Meeting of the SWAG Area Cancer Operational Group (formerly ASW) Held on Wednesday 20th June 2018, 10.00-12.00 Weston General , Grange Rd, Weston-super-Mare BS23 4TQ Present :

Asha Sahni SSG Support Administrative Coordinator SWAG CA SSG Support Service Belinda Ockrim Lead Cancer Nurse Yeovil District NHS FT Caren Attree Lead Cancer Nurse and NHS FT Carol Chapman Lead Cancer Nurse North NHS Trust Catherine Donnelly Senior Analyst Somerset Cancer Register Christine Nagle Cancer Performance Manager North Bristol Trust Ed Nicolle Cancer Manager Royal United Bath NHS FT Emma Newbold Lead Nurse Weston General Hospital Helen Dunderdale SSG Support Manager SWAG CA SSG Support Service James Curtis (Chair) Cancer Manager Gloucestershire Hospitals NHS FT Luke Curtis Cancer Manager Yeovil District NHS FT Nicola Gowen Project Manager SWAG Cancer Alliance Ruth Hendy Lead Cancer Nurse University Hospitals Bristol NHS FT Zena Lane Cancer Manager Taunton & Somerset NHS FT Apologies: Deirdre Brunton Lead Cancer Nurse Weston Area Health NHS Trust Hannah Marder Cancer Manager University Hospitals Bristol NHS FT Hazel Lear Product Specialist Somerset Cancer Register James Withers Data Liaison Manager National Cancer Registration Service Jessica Barrett Assistant Directorate Manager Salisbury NHS FT Jonathan Miller South West Cancer Alliance Manager NHS England South, South West Michelle Gregory Deputy Cancer Manager University Hospitals Bristol NHS FT Nathan Brasington Cancer Manager Weston Area Health NHS Trust Patricia McLarnon Programme Manager SWAG Cancer Alliance NHS England South, South West Samuel Wadham Cancer Manager North Bristol NHS Trust Sian Middleton Lead Cancer Nurse Gloucestershire Hospitals NHS FT Terry James Commissioning Manager Cancer Lead Wiltshire CCG

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1. Welcome and apologies

J Curtis welcomed all group members. Apologies received prior to the meeting were noted.

2. Notes and actions from the last meeting

As there were no amendments or comments following distribution of the minutes from the meeting on Wednesday 18th April 2018, the notes were accepted.

Actions:

004/17: Lung resection rates have been discussed at the SSG and Consultant Respiratory Physician A Low is investigating.

005/17: Network and pharmacy posts: a draft SLA based on the SSG SLA has been sent to the BHOC manager.

018/17: Feedback on cancer waiting times has been provided to the CWT team. Action closed.

019/17: The impact of the revised GP contract has been addressed. Action closed.

020/17: Support is being provided to address the 62 day target. Action closed.

021/17: A meeting has been arranged in July to discuss the Inter-patient Transfer policy. Action closed.

029/17: The SOP regarding transfer of cancer patients between organisations is being reviewed by SWAG SSGs.

034/17: The COG view on shared care patient ownership has been shared with WGH. Action closed.

037/17: Developing a resilience plan for chemotherapy protocols. A process is now in place for updating the most recent version of chemotherapy protocols on the website.

039/17: COG representation on the Prevention & Early Diagnosis group will be clarified.

039/17: Action N Gowen

040/17: Lead radiologist for lung – Danial Fox will act as the SWAG point of contact.

001/18: Cystectomy referral numbers will be assessed to see if there is a rising trend in referral.

001/18: Action J Curtis

002/18: Further information on the cause of delays in prostate referrals from RCH to NBT will be circulated. 002/18: Action J Miller

003/18: Issues regarding the Somerset CCG Service Level agreement have been resolved. Action closed.

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004/18: A report on improving 62 day performance was circulated with the CA Board papers. Action closed.

005/18: P McLarnon has received information on Quality Surveillance quality indicators for lung cancer. Action closed.

006/18: Data collection funding support for prostate is still under review.

006/18: Action P McLarnon

007/18: A letter has been sent to Somerset CCG regarding parity in commissioning of breast reconstruction surgery post cancer. The action will remain open until this issue has been resolved.

