 2.8 3.6 4.0 3.3 Referrals with suspected lower GI cancer 3.9 4.6 5.0 4.3 Referrals with suspected skin cancer 2.0 2.5 6.0 4.1 2.9 7.1 5.6.3.2 Conversion rate Conversion rate (% of TWW referrals with cancer) 8.9% 6.7% 10.5% 8.7% 9.2% 10.4% 9.1% 8.0% 10.2% 6.4% 5.6.3.3 Detection rate Detection rate (new cases which are TWW referrals) 50.6% 41.0% 54.6% 46.2% 54.1% 50.2% 49.1% 48.6% 43.9 31.6% 48.0%  

New cancer risk thresholds Most significant change :are much better grounded on epidemiological evidence from primary care, rather than the old guidelines that relied predominantly on secondary care data. This new evidence enabled the guideline developers to identify the patterns of symptoms, signs, and simple investigations associated with specific levels of risk of an undiagnosed cancer. It recognises the importance of combinations of symptoms in predicting risk of cancer. The guidelines also account better for age and smoking as the most important underlying risk factors when considering certain common symptoms. For example, someone aged >40 years with abdominal pain and weight loss should be investigated urgently for colorectal cancer. If they are aged >60 years, they should also be investigated for pancreatic cancer by CT or ultrasound. There is a section relating to non-specific features of cancer including appetite loss, weight loss, and fatigue. Weight loss is associated with a 7% overall risk of cancer but this includes colorectal, gastrooesophageal, lung, prostate, pancreatic,and urological cancers.

What do Macmillan GPs do? Leadership Service redesign Commissioning What do Macmillan GPs do? We have a renewed emphasis on the commissioning element of the Mac GP role, however, influencing commissioning decisions is something many Macmillan GPs have been doing for a long time. Core elements of the role include: Influencing the commissioning of cancer services within their locality Providing primary care leadership and representation Supporting pathway and service redesign Facilitating and enabling education of primary healthcare teams and enhanced communication Education Communication

Variation in Awareness of Increased Risk

Early Diagnosis is a complex, multifaceted challenge The NAEDI hypothesis

Developing practical solutions… Macmillan GPs also work with the broader community of up to 200 GPs, shaping practical solutions for common issues for cancer. Examples shown here include: Rapid Referral Guidelines - A GP desktop tool to support earlier recognition of signs & symptoms of cancer. This has been updated following the release of the new NICE guidelines in 2015 Decision support tools – an IT adaptation of the Hamilton Risk Assessment Tool and Julia Hippisley-Cox’s Q Cancer tool. This is now available to all GPs across the UK. The tool runs unobtrusively in the background at your Practice and calculates a patients’ risk of 6 different tumour types based on read-coded symptoms. The eCDS tool won a HSJ award for value & improvement in IT in 2014 and recently also won an award for Cancer Care at the HSJ Patient Safety Awards in 2015 Macmillan’s Revalidation Toolkit - This toolkit includes information and practical modules which aim to improve knowledge, understanding andskills in the areas of modern cancer care. The development of this accessible ready-to-use toolkit helps influence primary care professionals to: • critically reflect on their own practice • learn more about diagnosis and referral, and ongoing support in the treatment phase • raise awareness of complications of chemotherapy, radiotherapy and oncological surgery • learn about management of psychological and financial impact of a diagnosis/living with cancer, and self management strategies • educate themselves about the late effects of cancer and its treatment. The Revalidation toolkit can be accessed/downloaded as an editable online PDF, or in hardcopy via be.Macmillan

Developing practical solutions… Macmillan GPs also work with the broader community of up to 200 GPs, shaping practical solutions for common issues for cancer. Cancer Care Review templates – a supportive tool for undertaking QOF cancer care reviews, linked to useful Macmillan resources for patients Macmillan’s Out-of-Hours toolkit – practical support and guidance including free e-learning resources for those involved in delivering OOH care Electronic Holistic Needs Assessment (eHNA) – innovative approach to care planning. User-friendly and makes it easier to give people personalised support. For health professionals, it immediately shows them what's concerning the person in front of them, as they will have an electronic record of their questionnaire and care plan. For people with cancer, it joins up their care, meaning they are not repeating themselves to different professionals at different times. This helps promote better communication between primary and secondary care.

