Agenda item

Purpose: To provide an update on current performance re. waiting times and referrals, and the mitigation measures introduced.

Chris Lowrie, Directorate Manager Berkshire Cancer Centre, Nicola Costin-Davis, Royal Berkshire NHS Foundation Trust (RBFT) and Mark Foulkes, Macmillan Cancer Lead and nurse consultant RBFT, presented the report on Cancer Performance at RBFT (Agenda Item 6).

Mark Foulkes presented the report on cancer services at Royal Berkshire Hospital and the surrounding area. He started with an overview of cancer services at RBFT including the population served and the main sites for treatment. He gave a summary of the Cancer Access Standards including nine key targets of diagnosis and treatment, and the national ambitions. Mr Foulkes highlighted that to meet these targets they needed more patients referred in for assessment. Personalised care was a key ambition at RBFT. He noted the performance management in cancer care and that it would continue into the future. Mr Foulkes then gave an overview of the cancer pathway noting the challenges in diagnostics which would be detailed later in the presentation.

Andrew Sharp, West Berkshire Healthwatch, requested to ask a question. The Committee resolved to suspend standing orders to allow Andrew Sharp to speak and this remained for the rest of the committee meeting.

Andrew Sharp asked why diagnosis in the UK was a challenge compared to Europe. He asked if the 75% target was realistic. Mark Foulkes agreed that delayed diagnosis of cancer might in part be due to stoicism and groups of patients who tended to present later with cancer. This could be men and people who did not speak English as a first language. Those admitted into hospital tended to be older people and people who were more isolated. This was particularly the case during Covid as anecdotal evidence supported that people who were isolated tended to present later with symptoms. Dr Kajal Patel (Cancer Clinical Lead, Clinical Commissioning Group, CCG) added that it was quite complex. There were different factors leading to late presentation. These included deprivation, language barriers and cultural barriers. Screening uptake in different groups and awareness of red flags were also important but complicated. Any patient presenting with a red flag symptom was seen quickly but there were some cancers that had vague symptoms to start off with which were hard to pinpoint. These could go on for a long time before the cancer manifested. This led to a vague symptom pathway which GPs could refer patients on to. This was a suspected cancer of unknown pathway. There was work to improve awareness and increase screening. There were different layers and so many approaches were needed to have faster diagnoses. For every 100 people referred by GPs for a suspected cancer, on average less than seven had a cancer. Of course they wanted to refer all but that would subject more people to CT scans, high dose radiation and going through the pathway. It was those 7% that needed treatment on time.

Andrew Sharp highlighted that the communications across Berkshire West in terms of reaching out to the groups, screening and prostate cancer were impressive. He noted public health could be involved more in the awareness side and it being acceptable to go to the GPs.

Councillor Tony Linden noted Macmillan Cancer’s report highlighting longer waits and later presentations. He asked how much change there had been locally rather than nationally. Were the national concerns coming in locally? He asked why the performance levels had dropped significantly.

Councillor Jeff Brooks highlighted the 62 day wait and asked if there was any correlation with that and the outcomes, and further whether that would vary depending on the cancer type. He also asked why the target was 62 days and whether it was about outcomes or capacity. Mark Foulkes advised that the 62 day target was a national target set many years ago to bring the whole length of people waiting down by setting a line in the sand. He confirmed the faster you diagnosed patients the more likely they were to survive. In an ideal world they would like to reduce that 62 day target even further. However with the current situation, particularly in diagnostics, that would be difficult. He also highlighted that the targets drove change and investment, and many more issues would be touched on later in the presentation. Councillor Brooks asked whether there should be variation in the targets depending on the cancer type. Mark Foulkes responded that it would be very difficult to manage, however there were some other targets for different cancer types. If it happened across the board that would miss some cancers that could be slow or fast growing and so the general cancer waiting times were the best fit. Chris Lowrie highlighted that even though there were general targets there was still clinical prioritisation that occurred. Patients were prioritised on clinical priority and some patients that could wait sometimes did if they needed to get more urgent patients in.