007/18: Action H Dunderdale

008/18: Changes in fertility Cryopreservation following NBT service closure mean that NBT are now referring to RUH. Clarification is being sought about referrals to Exeter.

008/18: Action H Dunderdale

3. Somerset Cancer Register

3.1 SCR update

The 18.1 spring release is undergoing testing after which it will be rolled out live – the release includes updated COS and CWT datasets. The 18.2 autumn release will have Living With and Beyond Cancer (LWBC) enhancements in the Clinical Nurse Specialist (CNS) module and will include a prostate tracker. E-import improvements will include the ability to update an imported or manually entered record. A variety of outputs including MDT outcomes will be available in pdf format.

H Lear, who is leading on a remote monitoring project, attended a meeting in London last week regarding LWBC metrics (a slimmed down version of the current metrics) which are due to be signed off in August. SCR aim to provide dashboards for the new metrics and plan to consult with providers as this work develops to ensure it meets user needs and aligns with Cancer Transformation Fund reporting requirements.

The Cancer Waiting Times (CWT) team have contacted SCR about amendments to the dataset which should be finalised by August. SCR hope to launch these changes with the autumn release but if timescales are not feasible they will be available in the spring 2019 release.

The 19.1 spring release will include a chargeable remote monitoring application which will initially be rolled out for breast and colorectal. SCR have reviewed similar systems including My Health Record and True North to help inform development of this product. Due to cuts in SWAG Transformation Funding SCR are looking elsewhere for funding for this work. CWT centralisation will lead to back end changes; if front end changes are also required a training programme (including the option for onsite training) will be put in place. The SACT database will change in September – more drug delivery data will be required; organisations will need to be compliant by 1 December 2019.

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It was noted that Gloucestershire Hospitals NHS Foundation Trust (Glos) and Royal Devon & Exeter NHS Foundation Trust use InfoFlex rather than SCR.

4. Lead Cancer Nurse Update

4.1 LCN Update

Lead Cancer Nurses (LCNs) are still attending SSG meetings although it was originally intended that they would support SSGs for one year only. Colorectal and Urology SSGs have Cancer Nurse Specialist (CNS) co-chairs but it has been hard to engage CNSs from other cancer sites. CNSs are more likely to engage with items related to their area of work such as patient surveys and audits.

YDH: 2.5 Cancer Support Workers (CSWs) have been appointed; due to service pressures they have to date received minimal support. CNS provision is chronically understaffed, presenting challenges in delivering transformation funded work.

UH Bristol: Neuro- CNS support is a challenge across Bristol. 2 new neuro-oncology CNS posts will work in tandem with melanoma CNS support.

NBT: Consideration is being given to advanced nurse practitioner posts to fill clinical gaps at NBT – this is also being reviewed at WGH and UH Bristol who have just recruited to breast and TYA posts. Banding for these posts ranges across the region from Band 6 to Band 8a. The last Macmillan census report indicated that the CNS workforce was under-recruited and the majority of CNS staff were in lower paid bands. More and more is being asked of CNS staff who are given huge responsibility. It was agreed this would be raised with the CA in relation to work on workforce planning. 009/18: Action N Gowen

GLOS: J Curtis is interested in any work utilising nurses systematically in CWT improvement. At NBT urology and lung nurses are involved in improvement work. It was agreed that a paragraph about such work would be sent to J Curtis from each provider. 010/18: Action LCNs

As a provider Glos also works with the West Midlands which can cause difficulties in deciding which meetings to attend. LCNs are currently doing extensive work on the 28 day standard. Nurses do a lot of face to face work with patients supporting diagnosis. It is a good opportunity to give patient education on preventable behaviour to those who do not have cancer – it is possible Make Every Contact Count (MECC) and the research networks could be encouraged to support such posts.

TST: Taunton has a new Upper GI Band 6 CNS. CSWs have been appointed and are being managed by a Band 5. CA funding is being used to recruit a Somerset wide Band 5 as well as a project manager. The urology service is struggling due to retirement and lack of succession planning. A business case has been approved for a skin CNS and CSW – the service is seeing a huge increase in 2ww referrals on top of seasonal variation.

