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Meeting: Acute Oncology Expert Advisory Group (incorporating Audit) Date: 12 October 2018 Time: 2.00pm Venue: Evolve Business Centre Present: Jen Blake, AOS & CUP CNS, South Tyneside JB

Deepta Churm, Palliative Care Consultant / CUP Lead Northumbria DC

Alison Crispin, Macmillan AO CNS, Northumbria AC

Nicola Cosford, CUP/AOS CNS, Newcastle NC

Judith Curtis, AOS Specialist Nurse, South Tees FT JC

Hanni Mae Daduyo, Acute Oncology Support Sister, South Tees HD

Dawn Elliott, UGI/CUP CNS, Northumbria DE

Alison Featherstone, Alliance Manager, Cancer Alliance AF

Liz Fuller, Trust Cancer Lead & AOS Lead, South Tyneside LF

Rachel Goicoechea, Macmillan Care Coordinator, Northumbria RG

Chris Jones, (CUP Chair) Consultant Medical Oncologist, Newcastle CJ

Jo Mackintosh, Eng & Co Design Project Mgr, Cancer Alliance JM

Talal Mansy, Consultant Oncologist, South Tees TM

Jacqueline Marsh, AOS & CUP CNS, Newcastle JMa

Pamela Mohan, AOS Nurse, CDDFT PM

Neil Munro, Physician, CDDFT NM

Ian Neilly (NOAG Chair), Acute Oncology Lead, Northumbria IN

Bev North, Oncology Nurse, Newcastle

Tracy Nugent, AON, North Tees & Hartlepool TN

Anna Porteous, Palliative Care Consultant/CUP Lead, South Tyneside AP

Kendra Powell. AONP, North Tees & Hartlepool KP

Lynsey Robson AO Nurse Consultant, GHNT LR

Thelma Rosenvinge, Acute Oncology Nurse, CDDFT TR

Chantelle Steinbeck, AO CNS Northumbria CS

attendance Su Young, Business Support Assistant, Cancer Alliance SY

Apologies Katie Elliott, Primary Care Clinical Lead, Cancer Alliance KE

Jonathan Slade, Deputy Medical Director, NHS England JS

MINUTES

1. INTRODUCTION Lead Enc

1.1 Welcome and Apologies IN Welcomed all to the meeting.

1.2 Declaration of conflict Interest No Declarations of Conflict of Interest were made.

1.3 Minutes of the previous meeting 20.04.18 Enc. 1

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The minutes were agreed as an accurate record.

1.4 Matters arising Vice Chair

No expressions of interest have been received.

Standardisation of Alert Cards It was agreed to carry this forward to the next meeting.

Nurses Meeting This has not got off the ground but is a work in progress.

2. AGENDA ITEMS

2.1 Cancer Alliance Update Funding

100% Transformation Funding has been received for the 2nd half of the year. It is still unknown what will happen after March 2019. The Alliance has had to reprioritise some of the work plan to incorporate the increase in urology referrals. This is being done through work of the Service Improvement Leads.

Workforce Masterclass workshops have started and feedback has been positive. There are still places available on the Realistic Medicine and Reducing Emergency Presentation in Acute Oncology.

Pathways Optimal pathway work is ongoing. The Alliance are starting a piece of work on the Serious. Non Specific Symptoms (formerly Vague Symptoms) pathway. Members were asked if they currently had a Malignancy Unknown Origin pathways and whether there should be a standardised one across the region. It was confirmed that South Tees and Newcastle do have one in place. However, at South Tees imaging and full staging are required prior to primary care referral. It was noted that this was not a 2 week wait referral but does reduce having to go through other MDTs and patients having several trips to hospital. NM highlighted that clear guidance is required for GPs to refer patients and inform what tests should be done prior to being seen in secondary care. Action: CJ to pick up with KE following the audit data being presented. Any issues with CCGs to be picked up by CCG forum.

CJ/KE

2.2 Engagement & Co Design Project Update JM provided an update on the Engagement and Co Design

Project which is currently ¾ of the way through. The group are currently looking at a framework for patient involvement incorporating comms and capability. Within the project they are currently looking at all Expert Advisory Groups

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and the current patient representatives on each group reviewing the right person, right project, right time model and how the function of their role fit into their groups. AF highlighted that having a patient representative on a group was not a tick box exercise. The Alliance has 2 lay representatives who sit on the Board and they are willing to challenge the Alliance to ensure patient voice is given.

2.3 Clinical Guidelines It was noted that the contact details for each Trust within the

Clinical Guidelines were incorrect. It was agreed to share these with the group for amendments. It was also agreed to share the distribution list for updates and for contact numbers to be shared so these can be added to the clinical guidelines too.