Chris Lowrie continued the presentation and explained the graph in the report on two week wait referrals for patients referred with red flag symptoms. He highlighted the significant jump in average referrals per week after September 2021. He noted the peaks in referrals more recently and how busy they were. The reduced attendances in wave one of the pandemic, when screening programmes were temporarily suspended, increased health anxiety and GP access made it a complicated picture to understand the causal factors. They were expecting it to continue to grow but they did not know at what rate. There had been a 53% increase in breast cancer referrals and other cancers such as gynaecology, head and neck were up a third. Prostate cancer cases were particularly difficult to get to the GP and so they had done partnership working to increase referrals from men being screened. In terms of the 62 day access standard, during Covid they were oscillating around the access standard level of 80% but there was then rapid deterioration more recently. This was due to normal issues, increase in demand and MRI capacity. In March there was an uptick and the waits had improved. Action was taken quickly. However the scanning facilities took more time to address and a new provider started last weekend. This would take a few weeks to recover.

Councillor Rowles highlighted the concern around men stepping forward and whether there was something that could be done locally. Mark Foulkes agreed that publicity could target specific groups. Particularly older men and men from Afro-Caribbean backgrounds. They could also target demographically through GPs. Chris Lowrie explained there was a joint project with the CCG to create cancer champions in communities. For example targeting Nepalise and Urdu speaking communities. To reach hard to reach groups would make a difference to cancer sites in the future.

Councillor Alan Macro noted the recent uptick in this standard and asked how confident RBFT were in returning to the 85% target. Chris Lowrie highlighted the NHS England picture. In particular workforce concerns nationally. They had innovative roles such as a nurse consultant specialising in breast cancer treatment. They were taking this incredibly seriously and had an executive led steering group planned to go through specific issues, barriers, perceived barriers and what the future holds. This would help to build the strategy going forward. Workforce would continue to be a dominant factor at play.

Chris Lowrie continued the presentation to explain the 62 day breach trend. Diagnostics dominated the reason for breaches. This was not simple to resolve and it was difficult to manage staff and patient expectations. There had also been an uptick in patient choice since Covid. This graph informed actions going forward. The Thames Valley position was then explained showing RBFT along with other sites in the Thames Valley. He noted how complex the pathway was. Chris Lowrie then summarised actions taken on slide nine in the report.  He highlighted that holistic elements needed to support patients with cancer.

Councillor Linden asked how these figures looked locally in West Berkshire now and in the next 12 months. Chris Lowrie confirmed the data was local and that generally the profiles looked similar across the area. The West Berkshire figures and Reading figures were no worse than the national picture and in many places were significantly better. How that translated into the experience of people was also important and their data showed that they had maintained that patient experience against the odds. Even though there was deterioration around their diagnostics, it was not out of line with the national picture. Councillor Linden asked how the actions taken would impact on the figures. Chris Lowrie said that there were lots of moving pieces. The national strategy around community diagnostic hubs and capacity would be a pivotal change. The histopathology work, which was largely workforce related, would be coming in and both would make a marked difference in performance. The biggest single thing was around workforce and training a workforce for tomorrow. Nicola Costin-Davis confirmed that many issues were much wider than their strategy and about the pipeline of workforce.

Councillor Macro raised concern about blood tests being rejected by pathology and what was being done to address those kind of issues.  Chris Lowrie advised they had a significant workforce in pathology but that he was not aware this was a common problem with cancer pathways.

Dr Kajal Patel was then invited to present on the Wider Cancer Pathways of Berkshire West CCG. Dr Patel gave an overview of her role as a GP and Cancer Lead in Berkshire West. She worked with partners in improving cancer awareness and referrals of cancer to improve the process for parents. Dr Patel highlighted the Cancer Steering Group bringing together people from RBFT, GPs, Public Health, Macmillan Cancer charity executives, Cancer Research UK facilitators and Cancer Alliance. These meetings and the relationships brought about a lot of progress and changes could be made quickly.

