Achieving improved cancer outcomes- a pathway approach, engaging primary care

and partners

Kathy Elliott

Programme Director – NHS Improving Quality (Delivery Team)

kathy.elliott@nhsiq.nhs.uk

Declaration of Interests

• National programme of work, funded through national and local public sector funding. No payment for this presentation or for advice.

• Partnership initiative – with contributions from cancer charities and professional organisations

• Evaluation – independent, coordination of multiple data streams. Research funded by National Cancer Action Team/ Department of Health

Introduction• Our aim - to improve cancer survival and

‘save 5,000 lives per year’• Our approach - national policy, programme

and leadership; public awareness; a health services pathway approach; research and evaluation

• Engaging and change in primary care• Working with partners to achieve and

sustain large scale change – national / local

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Colorectal Cancer 1yr RS Lung Cancer 1yr RS

Breast Cancer 1yr RS Ovarian Cancer 1yr RS

ICBP: 1 year relative survival. Coleman et al, Lancet 2011

Why are we making a difference?

• Shared purpose – understanding and harnessing the different perspectives

• Clinical leadership – GP, hospital, public health• ‘open approaches’ – sharing ideas and data,

energy-generating• Relationships and networks with ‘reach’, building

bridges and sharing knowledge for action• Patient and public focus - and outcomes• Sustaining a focus and improvement over time

The NAEDI PathwayNational Awareness and Early Diagnosis Initiative

Low public awareness and/ or negative beliefs about cancer

Late presentation to a GP

Difficulty accessing primary care

Poor survival rates

Low uptake of screening

Emergency presentations

Delays in Primary CareLate presentation to hospital services

Delays in secondary care

More advanced disease at diagnosis

Avoidable deaths

Public Awareness

• Be Clear on Cancer (BCOC) – – a national campaign – tested local and regional– Tailored to specific cancer sites and symptoms– 40 complex data sets, with bespoke analysis,

using control areas where possible

• Alignment with other public awareness raising– Cancer Charities– Local outreach and targeting– Clinician, NHS and public health endorsement

Increasing Public Awareness – impact on lung cancer• National awareness campaign for symptoms of lung cancer;

6 weeks in 2012• Public awareness of symptoms increased from 41% to 50%• Urgent referrals for suspected lung cancer increased by 30%

May –June 2011 May-June 2012Cases 7639 8335Early Stage (1 or 2) 23.4% 26.9%Late Stage (3B or 4) 62.5% 59.6%Surgical resection 13.7% 16.0%

CRUK analysis of LUCADA data 2013

Supporting Primary Care

• Package of initiatives implemented at Network/ geographic area. Centrally driven/supported, locally determined and delivered

• GP cancer leadership – national and local• Practice level cancer information (n=8,500)

– Available to the practices and public; targeted peer (GP-GP)visits

• Practical tools, resources and people to support change

GP Leadership and Primary Care Support -Evaluation

• Participation in any NAEDI initiative – 74% of practices (4380) returning data. Spread across 20 Cancer Networks (70%)

• Significantly greater increase in 2ww referrals for practices engaging in practice plans, risk assessment tools, clinical audit, significant event analysis.

• Practices that produced practice cancer plans (alone or in combination with other activities) showed the greatest change

• The amount of variation in referral practice was less for intervention practices

Practice activities (cumulative from 2009 to 2013)March 2013 All Networks*

No. of practices providing information 5917 8327

Practice not engaged in any activity 1537 26% 3947 47%

No. of practices engaged in at least one activity 4380 74% 4380 53%

Referral Pathways

and access to diagnostics

Novel diagnostic pathways 148 3% 2%

Local adaptation of guidelines 700 12% 8%Action to reduce delays 575 10% 7%

Process mapping and redesign 301 5% 4%Case finding 572 10% 7%Other 82 1% 1%Total 946 16% 11%

