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. 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. Where the difference can be made

10. 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

11. If all cancer services adopted the winning principles &the key improvements this can save a million bed days Unscheduled (emergency patients) should be assessed prior to the decision to admit. Emergency admission should be the exception not the norm. Patients should be on a defined inpatient pathways based on their tumour type and reasons for admission. Clinical decisions should be made on a daily basis to promote proactive case management. Patient and carers need to know about their condition and symptoms to encourage self-management and to know who to contact when needed

12. 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.

13. **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 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 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 *Intra-operative - Sentinel Node Biopsy: In centres where adequate training has been provided. Extra theatre time e.g. 40mins is required for this procedure Primary care – optimising pre- operative health Blood pressure BMI, diabetes etc. Lifestyle advice Patient choice Patient information 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 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) ‘Patient involvement & Choice Guarantee’ ‘Professional & Patient Outcome Audits’ Continuing care for cancer patients Continuing cancer care assessment care plan (including referral as appropriate to AHPs) Education – self care management programme Palliative care Day Case/23 Hour Breast Surgical Pathway Patient informed decision making **Pre-operative - Surgical assessment at diagnosis clinic or minimum 7 days prior to surgery 7/10/2010

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

15. Transferring the lessons from Birmingham An exemplar in improvement

16. 13 National Clinical Spread Networks Thames Valley Merseyside & Cheshire Lancashire & South Cumbria Greater Manchester Humber & Yorkshire East Midlands Anglia Arden South West London Pan Birmingham North London Three Counties ASW

17. 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

18. 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

19. 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

20. Cytology : Phase 1 Turnaround position

21. Sample taken in primary care Laboratory Test Report issued from lab Result received by patient End to end TAT- 14 day max Laboratory process- Liquid based cytologyTime taken to reach laboratory Result issued by call/recall agency 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 Processing and printing 5 hours 30 minutes value added time

23. Innovation 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’ ‘The best way to improve services is through healthy plagiarism’. National Clinical Lead, Heart

24. ‘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’ The biggest enemies of improvement are: Source National Clinical Leads NHS Improvement

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

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