It is important that when there is a suspicion of cancer that the necessary diagnostic tests are completed quickly to either confirm or rule out cancer and that patients feel supported through this process. These pathways of care need to be underpinned by the opportunity for informed patient choice of investigations and treatment.
Our successful application for NHS England national cancer transformation funding has enabled us to develop and implement a large scale programme of work which includes:
- Design and implementation of optimal pathways for suspected and diagnosed lung and colorectal cancer and for patients who present with vague symptoms
- Supporting rapid diagnosis through the development of future imaging and endoscopy models as well as the procurement of digital pathology technology
As one of the most common tumour types in both England and Cheshire and Merseyside, there has been a significant increase in diagnostic demand for patients with suspicious symptoms. As such, this is a priority tumour type for the Cancer Alliance.
The main objectives for the colorectal pathway project are to:
- Review the current pathways across nine hospitals and work to design an optimal pathway for faster diagnosis
- Work with hospitals across Cheshire & Merseyside to implement the optimal pathway principles
- Reduce the number of appointments a patient needs to attend hospital for
- Ensure that all hospitals have implemented “Straight to Right Test”, where patients go straight to their first investigation and are diagnosed or excluded from cancer up to two weeks earlier
- Improve patient experience
Excellent clinical and managerial engagement across the region has been instrumental to the progression of this project. Additionally, the introduction of Early Diagnosis Support Workers and Patient Navigators across all of the Trusts is supporting teams to manage the increased demands on colorectal and diagnostic services. Acting as a point of contact for patients, they ensure appointment attendance and liaise with GP practices.
Driven by the design of the national optimal lung cancer pathway the Alliance is working to ensure the pathway is implemented across all trusts providing lung cancer services in Cheshire and Merseyside to facilitate faster diagnosis and improve patient experience. The project has made significant progress with excellent collaboration between clinical and managerial experts across the region.
The lung pathway navigators and support workers act as a direct contact for patients, ensuring their tests, investigations and results are all booked and completed in a timely manner. Patients have easier access to information and guidance, and someone to speak to if they have questions. A new patient experience survey will enable us to analyse if the new pathway is a better experience for patients, and allow feedback to help us improve further.
The main objectives of the new lung cancer pathway are to:
- Improve access to diagnostic imaging tests such as chest x-ray and CT scans
- Reduce the waiting time between referral and diagnosis
- Reduce the number of appointments a patient has to come into hospital for
- Streamline processes within hospitals to speed up the pathway
- Improve patient experience
- By diagnosing earlier and faster, this should improve patient outcomes
It has been recognised that there are patients who present with symptoms suspicious of cancer but who do not fit the criteria for a suspected 2 week wait cancer referral recommended by NICE. These patients in some cases do have cancer and often have poorer outcomes and experience of care. In response to this the Alliance has worked with Trusts to design and implement pathways to enable GPs to refer directly for specialist review. This project has developed clear pathways in all areas and enabled the recruitment of dedicated Clinical Nurse Specialists and Support workers.
Led by the Vague Symptoms Oversight Group the project aims to:
· Reduce the number of diagnoses resulting from an emergency presentation
· Drive improvement in patient experience by ensuring they have access to appropriate and timely investigations.
· Provide and evidence cost effective models of delivering vague symptoms pathways
· Reduce face to face consultations where these do not add value and
· Promote collaborative multi-disciplinary working between specialities and organisations
· Help deliver the 28 day and 62 day cancer standards
The diagnosis and treatment of Oesophago-gastric cancer remains a challenge. The method and context of patient presentation, pathway complexity and the specialised nature of diagnosis and treatment continue to impact on the stage of disease, time to diagnosis, patient experience, the time to delivery of a first definitive treatment and patient outcomes.
The combination of these factors together has meant that the OG pathway is now a priority for NHS England who recently produced a draft optimal timed pathway for OG cancer. Designed by a clinical consensus group, the pathway sets out key clinical steps, timings and principles for achieving the diagnosis of patients by day 28.
In response to this, Cheshire & Merseyside Cancer Alliance has established a Delivery Group, consisting of a range of clinicians from within the Upper GI speciality, CCGs, primary care, dietetics and patient representatives. The remit of the Delivery Group is to inform the design and implementation of an optimal, best practice pathway for suspected and diagnosed Oesophago-gastric cancer from referral through to delivery of the first treatment.
Additionally, the remit of this group will be to agree standardised key principles and protocols to underpin this pathway, which will then need to be implemented during 2019 and 2020.
Nathan Howes (Upper GI Surgeon, RLBUHT) has agreed to be overall project lead with a full time project manager to support the work. This resource that has proven to be invaluable for previous pathway work around lung, colorectal, prostate and vague symptoms.
After review, the group are now progressing with priority workstreams to support the project.
For further information regarding the OG Pathway, please email: firstname.lastname@example.org
Further Optimal Pathways
CMCA has recently started work to support improvements in the diagnosis of prostate cancer. The aim of the project is to develop and implement a safe, efficient quality driven timed patient pathway for patients with suspected prostate cancer across Cheshire and Merseyside. The team, building on previous work led by the urology clinical community has now developed and agreed an optimal timed pathway and is now undertaking focused implementation work at all trusts in Cheshire and Merseyside.
As a nationally recognised ‘trailblazer alliance’ CMCA has been asked to support the national cancer team to design an optimal, best practice faster diagnosis pathway for suspected and confirmed oesophageal cancers. A local project has been initiated which has garnered significant clinical engagement and will deliver improvements over the next 12 months.
Supporting Improvement in Diagnostics
The Endoscopy programme is forecasting increasing demand on endoscopy services over the next few years. Current national estimates show that the demand will grow at around 6% per annum however in Cheshire and Merseyside the demand grew at 8.4% last year.
The early objective of the project was to deliver a system-wide understanding of productivity, capacity and demand and workforce issues relating to endoscopy access for cancer diagnostic pathways. This information has enabled us to work with our partners to improve access, reduce waste and increase efficiency. Going forward we will develop a business case to demonstrate the optimum future endoscopy model for Cheshire and Merseyside including the option of shared, networked capacity.
Pathology is a vital component of the diagnostic approach to cancer. Digital pathology is an emergent technology that uses whole slide scanning of prepared pathology samples. These slides can then be digitally stored and transferred across Cheshire and Merseyside. This enables the development of new working models with shared networked workloads, faster access to expert opinion and improved opportunities for training.
Procurement of the technology is currently underway with the aim of having digital pathology slide scanners deployed across Cheshire and Merseyside. The pathology community is working to develop how this technology is best deployed to support cancer diagnostic pathways and new working models.
Rapid access to imaging such as CT and MRI is essential for most cancer diagnostic pathways. Imaging services are under increasing pressure due to the growing demand for these services and workforce challenges. Led by the Cheshire and Merseyside Radiology Forward View Group CMCA has funded a number of improvement projects to support imaging. These projects include:
- Implementation of home reporting workstations to increase out of hours reporting capacity and improve recruitment and retention
- Training to enable radiographers to develop the skills needed to undertake reporting
- Implementation of a business intelligence system to enable a Cheshire and Merseyside dashboard of imaging performance
- Delivering focused service improvement in imaging pathways and services