Awareness raising

Practice level initiatives linked to regional or national campaign 587 10% 7%

Practice preparedness for awareness campaigns 3436 58% 41%Other 325 4% 3%Total 717 12% 9%

March 2013 All networks* No. of practices providing information 5917 8327

Practice not engaged in any activity 1537 26% 3947 47%

Continuing professional development

Safety netting in the consultation 885 15% 11%

Uptake of training resources 1807 31% 22%Other 654 11% 8%Total 1815 31% 22%

Organisational development

Review of cancer metrics 2056 35% 25%

Action to implement administrative safety netting 557 9% 7%Practice Cancer Plans 949 16% 11%Other 556 9% 7%Total 2286 39% 27%

Audit

Use of RCGP / NCAT Criterion based Audit 1226 21% 15%Significant event analysis 1065 19% 13%Other 84 1% 2%Total 1525 26% 18%

Clinical decision making

Risk assessment tool 1556 26% 19%Risk profiling of individuals or patient groups 304 5% 4%Other 4 0% 4%Total 1622 27% 19%

* Assumes zero activity in non-responding networks

Mechanisms to facilitate change

• Continued education for GPs • Improvement of accuracy and use of 2 week wait

referrals – Clinical decision support tools

• Face to face engagement with practices. New work investigating intensity, capacity, and impact of practice context and motivation.

• Links to generic quality incentives• Shared purpose and vision• Use of tools to improve quality• Shift from projects to absorbing into mainstream practice

Challenges• Short-termism

– funding, fixed term contracts, organisational change, relationships between GPs and organisation of cancer services

• Clarity about roles– Realism of job objectives, individual’s roles and responsibilities

• Skills– Relationships between GPs and new (and changing) health care and public

health organisations

• Using theory and evidence– Dissemination; accessibility; easy to read and understand format for GPs

• Engaging clinicians and developing clinical leaders– Work with individual GPs ‘patchy’; clinical leadership in every practice

• Change takes time– ‘changing hearts and minds’ – as well as altering processes – Primary care a complex environment – isn’t a ‘one size fits all’ solution to

implementing change

Model of patient pathways to treatment

Walter et al, J Health Serv Res and Policy 2012

In conclusion

• Sustaining focus on improving cancer survival over time, with changes in leadership and policy

• Change, aligned across the patient pathway, including public awareness and primary care. The pre diagnosis part of the pathway is important.

• Demonstrating impact - quality of care and outcomes

• Applying learning from health service change to achieve improved patient care and population outcomes in specific diseases

Key weblinks and papers• National (England) Cancer Policy – Improving Outcomes – a strategy for cancer

– https://www.gov.uk/government/publications/the-national-cancer-strategy-3rd-annual-report--2• NAEDI

– General website - http://www.cancerresearchuk.org/cancer-info/spotcancerearly/naedi/AboutNAEDI/

– Evidence - http://www.nature.com/bjc/journal/v101/n2s/index.html and research conferences– ICBP – http://www.cancerresearchuk.org/cancer-info/spotcancerearly/ECBP/

• Be Clear on Cancer– Resources - http://www.cancerresearchuk.org/cancer-info/spotcancerearly/naedi/beclearoncancer/ – Evaluation -

http://www.cancerresearchuk.org/prod_consump/groups/cr_common/@nre/@hea/documents/generalcontent/cr_113267.pdf

• Support for Primary Care– GP Practice Profiles http://www.ncin.org.uk/cancer_information_tools/profiles/gp_profiles – RCGP - http://www.rcgp.org.uk/system-pages/search-results.aspx?keywords=Cancer

• Large scale change– http://www.nhsiq.nhs.uk/resource-search/publications/nhs-inst-leading-large-scale-change.aspx

• NHS Change Model– http://www.nhsiq.nhs.uk/capacity-capability/nhs-change-model.aspx

• Full primary care evaluation - all reports available via (archived) NCAT website and on Durham University website.