NOAG

2.4 Acute Oncology Trust Updates South Tees

Acute Oncology Study Day scheduled for 5th April at JCUH. An application has been submitted to get Macmillan Funded Chemo Unit North Tees Recruitment has been made to a part time post CDDFT Trust has been 1 person down for 6 months Sunderland No Update Available South Tyneside Nil new at present Gateshead A business case for a Band 4 and 6 posts funded by Macmillan has been done and it is hoped to recruit to these in the new year. Chemotherapy Day Unit is now all Macmillan adopted. Newcastle Trust is currently trialling a 7 day service however they are struggling with the demands across both sites. The trust has been down 1 person for 9 weeks Northumbria Lot of work has been done on Neutropenic Sepsis including bringing in an alert sticker which is being used in A&E. Cumbria No Update available

2.5 Acute Oncology Nurse Update The nurses reported that they want to look at patient feedback

in acute oncology using the Northumbria model and spreading this across the region. Within this they will also look at patient information sharing especially for cross trust working.

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Northumbria have honorary contracts which will help with this and gain access to sites.

2.6 Neutropenic Sepsis Audits and Updates

Audit presentations and data was provided by the following Trusts:

South Tees

North Tees & Hartlepool

Gateshead

Newcastle

Durham

Northumbria

South Tyneside A discussion was held within the group regarding the audit criteria for the audit and a request for a clearer definition for future audits. It was noted that all Trusts are currently auditing slightly differently and they should all be doing the same thing. Suggestions for the criteria discussed were:

Time from emergency presentation to acute area to antibiotics

Recently had chemo or haematology

Potentially Neuro / sick / Source of sepsis / trigger / high temp / low temp / clinical suspicion

MSCC

2.7 MSCC Trust Updates

Newcastle reported that audit data / pathways were poor and highlighted that they were looking at making the pathway better and that the pathway proforma is changing to include spinal and OOH MRI. County Durham reported that 84% of patients were scanned and patient factors were slowed down for time to MRI. The Trust welcomes the changes that are to come.

2.8 MSCC Audits and Updates

MSCC audit presentations were given by the following Trusts:

South Tees

North Tees

Northumbria

Gateshead

CUP

2.9 2 Week Wait Referral MUO Pathway Feedback

CJ gave a presentation on the pilot for the 2ww referrals. There is a lot of work to be done to ensure the referral form is correct and that these are being completed correctly too ensuring the necessary tests are undertaken.

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Further amendments to the form are to be done and CJ will discuss further with KE for this. Some Trusts identified barriers with radiologists and have various ways in which referrals are made. CJ asked the group if they would be happy to use a standard form across the region. North Tees and Gateshead would be happy to use the form. LF raised concerns regarding delays for lung cancer referrals. The outcome from the audit was 50% of 2WW referrals do have cancer.

2.10 Clinical Trials A new clinical trial for CUP started 10 days ago and CJ has

shared this with CUP teams across the north of the region however did not have contact details for the South. This was requested. The trial has to be done through the Bobby Robson Centre to enable the new drugs. There is a specific criteria for those who can undertake the trial this includes:

• fit patients, PS 0-1 • willing to travel to Newcastle • histology showing adeno or poorly diff carcinoma

– squamous and high-grade NET not eligible • full work up according to ESMO CUP guidelines • no previous chemotherapy • metastatic or advanced unresectable disease • suitable for gem/cis, gem/carbo or carbo/taxol

Patients are to be seen at least every 3 weeks and feedback will be given back to Trusts. The trial has requested 10 patients over the next 2½ years.

3. STANDING ITEMS

3.1 Any Other Business None

3.2 Next Meeting Date Friday 15 February 2018, 2.00 – 4.00pm

Friday 4 October 2018, 2.00 – 5.00pm (Incorporating Audit Event) Evolve Business Centre

4. MEETING CLOSE

Contact [email protected] Tel 011382 53046

mailto:[email protected]

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Meeting: Acute Oncology Expert Advisory Group Date: 20th April 2018 Time: 2.00pm Venue: Evolve Business Centre Present: Jen Blake, AOS & CUP CNS, South Tyneside JBl

Jackie Brown Cancer Manager, NTH JBr

Nicola Cosford, CUP/AOS CNS, Newcastle NC


Liz Fuller, AOS Lead/RTSP Cons , South Tyneside LF

Liz Goddard AON, North Tees LG

Rachel Goicoechea, Macmillan cancer care co-ordinator, Northumbria RG

Alistair Irwin, (MSCC Chair) Consultant, Newcastle AI


Pam Mohan, AOS Nurse, CDDFT PM

Ian Neilly (NOAG Chair), Acute Oncology Lead, Northumbria IN

Tracy Nugent, AON, NTH TN

Kendra Powell. AONP NTH KP

Anne Richardson, Service Improvement Lead, Cancer Alliance AR


Chantelle Steinbeck, AO CNS Northumbria CS

Jen Virdrine, Consultant Palliative Medicine, Newcastle JV

attendance Laura Lund, Business Support Assistant, Cancer Alliance LL

Claire McNeill, Senior Administrator, Cancer Alliance CM

Apologies Catherine Simpson, Acute Oncology Nurse Specialist CS

Louise Davison, Acute Oncology Nurse Practitioner LD

Deepta Churm, Palliative Care Consultant / CUP Lead Northumbria DC

Thelma Rosenvinge, AOS Nurse, CDDFT TR

MINUTES


1.1 Welcome and Apologies IN Welcomed all to the meeting.

1.2 Declaration of conflict Interest No Declarations of Conflict of Interest were made.

1.3 Minutes of the previous meeting 18.10.2017 Enc. 1 All agreed the minutes were a true and accurate record

1.4 Matters arising Audit Proforma

IN handed out copies of the proposed audit proforma. Group discussed the proposed document and suggested

