Northern Cancer Network s1

Early Cancer Detection: Case Analysis & Quality Improvement Ideas

Putting Appraisal to Work

Template:

Case Review and Significant Event Analysis are at the heart of appraisal, and a good place to demonstrate that you monitor and maintain your fitness to practice by spotting learning needs and other areas for development.

Cancer pathways in the UK urgently need improvement. The three London appraisal teams had the idea of using the appraisal system to coordinate a collective investigation by front-line doctors into the problem. We would like you to consider including one of your recent cancer cases in this year’s appraisal, and to share your thoughts on anything that with hindsight might have made a difference to the subsequent outcome. This will include personal and practice learning or development needs of course, but patient factors also delay presentation, as does GP access to diagnostic tools. The GMC requires you to include case reflection for revalidation, but it is not compulsory to use a cancer case; you may have others of greater significance for your own development. However, by coordinating on a common theme there is an opportunity to develop and improve the influence of front-line clinical thinking on commissioning decisions.

If no cancer case comes to mind, we suggest you ask your practice managers to list the 20 most recent cancer diagnoses in the practice and to inform each doctor involved in the pre-diagnosis phase to examine the cases, including locum doctors. There is no reason why several doctors could not look independently at the same case. You could even reflect on a case that you were not personally involved with.

After discussing the case in your appraisal, we shall invite you to contribute your completed SEA template to a central database for academic study.

Based on the structure recommended by NPSA, adapted from E Mitchell & U Macleod’s work by the Pan-London Area Teams ~ 2 ~

ANALYSIS OF CANCER DIAGNOSIS Advice on completing the template

Some tips based on previous usages of the template: 1. Choice of Case is Important: Choose a case that requires significant reflection, and is likely to generate learning or a change to pathways or patient education. Good examples are a delayed diagnosis or one that follows an emergency admission. Avoid cases that are unlikely to provoke new learning, such as a patient with a breast lump appropriately referred on first presentation. If you include a case involving external problems such as hospital or patient attributable delay, make suggestions for improvement. If you really cannot find a case that you were involved in, choose one that you were not involved in. 2. Discussion with Colleagues: SEA is best done as a team activity, perhaps in the practice or in a locum group meeting. Include any discussions that have taken place, who participated and who was responsible for implementing any changes. The SEA report should say whether all relevant individuals attended and whether the conclusions should be discussed with any other staff inside or outside the team. 3. Implementation and Action: Describe any action that you or your practice have already taken on learning points identified. Please speculate on solutions that, in an ideal world would make a difference to a similar case in future. Any suggestions you make can become quality improvement projects in coming years, and you will be offered the opportunity to become involved in implementing them in various settings. 4. Staging of Tumours: We have a simple A, B, C system described below. For non-solid tumours such as leukaemia it would be helpful to make some sort of comment on how advanced the disease was considered to be.

ANALYSIS OF CANCER DIAGNOSIS Cancer SEA Report Template Diagnosis (Cancer Type): Carcinoma of stomach Date of diagnosis: 14.6.14 Stage at diagnosis: A= confined to organ, T4aN3R0 B=local spread, C=distal spread: Number of consultations with hindsight: 4 Route to diagnosis, e.g. screening, 2WW referral to gastroenterologist referral etc. Age of patient at diagnosis: 91 Sex of patient: F Is the patient currently alive (Y/N): Y If deceased, please give date of death: Date of meeting when SEA discussed: N.B.: Please DO NOT include the patient’s name in any narrative, and anonymise any individuals involved at each stage by referring to them as GP1, GP2, Nurse1, Nurse2, GP Reg1 etc.

1. WHAT HAPPENED: Facts of the Case. Describe the process to diagnosis for this patient in detail, including the number and dates of consultations, referral and diagnosis and the clinicians involved in that process. Consider for instance:  The initial presentation and presenting symptoms (including where, if outside primary care).  The key consultation at which the diagnosis was made.  Consultations in the year prior to diagnosis and referral (how often the patient had been seen by the practice; for what reasons; the type of consultation held: telephone, in clinic etc; and by whom - GP1, GP2, Nurse 1 - saw them).  Whether s/he had been seen by the Out of Hours service, at A&E, or in secondary care clinics.  If there appears to be delay on the part of the patient in presenting with their symptoms.  What the impact or potential impact of the event was.