Starting different conversations… “ What could Primary Care be doing to Reduce Cancer Risk? •Delivery of Very Brief Advise for Smoking (VBA) •Delivery of Alcohol Advise opportunistically & at all Health Checks •Signpost & increase uptake of smoking & weight management services •Implement Primary Care Cancer Screening Best Practice Guidance to Promote Uptake Another key part of the role is peer-to-peer influence Mac GPs can help to influence other local GPs in ways that otherwise would be difficult to reach

What can Primary Care do to Improve Access? •Support national BCOC & locally tailored campaigns & encourage presentation of symptomatic population •Patient Participation Groups & User Groups supporting national, local & tumour specific campaigns •Case Finding & Review High Risk Patients (Proactive Care) •Increase awareness of Cancer Screening Programmes to over 70s when delivering Flu and Shingles vaccines http://www.cancerresearchuk.org/health-professional/early-diagnosis-activities/be-clear-on-cancer Be Clear on Cancer campaigns aim to improve early diagnosis of cancer by raising public awareness of signs and/or symptoms of cancer, and to encourage people to see their GP without delay. The programme is led by Public Health England, working in partnership with the Department of Health and NHS England. Each campaign is tested locally and then regionally, with a view to rolling them out nationally if they prove to be effective

Small commuity...BIG POTENTIAL Reaching around 16,000 GPs in the UK Influence in commissioning 20 GPAs & 150+ Mac GPs Increased confidence Training Peer Support Earlier recognition and referral Communication Influencing better cancer care for half the UK population Better care pathways Improved services for people living with cancer More support for patients Macmillan GPs are part of this much larger community, which provides an ongoing channel for communication, sharing good practice, influencing behaviour, sharing learning Collectively, the community can have a powerful ripple effect across the UK GP network note *figures based on each GP networking with up to 20 Practices locally in their cancer leadership role 20 Practices represents approximately 80 GPs each Multiplied by 200 GPs, this reaches almost half the UK GP population

Reducing Delays in Primary Care Education •Annual Audit & share outcomes at Practice Meeting •All PCHT attend cancer training to include non-clinical staff •Use of Practice Profiles to reduce variation in cancer outcomes Raising Awareness •Cancer regular agenda item at Practice Meetings •Endorse screening communications, clean lists, flag & ensure DNAs followed up •Use of Decision Support Tools •Agree & implement Safety Netting Protocols Developing Practice •Practice Nurses to raise cancer awareness at LTC appointments •Upload revised 2ww referral forms •Use pan-London ED colorectal, gynaecological & lung pathways •Agree & Implement Safety Netting Protocols 9 outcomes: 2030 A reminder that Macmillan GPs have a whole pathway approach to cancer now rather than (historically) End of Life Care.

Resources & Data Revalidation Toolkit http://www.macmillan.org.uk/Documents/AboutUs/Health_professionals/RevalidationToolkit.pdf Rapid Referral Guidelines http://www.macmillan.org.uk/Aboutus/Healthandsocialcareprofessionals/Macmillansprogrammesandservices/Earlydiagnosisprogramme/Earlydiagnosisprogramme.aspx Detecting Cancer Earlier in Primary Care: Using Cancer Decision Support Tools to improve the management of cancer in primary care SECSU.tcstlondon@nhs.net •Primary Care Facilitator Programme http://www.cancerresearchuk.org/health-professional/early-diagnosis-activities/primary-care-engagement-facilitator-project •Talk Cancer http://www.cancerresearchuk.org/health-professional/prevention-and-awareness/talk-cancer •Cancer Data Cancer Commissioning Toolkit - http://www.ncin.org.uk/cancer_information_tools/cct Public Health Profiles - http://fingertips.phe.org.uk/profile/ http://www.cancerresearchuk.org/cancer-info/cancerstats/local-cancer-statistics/ Use this slide for detailing information about specific local services and contact information. This could be contact numbers, websites etc. This will be different for each area and will need to be kept up to date as services change.