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an amendment to “Time of pyrexia” to “Time to pyrexia or temp below 36”. All agreed to use the new document, which will be circulated with the minutes. IN to forward a copy of the amended document to CM. MSCC – standardised form has been put on hold to allow all to continue collecting data as current process.

CM

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2. AGENDA ITEMS

2.1 Cancer Alliance Update

One Year On Event Feedback

Event went really well and feedback is very positive. Current plan is to hold another event September 2019

Transformation funding

Transformation funding has been confirmed for this year as collectively as an Alliance we managed to achieve 62 day target. This means the alliance will received 100% for the first 6 months and then the national team will undertake a further review due in September.

Work Programme

Alliance is currently working on this and once completed will be circulated to all groups.

2.2 Terms of Reference

Group discussed the draft terms of reference and the following was agreed;

Patient representative – no patient representative at the moment. AR will contact Joanne Macintosh at the Alliance to address this.

Palliative care representative will need to move up to core.

Clinical research network presentative- no current member need to address this.

No TYA representative required. Vice chair – position is currently vacant. If anyone would like to send in an expression of interest of would like further details please contact [email protected] CM to add Chair job description to the minutes for information. Group agreed with the amendments made. CM to circulated amended document.

CM

CM

Enc 3


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2.3 Engagement & Co Design Project Update

AR advised Jo Macintosh (JM) was the lead for this and would be invited to attend the next meeting. Jo is working on embedding patient voice in all decisions and co-designing services. JM to present at the next meeting. AR to action.

AR

2.4 Clinical Guidelines

CM will email out the clinical guidelines for all to review. Amendments to be sent to [email protected] by end of June 18. The guidelines will then be circulated to the group to review but will need to be brought back to the group for formal endorsement at the next meeting

CM

2.5 Clinical Advice for Provision of acute Oncology Services

Received for information

Enc 4

NOAG

2.6 Acute Oncology Trust Update

Northumbria Now have 3 members of staff and working to develop service and working with neutropenic pathways

North Tees and Hartlepool 2 WTE and no plans to expend. Service is well established within the trust and neutropenic sepsis figures are very good. 95% patients have MRI within 24 hours.

Gateshead 1WTE to cover AOC and CUP- looking at Macmillan to fund a band 6 post. Currently looking how to work with band 4s for holistic needs.

Durham

Now have 4 WTE AOS nurses – 2 at Darlington and 2 at Durham

South Tyneside

Nothing to update.

Newcastle Now have 3 WTE so currently at full capacity. Trialling 7 days service as well as looking to improve links with RVI.


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South Tees 2.6 WTE currently the .6 post holder is on maternity leave. Overall a vast improvement MSCC and sepsis. 2 band 4 Macmillan coordinators have made a positive impact on the service. Train the trainer day NECON 2- Judith Curtis advised they was still a few placed available for the train the trainer day on the 19 June., anyone interested please contact her .

All

2.7 Acute Oncology Nurses Update

Plan to restart this meeting. Nurses to meet an hour before this meeting which will be Friday 12th October 2018, 1.00pm – 2.00pm CM to check room available for this time.

All

CM

2.8 QR Codes

Group discussed QR codes and IN was trying to introduce these to be provided on chemotherapy books to enable DRs to get quick and accurate guidance on how to deal with toxicities. Document to be attached to minutes.

Enc 5

2.9 Alert Cards

JC advised they have an immunotherapy alert card as well as chemotherapy alert card and if anyone would like a copy to contact her at [email protected] MSCC leaflet –people confirmed they are modifying them locally. Post meeting note; Nurses to discuss standardisation of Alert cards at the next nurses meeting.

NURSES

MSCC


Sunderland spinal service in flux at the moment. With commissioners at the moment to review- but could possibly move and that will affect how quickly patients


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can be treated.

Statistics AI discussed the need to collect data relating outcomes and the need to accurately record this data collection. Data required is ;

o 30day mortality o time to treat o Patient seen in 24 hrs o MRI within 24 hour and plan

Rehabilitation No neuro rehabilitation but don’t have a cancer specific pathway. Working with physiotherapist to address this.

Repatriation Group discussions agreed that repatriation of patients remains an issue. Guidelines are beds should be kept open to repatriate patients this does not appear to happen. Group discuss the issue of bed manager’s lack of understanding. Group agreed to pull together an agreement to address this. AI to draft document and bring to the next meeting.