The patient is female aged 91. She had a long history of hiatus hernia for which she had taken PPI in the past. In January 2014 she had worsening symptoms of gastritis and acid reflux when eating spicy food and the dose of the PPI was increased from 30mg to 40mg omeprazole daily. This initially improved her symptoms however in February she felt no benefit and was reviewed, FBC was taken and the patient was referred to gastroenterology on a routine referral on 19 March. On 31 March she noticed difficulty swallowing and weight loss. A 2 week wait cancer referral was sent. The patient was seen in the gastroenterology clinic 1 week later and was booked for an urgent endoscopy and barium swallow. The gastro SpR commented that this was likely to be a benign stricture At the gastroscopy there was a large amount of residual food in the stomach, a suspicious area of inflammation was seen however it was not possible to biopsy as the patient vomited and the scope was withdrawn. The barium swallow did not show any mass but showed a pharyngeal pouch. A CT scan was ordered with showed a mass in the stomach with no further spread. The patient continued to lose weight and was prescribed ensure. A further endoscopy was planned and a biopsy confirmed a distal antral tumour. The patient was now unable to keep food down and was admitted for a laparotomy in May 2014.

2. Identification of Key Moments: Issues to Reflect upon

Consider for instance:  If this was as good as it could have been, what factors contributed to speedy diagnosis?  If you consider that diagnosis was delayed, what underlying factors contributed? What patient factors contributed to manner or timing of presentation, e.g. denial, education, description of symptoms etc.  Comment on safety-netting / follow-up that was used in contacts prior to the diagnosis.  Were appropriate diagnostic services used? What might have helped, and how could it be implemented? ?  In preceding patient contacts, and with the benefit of hindsight, what might have conceivably led to a diagnosis?  Could a diagnosis have been made earlier in a utopian world, and how?

The staging and grading confirmed a T4aN3R0 carcinoma of the stomach Following on from this a decision was made by the MDT not to start chemotherapy due to the patient’s age and condition.

The key moment was when the patient had difficulty swallowing and started losing weight, this was markedly different from previous symptoms and triggered the 2WW cancer referral. There were no missed opportunities in previous consultations and the patient and her daughter were very quick to report new symptoms

Appropriate diagnostics were used, with hindsight the patient could have been asked to fast for longer before the first endoscopy so that a biopsy could have been taken at that stage

3. LEARNING, QUALITY IMPROVEMENT & COMISSIONING List the learning and development points that arise from this case, both for you and for wider general practice. Include personal learning points, but also anything that would improve the pathway for similar cases in future. Consider:  Education and training.  Protocols, pathways, procedures.  Access to diagnostic tools or ambulatory care, or consultant led telephone triage.  Follow-up & safety-netting systems.  Team working, lines of communication both internally and with secondary care.  The role of the NICE referral guidelines for suspected cancer, and their usefulness to primary care teams.  Please include any references to literature, if you have done some reading as part of your reflection, and don’t forget to include this SEA in next year’s appraisal, with reflection on any quality improvement activity.

Learning, Development or Quality Improvement points:

My learning is that cancer can develop on the back of a long history of another diagnosis eg in this patient she had a history of hiatus hernia It is important to be alert to changes in a long standing condition and to keep an open mind that a new diagnosis may be required. This patient was seen by more than 1 doctor so it was important that at each consultation there was a logical flow of investigations, follow up and referrals.

4. Implementation of Quality Improvement: Outline here any actions already implemented or agreed. Consider:  If a protocol is introduced or amended: what are the key features, and how is it monitored?  If any other changes have been decided, what improvements are expected?  If you have identified issues for your network, CCG or NHS England, how is this to be communicated and developed?  Are there any actions in relation to appraisal, e.g. repeating the exercise next year, audits in the practice or network?

There have been no changes implemented as a result of this SEA

5. DEVELOPMENT OF THIS PROCESS: Has this SEA has been valuable to individuals, to the practice team and/or to patients? Consider any detail about the process that might be useful to share, regarding meetings, attendances, format etc. Please also reflect and comment on how the appraisal system can be developed within NHS England so that clinical thinking can have a more intelligent influence on planning and commissioning. As an exercise in coordinated thinking, is this working?

It has been interesting to review this case using this template, it has helped me to see the whole patient pathway and the key moment when the decision was made to make a 2WW referral I think in hindsight the previous routine referral was appropriate although the symptoms changed very soon after this.

SOME INFORMATION ABOUT THE SETTING FOR THIS CASE *

Setting for your consultations e.g. GMS practice, OOH, UCC etc. PMS practice

Which CCG? Barnet

Are you a Partner, Salaried Doctor, or Locum or Other Locum

Number of Patients at the Practice 3500

How many F.T.E. GPs are there (inc. principals, salaried GPs, trainees etc.)? 2

Is the practice a training practice? Yes/No No

Does the practice teach medical students Yes/No No * This information is useful when collating results across practices and/or localities

Based on the structure recommended by NPSA, adapted from E Mitchell & U Macleod’s work by the Pan-London Area Teams