strength through partnership central south coast cancer network dr richard roope, csccn primary care...

Strength Through Partnership

Central South Coast Cancer Network

Dr Richard Roope, CSCCN Primary Care Lead

Cancer Early Diagnosis Meeting 8.2.2012



Macmillan GP Roles


Central South Coast Cancer NetworkCSCCN


Southampton & West(Vacant)

NortheastCharlotte Hutchings

Portsmouth & Southeastern(Vacant)

Isle of WightDavid Issacs

Network Leadership/coordination(RMR)



Macmillan GP Roles

•Advert to all practices in SHIP area•Interviews on 20.2.12 & 22.2.12



Macmillan GP Roles

Mainland•Awareness and Early Diagnosis -•Survivorship - •End of Life – Charlotte Hutchings

Isle of Wight•Awareness and Early Diagnosis )•Survivorship )David Issacs•End of Life )



CCG Engagement



CCG Engagement

• Approach made to all CCGs to establish lead for cancer.

• Opportunity to meet up to discuss role of network and work streams



RCGP events

•19.1.12 – “Early Detection of Cancer Study Day”



RCGP events

•30+ GPs from across SHIP area•Case studies including RAT tool



RCGP eventsFeedback•“What actions do you now intend taking?”

•“Talking to my partners re safety netting and circulate the guidelines for urgent referrals”•“Look at practice NCIN profile for cancers”•“Set up a follow up system for patients with symptoms potentially needing referral for cancer”•“Use RAT tool for bowel/lung cancers”•“Share information with partners”•“Teaching for patient group”•“Audit our cancer care”



RCGP events

•Next meeting planned for 5.7.12



Target events



Target events

•Portsmouth 25.1.2012



Target events

•Portsmouth 25.1.2012

•Break out groups x2•70 GPs attended•Full feedback not yet collated



LMC Event

•Afternoon meeting on 25th April 2012

•E-mailed to all GPs in Wessex LMC patch



LMC Event

•Afternoon meeting on 25th April 2012

•“Early cancer diagnosis leads to better outcomes - everything the GP wanted to know but was afraid to ask!”

•E-mailed to all GPs in Wessex LMC patch



LMC Event• Avoidable deaths pa if survival in England matched

the best in Europe• Breast ~2000 • Colorectal ~1700 • Lung ~1300 • Oesophagogastric ~950 • Kidney ~700 • Ovary ~500 Brain 225• NHL/HD 370 Melanoma 190• Bladder 290 Cervix 180• Myeloma 250 Oral/Larynx 170• Endometrial 250 Pancreas 75• Leukaemia 240



LMC Event

• 54 booked within 2 hours....



Practice Profiles – Dec 2011




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Index Min Max Range

2ww per 100,000

331 3200 9.67

2ww Age standardised

0.22 2.30 10.45

% 2ww conversion

0% 31.25% ∞% of cancers via 2ww

0% 100% ∞

• Huge variation of practice across SHIP – 2 week wait referrals

CWT 20010/11



Index Min Max Range

Emergency presentations per 100,0001

26 1625 62.5

% of cancer presentation via emergency route2

0% 57.14% ∞

• Huge variation of practice across SHIP – Emergency presentation

1. HES 20010/11

2. RtD 2008




% Emergency Presentation of Cancer - Southampton PCT [Average: 26.2%]

0%

10%

20%

30%

40%

50%

60%

70%

80%




% Emergency Presentation of Cancer - Hampshire PCT [Average: 21.7%]

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%




% Emergency Presentation of Cancer - Isle of Wight PCT [Average: 23.2%]

0%

10%

20%

30%

40%

50%

60%

70%




% Emergency Presentation of Cancer - Portsmouth PCT [Average: 26.2%]

0%

10%

20%

30%

40%

50%

60%

70%

80%




• Variable take up• Isle of Wight 100%• IOW>Portsmouth>Hampshire>Southampton



Practice Audit



Audit

• A challenge...• Money available• New staff appointed – personal approach



Risk Assessment Tool



Agenda Item 2.2



Agenda Item 2.3



• Mousemat and Desk Easel




Ratmat:




• Gate keeper role

• UK general practice is regarded by many to be the best in the world• The gatekeeper role has brought many benefits to patients, not

least by ensuring the correct specialist is seen• It has also brought disadvantages, arising from GPs’ desire and

more recently, external pressure to use resources appropriately.• Potential for collusion with patient: “Do I really need to….?”• In cancer this means not investigating the low-risk symptom – and

NICE tells us not to. However this may contribute to poor cancer outcomes in the UK. (cf Denmark)


Central South Coast Cancer NetworkBackground

How do GPs decide who to refer?• Some is from what has been learnt during training and

CPD• Some from ‘sixth sense’• Some from advice – like NICE• Some from patient pressure• Some from reading up research




• Colorectal Cancer

• This is one of the four commonest cancers, and possibly the one with most to benefit from improvements in diagnosis.