Figures for audit Group discussed when does clock start re presentation as guidance appears to say any health care professional which would include a GP. AI to clarify this and feedback at the next meeting.

Outcomes AI advised Newcastle is struggling to collect data on patient outcomes, but this needs to be addressed and specifically mortality data.

Leaflet All patients should receive this leaflet however group were reluctant to do this as it scares the patients Group agreed to provide leaflet to patients who show any Neurological systems.

AI

CUP

2.11 2 Week wait Referral Feedback Form

CJ developed 2ww referral form with Katie Elliott Cancer Enc 6

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Alliance Clinical Lead. Presentation attached for information. CJ asked if anyone else would like to pilot this please contact either himself or Katie Elliott.

CUP services updates

Newcastle New AOS nurses now have 3wte who support CUP services which has provided additional support. Robust service with once a week clinic and weekly MDT. Now piloting the CUP 2 ww referrals

Northumbria

Developing the service- weekly MDT sitting beside upper GI

North Tees Standalone service, Main concern is the delays experienced before being referred to CUP MDT- normally been through a couple of other MDTS Non-surgical patients are a challenge. Awareness is key but progress is being made.

Gateshead Standalone MDT – building up the service and now making an impact and getting a number of referrals. No CUP clinic at the moment but looking to address this.

South Tyneside In process of rewriting the pathway and has contact CJ for assistance. Trying to get band 7 nurse which is proving difficult. Band 5 alliance funded post focussed on red flagging patients to try to get these patients referred early on.

Durham Don’t get a lot of referrals- MDT links to JCUH and now established. One a week clinic. Generally most refer but normally been through a number of MDTs first.

South Tees CUP MDT and clinic in place. Telecom with Darlington and Durham. Establish clinic with a number of inappropriate referrals- working with practices to address this. GP lead doing an article in GP newsletter to highlight the fact referrals for vague symptoms appear to be referred to CUP.

2.12 Clinical Trials

CJ discussed the MS39795 Study with is detailed in the attached enclosures. CJ advised this was a fantastic opportunity and will be contacting all with inclusion criteria

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Patients would need to attend Newcastle for treatment so patients must be fit to travel. Group queried if fit patients could be referred direct to Newcastle to avoid delay. CJ advised that would be acceptable.

3. STANDING ITEMS

3.1 Any Other Business Patients satisfaction survey

North Tees & Hartlepool questioned how to increase the amount of feedback given the severity of the patient’s condition. CJ suggested asking for nurses to record feedback when consultant has discussion with the patient. North Tees and Hartlepool also advised they have a text service so any text received can also be used. Suggestion made to leave it a month and then send questionnaire and this has improved completion rate to 50%

7 day a week acute review LF asked all how they are responding to 7 day a week

acute review. A number of people record telecom consultation at a weekend as a review.

Audit Event Group agreed to present date covering July 17 to September 17 at the audit event on the 12 October 2018.

3.2 Next Meeting Date

Friday 12 October 2018, 2.00pm- 5.00pm Audit Learn and Share event

4. MEETING CLOSE



Northern Cancer Alliance Expert Reference Groups

Chair Job Specification February 17

Job Title: Chair Expert Reference Group

Responsible to: Clinical Lead Cancer Alliance

Accountable to: Northern Cancer Alliance Manager

ROLES AND RESPONSIBILITIES The Expert Reference Group (ERG) Chair has overall responsibility for the development of co-ordinated, cohesive and integrated networked cancer services for a specific tumour site. This will be achieved primarily by ensuring that the ERG operates efficiently and effectively to facilitate these developments across the Alliance. Specifically, the Chair should:

Work with the Northern Cancer Alliance to ensure all Trusts in the network are involved and primary care is appropriately represented.

Aim to ensure groups are multi-professional in nature.

Take responsibility for delivering on the Cancer Alliance Work Plan for the Group.

Ensure that systems and processes are in place to:

- Review (and update) local and national outcomes - Collect minimum cancer data sets - Support accreditation/quality assurance - Facilitate user involvement in the development of services

Ensure that any Tumour specific issues of clinical governance are supported by

adequate protocols across the region.

Organise meetings at least twice a year. The Northern Cancer Alliance will provide support to book rooms and circulate agendas for these meetings. (see ERG TOR for additional local meetings)

Prepare the agenda for and chair ERG meetings ensuring that adequate time is allowed

for each item under discussion and stakeholders’ views are sought.

Ensure that minutes and action notes are circulated as appropriate.

Ensure a vice chair is nominated. This would support succession planning and help in attending various meetings.

Ensure that the Cancer Alliance Manager is briefed about the progress being made by the ERG or any specific issues.

Lead discussions with other ERGs on issues of common interest.