WGH: There is a CNS shortage in haematology but the main concern is oncologists – there will be no speciality staff grades at the end of July. Page 4 of 8

RUH: There is room for improvement in relation to utilisation of specialist nursing staff in the skin service. Lung and haematology are understaffed. RUH plans to cease their neuro service – they currently have no specific CNS coverage for these patients. A meeting with other providers to discuss practicalities and timeline is being arranged.

5. Cancer Alliance & Transformation Funding

5.1 Cancer Alliance Board Meeting Update

SWAG CA has been awarded £750,000 from the National Support Fund (NSF) for Quarters 1 and 2 of 2018/19. The funds are intended to support 62 day recovery. Some of the money will be used to support work with primary care on 62 day standard delivery. A post will be created to act as a conduit point for all 62 day performance monitoring and facilitation work with the aim of improving performance across SWAG. The funding will also support work on MDT reforms.

The short timescale given for STPs to submit NSF plans to the CA led to inconsistent decisions across SWAG. YDH had a request for project management and pathway redesign rejected by the STP as they saw this as short term funding. The CA will clarify the purpose of the funding with the STP.

011/18: Action N Gowen

COG members see the bar on using the money for capital funding as a barrier to achieving performance; it was agreed that this issue would be escalated through the CA.

012/18: Action N Gowen

Glos have written to the CCG about rising 2ww figures and the potential impact of the Blood in Pee campaign. There is a 30% increase in urology referrals compared to last year and previous campaigns have been linked to a marked increase in referrals. A cervical screening campaign is planned for January 2019. Recall of women following the recent breast screening incident is predicted to result in one extra screening a week; however this may be higher for some providers, for instance Yeovil – the incident happened during their screening round. FIT screening is being rolled out across England using a lower threshold than that used in Scotland. The CA will ensure all communications about the FIT project go through CCGs to mitigate possible confusion with bowel screening. It will be important from a data perspective to ensure systems are in place to distinguish between the two types of FIT testing. A presentation from last week’s BSW STP meeting will be circulated. 013/18: Action E Nicolle

The radiotherapy service specification is due to be published soon and will promote consolidation of services. The new head and neck specification includes minimum numbers for services and practitioners.

Some Trusts are concerned about their lack of representation on the CA Board; this is particularly relevant now that the CA is involved in the operational roll-out of projects. COG members would like

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the issue discussed formally to reach an agreement where the majority of providers can be represented. 014/18: Action N Gowen

5.2 62 day update

TST’s biggest challenge is urology. May’s provisional performance figure is c72% due largely to delays in prostate cancer cases. To date this quarter 44% of breaches are due to patient choice.

YDH met 2ww performance for quite a while but will not meet the standard in June due to colonoscopy delays which could impact on July and possibly August 62 day performance. A surgical registrar has been moved to endoscopy with backfill from a locum and a nurse endoscopist is being trained. Radiology is now fully staffed, resulting in improved performance.

RUH generally achieve the 2ww target – breaches are usually due to patient choice. The 62 day target was not met in April (the first time in 11 months) but should be met for May and June. The main issue is endoscopy delays. Head & Neck cases often breach when treatment is shared across RUH and UH Bristol. The skin service is likely to impact on figures – one dermatologist has left and another will leave towards the end of the summer.

Glos is performing well on the 2ww target. There is still a lower GI backlog due to endoscopy capacity though this has improved in the last 2 months. Half of the 62 day breaches are urology which is 2 consultants down. Gynae is improving with the introduction of exclusion clinics.

NBT has had increases in breast and urology referrals which has had an impact on April 2ww performance. Unadjusted 62 day performance is c85%.

WGH has stretched radiology services and are not hitting targets for breast, urology and colorectal; however, performance is improving.

UH Bristol’s performance will be based on trajectory due to the fire in the Bristol Haematology & Oncology Centre which has had a huge impact on capacity. Support from other SWAG trusts has been crucial during this period.

Following the above updates COG members agreed that SWAG might not hit the 80% 62 day target for transformation funding – this would result in 50% of funds being released for Quarters 3 and 4.