• Half of patients never have a NICE-qualifying symptom• Only a quarter are diagnosed via 2-week rule clinics• A quarter present as emergencies• Earlier diagnosis may give a stage shift or prevent some of

the emergencies• Duke’s A 93% 5ys: Duke’s D 7% 5ys



RAT – Colorectal Cancer

• Implement the Risk Assessment Tool (RAT) Positive predictive value



• Patient pathway:Awareness

Presentation

Investigation

Referral

Diagnosis



• Helps to decide which patients below the risk level implied by NICE guidance may benefit from urgent investigation

• Uses a combination of symptoms, signs and investigations.• Generates the proportion of patients with the listed symptom(s)who

have that cancer type

Using the RAT tool



• Used to supplement NICE guidelines• For patients ≥40• Is used after first and subsequent patient visits

Using the RAT tool



RAT – Colorectal Cancer• Implement the Risk Assessment Tool (RAT)

Positive predictive value

•Amber and red suggests 2WW referral.•Yellow and no colour best managed by review within 1º Care



RAT – Lung – Non-smokers

• Implement the Risk Assessment Tool (RAT)



RAT – Lung - Smokers

• Implement the Risk Assessment Tool (RAT)




• Embedding in 2WW referral form

• Likely to highlight a learning need. • Likely to change practice. • Likely to engender earlier diagnosis.• Likely to result in more 2WW referrals etc.• Likely to reduce emergency presentations



Agenda Item 2.4



Primary Care Safety Netting



• Safety-netting– Practice system if patient fails to attend for

investigation or clinic?– Practice system if results/correspondence go to

ground?– Not sufficient to say:

“Come back if it doesn’t get better”


Central South Coast Cancer NetworkSafety-netting


Central South Coast Cancer NetworkSafety-netting - Screening

• Bowel cancer screening DNA notifications– Enter into computer history– Flag record (computerised post-it) so next

contact with Primary Care Team patient will be reminded

– Letter sent to patient from surgery• may be worth GP signing• To provoke a response may include phrase along

lines of:



Dear

We have recently been advised by the National Bowel Screening Programme that you failed to return the test kit for analysis.

The Practice firmly believes that this simple test is a valuable aid in detecting any potential signs of bowel cancer cells, and would

encourage you to reconsider your decision.

You should continue to be aware of any bowel symptoms such as:– A persistent change in bowel habit, especially going to the toilet more often or diarrhoea for several weeks– Bleeding from the back passage without any obvious reason– Abdominal pain especially if it is severe– A lump in your abdomen

Please remember that these symptoms do not necessarily mean that you have bowel cancer, but if you have one or more of these symptoms for four to six weeks, you should see your GP.

Should you no longer have the test kit and now wish to take part, you can call the Screening freephone number 0800 707 6060 and ask for another.

If, after careful consideration, you decide not to take part, please would you let us know by returning the slip below. Your decision will have no impact on any future medical services provided by the Practice.Yours Sincerely,

Main and Branch Surgeries

I do not wish to take part in bowel cancer screening, and am aware this may delay the diagnosis of bowel cancer were I to develop it.

(signed)…………………………………………………



I do not wish to take part in bowel cancer screening, and am aware this may delay the diagnosis of bowel cancer were I to develop it.

(signed)…………………………………………………



Safety-netting – Investigations if cancer is on differential diagnosis

• Blood tests (if checking for tiredness, shortness of breath)

• CXR• USS for ?ovarian cancer

• Systems in practice so if result not received can be followed up.


Central South Coast Cancer NetworkSafety-netting – 2ww referrals

• A surprising number of 2ww referral patients who fail to attend/postpone

• Make sure patient understands that referral is to exclude the possibility of cancer

• Have system to follow up/flag up any DNAs at 2ww appointments (similar to screening DNAs)

• May be regarded as good practice to ask patient to have GP follow up 4 weeks after referral to 2ww, as by then the diagnosis is likely to have been met.



Other elements of safety-netting include:

• Communicating the existence of uncertainty • Outlining exactly what the patient needs to look out for • How to seek further help and • What to expect about time course



Patient Pathway: LAEDI - 2012 - Summary

Awareness

Presentation

Investigation

Referral

Diagnosis

New Practice Profiles:•Target Meetings•RCGP/LMC Meetings•Practice visitsSafety netting

National Bowel cancer awareness: Jan 2012•Nationwide•Multiple Media•Primary Care

RAT launch January 2012

Pan network 2ww referral forms

Lung Cancer Education Day 21.3.12

Engaging with CCGs

Summer 2012“Be Clear on Cancer”Lung cancer


Central South Coast Cancer NetworkCSCCN LAEDI Programme:

• Any questions?

strength through partnership central south coast cancer network dr richard roope, csccn primary care...

Documents

cancer care slide

cancer presentation

role of network

early cancer diagnosis

collated slide

rat tool slide

personal approach slide

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