VICE CHAIR

The ERG Chair is a challenging role. Good practice would be Chair and Vice Chair (preferably one from North and one from South) this would support succession planning. NOMINATION AND SELECTION PROCESS

Nominations for Chair and Vice Chair, to come from the ERG, followed by a selection process (undertaken by the Northern Cancer Alliance Board). TERM OF OFFICE

2 years with an option to a further 2 years (maximum 4 years Term of Office). The chair and the vice chair may agree to switch role after 1-2 years. SUPPORT

Employing Trust The chair must secure its own Trust support to undertake the role Northern Cancer Alliance staff/ team

PERSONAL QUALITIES AND EXPERIENCE Ideally, the Chair will:

Be able to influence others to develop a commonly held vision for the development of the service

Demonstrate enthusiasm for working collaboratively with other organisations, including other Trusts and primary care

Be energetic and enthusiastic and capable of enthusing others Have excellent communication skills Be a team player, able to lead and work within a multidisciplinary environment, with an

appreciation of the skills which different professions can bring to the service Have capacity in their current workload to carry out the function of Chair Be a recognised expert in the care of cancer patients for the tumour site Have widespread experience in the general care of cancer patients Show commitment to developing the Site Specific Group Have the ability to think strategically

Review Date: March 2019

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Meeting: Acute Oncology Expert Advisory Group

Date: 18 October 2017

Time: 2.00pm

Venue: Evolve Business Centre

Present:



Alistair Irwin, (MSCC Chair) Consultant, Newcastle AI


Ian Neilly (NOAG Chair), Acute Oncology Lead, IN

Thelma Rosenvinge, AOS Nurse, CDDFT TR

Clare Bradbury, Cancer Care Co-ordinator, South Tees FT CB

Liz Fuller, AOS Lead/RTSP Cons , South Tyneside LF

Jen Blake, AOS & CUP CNS, South Tyneside JB

Carolyn Harper, Head of Cancer and Palliative Care, Gateshead CH

Susanna Young, Business Support Assistant, Cancer Alliance SY

Karen Dunn, Business Support Assistant, Cancer Alliance KD

Apologies Neil Munro, Physician, County Durham & Darlington NM

Tracy Nugent, AON, North Tees TN

Amanda Walshe, Lead Cancer Nurse, Northumbria AW

Kath Jones, Network Team Lead, NESCN KJ

Radha Todd, NUTH RT

Faye Laverick, AOS Nurse, Sunderland FL

Catherine Simpson KS

Emily Park EP

MINUTES


1.1 Welcome and Apologies

IN welcomed everyone to the meeting and apologies were listed above.

1.2 Declaration of Interest

None.

1.3 Minutes of the previous meeting 14.12.16

The minutes of the previous meeting were agreed as an accurate record.

Enc 1

1.4 Matters arising

Previous MSCC Audits Audits from the previous year were accessible via the

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Website, anything prior to that could be requested via email to Su Young.

2. AGENDA ITEMS

2.1 Cancer Alliance Update

Transformation Bid Transformation funding had now been received for Q1 & Q2. A number of new appointments had been made including Service Improvement Leads and Clinical Leads: Service Improvement Leads

Claire Doney - Newcastle

Ann Richardson – Tees North & South

Mary Lunney & Ross Berry- Cumbria

Kelly Craggs - Sunderland

Michelle Wren – Northumbria Clinical Lead – Lung

Dr Liz Fuller It was noted Milestone plans and Implementation plans had been agreed by the National Team. KD Business Support Assistant, Cancer Alliance would provide future Admin support to the Group.

Delivery Plan The delivery plan had been condensed into a plan on a page, this was now accessible via website. http://www.necn.nhs.uk/wp-content/uploads/2014/04/Cancer-plan-on-a-page-FINAL.pdf

CUP

2.2 CUP Audit Presentation

CJ presented an audit entitled 2017 CUP NSSG Audit “Referral Pathways and Keyworker”. This Presentation is accessible via the Website. With regards to the submission of Audit Forms it was noted 4 Trusts had responded. JC expressed concern

http://www.necn.nhs.uk/wp-content/uploads/2014/04/Cancer-plan-on-a-page-FINAL.pdf



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that South Tees had collected and submitted information but it did not show in the presentation, CG confirmed this had not been received. Going forward CJ highlighted future audit suggestions: Focus on local audits

- Timely assessment of CUP referrals - MDT recommendations versus outcomes - 30 day morbidity and mortality

2.3 2 Week Wait Referral Form Feedback

As the Alliance was looking at all 2WW referrals forms, a revised urgent referral form for malignancy of undefined origin (MUO) in adults was shared. The following was discussed:

Referral and eligibility criteria

Referral pathway - 5 referrals since end of August, however, these did not follow the pathway for CUP.

Learning and Action Points – Pathway for MUO referrals will be presented again to Newcastle GPs

Suggested changes to the 2WW MUO form – tick box for mandatory requirements, a number of suggestions were made by the Group, these would be factored into the revised form.

CJ confirmed the form would be redesigned and the pilot would continue. Further case studies would be shared at the next meeting.

CJ

2.4 Clinical Trials

No clinical trials for CUP patients to report. This item was part of the old peer review requirements and should now be removed from future Agenda.