Dr Patel gave an overview of some of the work in 2021-22. These were priorities from the local Cancer Framework and the NHS Long Term Plan. During the recovery from Covid they had local campaigns, webinars and patient participation group talks to encourage people to see their GP when they had red flag symptoms. Reassurances were given to support people concerned about Covid in hospitals. Secondly the Cancer Champions programme was highlighted. This was grass roots people talking to the community. There were 40 volunteers trained to share experiences, leaflets, stalls etc to help break cultural barriers. Thirdly the Cancer Collaborative Project was to make test leaflets and results more applicable to patients with different languages. The Quality Improvement Scheme was to look at diagnosis of cancer and getting patients diagnosed with cancer earlier. Practices were asked to increase screening for breast, bowel and cervical cancer and to focus on traditionally low uptake groups for attending health care appointments, such as learning disability groups and mental health patients. Practices were also asked to do an audit on the route analysis to see what led to the patient’s journey of cancer. This was to gather local clinical learning to be shared and help the practice to be responsive to the local population. The Cancer Care Review Scheme was to ensure cancer patients received primary care also from GPs and to link with the voluntary sector. The Personalised Care was through Holistic Needs Assessments and End of Treatment Summaries. They had held wellbeing events through the cancer rehab service. They also had Prostrate Cancer awareness campaigns in the community to increase urgent cancer referrals.

They had done a lot of GP support and education. Some through Covid on pathway changes, new tests, the local vague symptom pathway and support packs. Dr Patel highlighted the Cancer Steering Group explained earlier which brought together key stakeholders monthly to discuss and agree on cancer priorities for local patients. Dr Patel then gave an overview of the key priorities for 2022 and 2023 given in the report including cancer champions, implementing Faster Diagnosis pathways, personalised care nurse facilitators and personalised care.

Councillor Macro highlighted concern about impact of Covid on reducing regular reviews by GPs, for example diabetic reviews, and whether this lack of regular contact with GPs would store up problems for the future. Dr Patel advised that in their practice they called people for reviews as normal despite increased pressure on access. Health anxiety and mental health increases had impacted the system and so there was not an infinite amount of appointments. All targets were strived towards. The difficulty in recruiting meant they were using more team members to help with some of these reviews. For example pharmacists doing medication reviews in place of a GP. There was a GP shortage. Digital access had also increased pressure on GP time which was outside of the appointment time. This meant that points of contact with GPs had doubled or tripled which increased administrative workload on top of clinic times. Councillor Macro asked if there would be an impact on using other members of staff to undertake reviews or were they less likely to pick up on cancer. Dr Patel advised that it depended on what the appointment was for. Red flag symptoms would always go to the GP. Patients were only booked in to see patients for something that was in that clinician’s scope of practice.

Councillor Brooks referred to the slides and noted that the phrasing included some jargon and raised concern about digital access increasing pressure on GPs. Councillor Brooks asked for examples around what the cancer champions did. Dr Patel explained some of the terms used in the presentation. Dr Patel agreed there were difficulties with digital access and there was a fine balance to strike. Dr Patel gave an example of a cancer champion talking at a community centre in Reading about cervical screening. She invited women, had leaflets in different languages and gave an introduction and answered basic questions. Another example was a cancer champion doing a talk in a mosque on bowel screening. This was not someone medical, but their own peer giving advice and information in a place of non-confrontation. A champion attended Reading Festival to give advice on screening. One cancer champion went on the Nepalese Ghurkha radio every Friday morning talking about different topics. They were trained to identify red flags in order to communicate it to different groups.

Councillor Linden noted that there was potentially a barrier with receptionists who were not medically trained. He also noted the shortage of pharmacists nationally. Dr Patel explained that pharmacists specialised and primary care pharmacy was a new phenomenon. This reflected that primary care was changing where they were doing more specialised care than they had done before. There were new ways of working to meet demand and everyone worked at the top of their licence.

Councillor Graham Bridgman informed the Committee that there was a West Berkshire Pharmaceutical Needs Assessment in draft for consultation.