A meeting is being arranged in July with NHS Improvement (NHSI) to review Trust recovery plans and practice with regard to shared pathways; each trust is being given space for two delegates, the aim being to focus on performance. The event will include sessions on sharing ways of tackling PTL and engaging complex hard to reach patients. Ewan Cameron, NHSI diagnostics lead, will talk about a recent diagnostics audit and implementing diagnostics bundles.

5.3 LWBC update.

NBT and WGH have recruited most of their transformation funded posts. NBT are interviewing on 10th July for a data co-ordinator post. A CSW event on 18th July was cancelled as it clashed with Page 6 of 8

Macmillan certificate training. Glos has used some funds on Infoflex adjustment to help them meet LWBC metrics.

5.4 Lung & Prostate Pathway updates

YDH went live with lung chest x-ray to CT on 1st June – the pathway is currently being managed by existing staff. To date one patient has been through the pathway.

RUH have implemented the lung reporting tool. The team are trying to resolve the issue of radiologists being unable to request CTs. Outsourcing reporting for the project is not a sustainable model – this is a risk that has been noted by the CA across SWAG. The prostate pathway has enough people trained to deliver the service but there are still radiology capacity issues.

GLOS went live with the lung pathway on 14th May. There is a CT backlog which is being addressed through monthly reviews and an agreement to priorities lung CTs. Patient focus group work is planned to capture the benefits of the pathway. The consultant involved is telephoning patients to discharge if their results are clear. A prostate review meeting has been held with the CA, looking at ways to improve the pathway. It was thought that there is a cohort of patients who do not fit the criteria for referral to MRI. Further information will be obtained and circulated.

015/18: Action H Dunderdale

NBT has launched the lung pathway and has active CNS engagement. Capacity for CT reporting is an issue which is being addressed. The CCG are doing work on investing time in primary care with regard to the lung pathway. Prostate clinics have been rearranged – there are now two a week and multiparametric MRI slots are aligned with these clinics.

RUH have started well on the lung pathway. They have been working on patient information leaflets – GPs are often not giving patients written information about the pathway.

TST launched the lung pathway on 1st June. A project group has been set up and meets regularly – there has been CA representation at some of these meetings.

The deadline for the lung highlights report and the first data report is 29th June. A risk assessment and evaluation plan will be presented to the steering group next week. Trusts are able to report on CX3 but are finding it challenging to report on CX1 and CX2. The lung milestones report will be forwarded to H Dunderdale for review within the lung SSG. 016/18: Action N Gowen

6. Network Issues

6.1 SW Access Policy. A straight to test referral process could be implemented that would precede suspected cancer referral. Relevant cases would then need to be upgraded to the GP urgent suspected cancer referral pathway. Peninsula providers are currently making changes to the South West Access Policy which differ to the national policy. SWAG providers would prefer to stick with the 2ww system. It was agreed that wording would be drafted and circulated about direct access standards complying with 2ww standards. Page 7 of 8

017/18: Action N Gowen

6.2 SSG update

A webinar on Cancer Care and MDT reforms, hosted by Professor Martin Gore, was held yesterday.

• Streamlining MDTs should work around the needs of radiology and pathology colleagues • The key to streamlining is teamwork • Teamwork in MDTs can be measure, assessed and improved, and there 3 validated tools that can be used for this purpose • Training is required to use the tools to assess MDT performance • The quality of decision making has been shown to drop dramatically after discussion of 20 patient/after 1 hour • Introduction of a 10 minute break in the MDT has been shown to bring balance to the quality of decision making and reduce the overall time of the meeting.

The webinar is available via this link: https://attendee.gotowebinar.com/recording/5671196705207718915 (this may need to be forwarded to a non-NHS computer login for it to open).

A meeting of SWAG clinical cancer leads on improving MDT performance is scheduled for 16th July. It has been proposed that MDT teams under consistent pressure should visit well performing MDT teams.

The SSG update will be circulated to COG members due to time constraints.

018/18: Action H Dunderdale

7.0 Any Other Business

There could potentially be another £750,000 NSF money in October. The CA is developing ideas for spend of funds should the money be awarded.

Date of next meeting: Wednesday 22nd August 2018, 10:30-12:30, Yeovil District Hospital

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