KD

NOAG

2.5 Neutropenic Sepsis Audit Presentation

All Audit presentations discussed can be accessed via the Website Northumbria Neutropenic Sepsis Audit Figures July – December 2016

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Number of patients 49 iv antibiotics after pyrexia Times not documented in 4 patients 2 were given oral antibiotics 27% in 1 hours 72% in 2 hours 83%in 3 hours Will shortly have an acute oncology nurse everyday which should improve the situation. CDDFT Neutropenic Sepsis Audit Figures July – December 2016 Total number of patients 57 Median time to antibiotics (mins) 40 Range (mins) 1-339 Average (mins) 56.4 % who had antibiotics within 1 hour 70.9 A number of observations were listed Newcastle Hospitals Neutropenic Sepsis Audit Figures July- December 2016 Number of patients 204 Confirmed neutropenic patients 101 Percentage of patients receiving antibiotics with 1 hour target: 79% Median door to needle time to receiving antibiotics Median 45 mins Range (0.490 mins) Average 74.4 mins South Tyneside 52 patients 29 treated within 1 hours 55.8% Average time to antibiotics 54 minutes Shortest Time 5 minutes Longest Time 235 minutes Capacity to do training in A & E was noted as a problem. It was agreed a proforma for future Audits would be beneficial. SY would look for a previous proforma spreadsheet. CH indicated Alison East had updated this, SY to liaise with Alison East.

SY

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2.6 Patient and Carer update

Jo Mackintosh had recently been appointed as Engagement and Co-Design Programme Manager and would be joining Groups once she took up her post. A Steering Group had now been established; membership included a number of patient, carers and Trust representatives.

2.7 Acute Oncology Nurses Update

The following updates on Acute Oncology Nurses across the Trusts were noted: Northumbria

1.5 Oncology Nurse in post

Admin support based at NSEC

Funding from Macmillan for 4 years then Trust would carry it on.

CDDFT

2 Oncology Nurses in post

New nurse to start Durham in January

Admin support South Tees

2.6 full time AOS & CUP nurses

2 Band 4 Cancer Care Co-ordinators

Audit date only available for 3 months

12 January Acute Oncology Study Day, James Cook Hospital

30 November Oncology talk on Lung Cancer and Sepsis update, Judges Hotel Yarm

11 December Study Day Management of Immunotherapy

Recent Study Day at Trust was well represented, willing to do further train the trainer for Triage. Further details on all Study Days is available from Clare Bradbury [email protected] Gateshead

1 AO Nurse

Audit presentation MSCC

Looking at developing CUP Clinic and 2 week referrals

Working with chemotherapy to cover shortage of staff


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South Tyneside

New lung AO nurse being trained

Admin post to go out to advert soon

2.8 Nursing Audit

No data received to present.

MSCC

2.9 MSCC Audit Presentation AI

All Audits presentations discussed can be accessed via the Website. Northumbria Retrospective July – December 2016 13 patients 5 had MRI within 24 hours 6 within 72 hours 7 later 4 had surgery 9XRT 10 alive 30 days post therapy 6 alive 3 months post therapy 1 bed bound 2 Transfer with assistance 2 walking with aids 3 walking independently Lung50% Prostate 34% Colorectal 8% 8via EC 3 via Oncology Clinic 1 each via neurology and orthopaedics CDDFT MSCC Audit Figures July – December 2016 Total number of patients 32 MSCC no 27 MSCC yes 5 Treatment type - Best supportive care 2, radiotherapy 2 Surgery 1 Newcastle 116 referral 65.5% had radiotherapy 17.7% had surgery 12.2 %had BSC 4.4 %had other

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South Tyneside Number of patients 45 84.4 of MRIs within 24 hours of request 40 had confirmed or impending MSCC Future Audits Audit pro-forma for July – December 2017 to be sent and re-done. AI would forward pro-forma to SY to share with the Group prior to discussion at the next meeting. It was agreed next year’s data would start in January. NICE Guidelines – patients to be nursed flat with spinal injuries – AI to change wording on pathway and send it to SY to share with the Group.

AI

AI/SY


Acute Oncology leaflet was discussed. IN acknowledged that the Quality Surveillance Team had felt it was inappropriate to contact GPs. It was noted in Newcastle patients contacted MSCC co-ordinator. LF suggested changes to wording. IN to contact Katie Elliott and Chris Tasker to discuss.

IN

3. STANDING ITEMS

3.1 Any Other Business

QR Codes IN referred to a Publication from the British Nursing Journal in relation to QR Codes, this enabled Junior Doctors quick access to Management Guidelines. QR Codes would be discussed at the next meeting Alert Cards Alert Cards for patients – it was acknowledged standardisation would be beneficial. All alert cards to be shared and discussed at the next meeting

KD KD

3.2 Meeting Dates 2018 - TBC

To be confirmed. The Group expressed a preference for future meetings to be held on Friday afternoons.

4. MEETING CLOSE



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Meeting: Network Acute Oncology Group Date: 14 December 2016 Time: 2.00pm Venue: Evolve Business Centre

Present: Jennifer Blake, Lung Oncology Nurse, South Tyneside JB

Deepta Churm, Palliative Care Consultant/CUP Lead, Northumbria DC

Emma Craig, AOS CNS, Newcastle EC

Judith Curtis, AOS Specialist Nurse, South Tees JC

Alison East, Lead Cancer Nurse, Newcastle AE

Dawn Elliott, CUP & Upper GI Lead, Northumbria DE

Chris Jones, (CHAIR CUP) Consultant Medical Oncologist, Newcastle CJ

Kath Jones, Network Team Lead, NESCN KJ

Faye Laverick, AOS Nurse, Sunderland FL

Pamela Moman, AOS CNS, County Durham & Darlington PM

Neil Munro, (CHAIR NAOG), Physician, County Durham & Darlington NM

Bev North, MSCC Co-ordinator, Newcastle BN

Tracy Nugent, AON, North Tees TN

Emily Park, AOS/CUP CNS, South Tees EP

Ruth Plummer, Medical Oncologist, Newcastle RP

Kendra Powell, AONP, North Tees KP

Lynsey Robson, AO nurse & CUP, Gateshead LR

Oliver Schulte, Consultant Radiologist, South Tyneside OS

Angela Simpson, AOS CNS, Newcastle AS

Richard Thomas, CUP Lead, North Tees RT

Amanda Walshe, Lead Cancer Nurse, Northumbria AW

Susanna Young, Administrative Support, NESCN SY

Apologies: Dawn Ashley, AOS Lead Nurse, North Tees DA

Fiona Chatfield, AOS Nurse, Northumbria FC

Julie Huggan, AOS CNS, Newcastle JH

Alistair Irwin, AI

Ian Neilly IN

John Painter, Consultant, Sunderland JP

Mike Rickards, A&E Consultant, Northumbria MR

Helen Roe, Nurse Consultant, North Cumbria HR

Thelma Rosenvinge, Acute Oncology Nurse Specialist, UHND TR

MINUTES


1.1 Welcome and Apologies NM welcomed everyone to the meeting and apologies

were listed above.

1.2 Declaration of Interest

2

None

1.3 Minutes of the previous meeting 17.06.16 The minutes of the previous meeting were agreed as an

accurate record.

Enc 1

1.4 Matters arising NOAG Chair Nominations

No nominations have been brought forward. NM informed the group that he would no longer be able to carry on as chair from the end of this year. NM asked the group for nominations.

2. AGENDA ITEMS

2.1 Cancer Alliance Update KJ gave an update on the Cancer Alliance.

The Cancer Taskforce Strategy (2015) outlined 6 priorities –

prevention

early diagnosis

patient experience

living with and beyond cancer

high quality and modern services

commissioning provision and accountability

Cancer Alliances are seen as one of the vehicles to implement these priorities working across meaningful geographies built around patients flows. The aim of the Cancer Alliance is to improve outcomes and patient experience by bringing together all local partners to plan and provide sustainable high quality integrated services. The Northern Cancer Alliance will be the same geography as the current cancer network, will use current network staff to provide some infrastructure and will cover 3 STP footprints – Northumberland, Tyne & Wear, West, North & East Cumbria and Durham, Darlington, Tees, Hambleton, Richmondshire and Whitby. The Cancer Network are currently conducting a series of meetings with Commissioners and Providers to develop a Memorandum of Understanding and to consider the structure and governance processes. The first Board meeting took place at the beginning of November and the national team have been advised of the Northern Cancer Alliance geography and leadership team.

3

Chair - Mr Andrew Welch - Medical Director, Newcastle Hospitals

Alliance Manager – Mrs Alison Featherstone

Clinical Lead - Dr Tony Branson Funding has been confirmed until March 2017 and the team are currently developing the delivery plans which are to be completed by 18 January. A structure is now available and attached for information. Transformation fund bids are now available to apply for and the deadline is middle of January. The first piece of work the alliance will be working on is a regional breast service review.

2.2 Immunotherapy Presentation A presentation was given by Ruth Plummer on

Immunotherapy and Toxicity. A copy of the presentation and guidelines are attached. The presentation was well received and created a wide discussion within the group. The following items were discussed:

Expected timescales for patients to be reviewed

Side effects

Commissioned drugs by NICE

Auto-antibody screening

Implementation of alert system (not been developed yet)

Issues around endocrinologists taking patients on if not receiving treatment at that hospital.

Ways of expanding across the region

Patient information leaflets to identify side effects

Training for acute oncology to include immunotherapy.

Enc 2

2.3 Spinal Cord Co-ordinator Bev North from Newcastle gave a talk to the group on the

changes that have been made to the pathway. It is hoped this change will enable the service to be more streamlined and be available to the Trusts via the intranet. A new NHS.net mail account has been set up for receiving all forms and any access to the service. Some issues have been raised regarding the switchboard and the transferring of calls to the relevant people and this is being looked into. The form is still in draft form however it is hoped that this will be available soon however the current form should be

Enc 3

4

used in the interim. SY agreed to forward a word version of the form to group members. It was noted that the south of the region do not have a form however they have been making communication between sites. They noted they would be happy to adopt a form for audit purposes.

SY

2.4 Acute Oncology Audit Event Evaluation Report The evaluation report following the audit event in June

was circulated for information and attached.

NOAG

2.5 Work Plan The work plan requires updating and aligning with the

delivery plan for the cancer alliance. It was agreed to include immunotherapy for the education event.

2.6 Patient and Carer Update SY informed the group that Claire Singleton (patient

representative) has now stood down from this role. The group thanked Claire for all the involvement and support she has given to the group. A new patient rep is required and SY agreed to forward the information through to AE.

SY

2.7 MSCC Trust & Nurses Updates Updates were provided by both Trusts and Nurses.

The nurses met prior to this meeting where the majority of their discussion was regarding the 7 day working and the challenges this is providing. This is currently being done in the south of the region. It was suggested that this be audited and reviewed at the education event for in hours and out of hours. Northumbria reported that the AO service was previously done through the oncology day units however since the new hospital opened this has caused issues as some patients seem to be going through as A&E admissions.

2.8 NICE Neutropenic Sepsis Guidelines These have been released

CUP

2.9 Trust Updates and Feedback from Peer Review CJ informed the group that the final reports following the

Peer Review visits were received last week. Each provider discussed their findings following the visits. CJ

Enc 4

5

agreed to look and share an overall summary document from the network.

CJ

2.10 Feedback from CUP Patient Satisfaction Survey CJ gave a presentation on the patient satisfaction survey

results. A copy is attached. The following themes were identified:

• generally very positive comments on access to and communication with CNS/key worker

• some patients may not be getting a permanent record of their treatment plan or consultation

• some patients may not be getting information about the CUP team

• patients are aware of cancer research going on in their hospital, but it is not often discussed directly and responders had not taken part in any research

CJ agreed to share the CUP team information form with the group for them to use as a template.

CJ

Enc 5

2.11 Primary Care 2 Week Wait Referral Form The referral form has been finalised but not yet launched.

It has been agreed to pilot the form and feedback from the pilot will be given at the next meeting.

SY

2.11 Clinical Trials CJ noted that there is still no specific CUP trial however

he informed the group that CUP will be part of the next cohort of the 100,000 GNOMES trial. CJ agreed to keep the group updated.

2.12 Work Plan The work plan was discussed and progress has been

made. It was agreed to add the primary care referral form to the work plan and this will also be aligned to the delivery plan for the cancer alliance. It was noted that there is a need to have a CUP audit and a suggestion was made to do an audit on the roots of referrals. CJ agreed to create a form for collecting this data.

CJ

Enc 6

3. STANDING ITEMS

3.1 Any Other Business Handover of Key Worker

TN raised an issue of patients not receiving the correct treatment once they have been transferred over to a key worker. It was agreed to keep this under a watching brief and discuss more in depth if required.

6

Thank you to Neil Munro The group thanked Neil for the work he has done as Chair of the NAOG and wished him well for the future.

3.2 Meeting Dates for 2017 TBC

4. MEETING CLOSE



USS shows axillary nodes

Radiology flag to GP to refer to

CUP team

Faxed letter No CXR No PSA

Final diagnosis Metastatic melanoma

67

MRI shows possible bone

metastasis


CUP team

2WW form e-referral

CXR Myeloma screen

Final diagnosis Benign

59

USS shows axillary nodes


CUP team

2WW form e-referral

CXR No PSA


61

USS shows adrenal lesion


CUP team

2WW form e-referral

CXR


66

MRI shows bone marrow

replacement and midline soft tissue


CUP team

2WW form e-referral

CT requested Tumour markers

Final diagnosis Lymphoma

34

Clinical Advice to Cancer Alliances for the Commissioning of Acute Oncology Services

This document was produced by NHSE Chemotherapy Clinical Reference Group August 2017

Title of document: Clinical advice to cancer alliances for the commissioning of Acute Oncology Services

Author. NHS England Chemotherapy Clinical Reference Group

Issue/approval date: 10/2017 Next review date: 10/2018 Page 2

Document Title

Clinical Advice to Cancer Alliances on Commissioning of Acute Oncology Services, including metastatic spinal cord compression

Date of issue: August 2017 Date of review: August 2018 Prepared by: This guidance is prepared by the Acute Oncology Expert Advisory Group, Chaired by Dr Ernie Marshall, on behalf of the NHSE Chemotherapy Reference Group Chaired by Professor Peter Clark. The Acute Oncology Expert Advisory Group has a wide geographical and multi-disciplinary representation from the full range of professionals involved in delivering acute oncology services, as well as oversight from the fully constituted Chemotherapy Reference Group. The EAG’s secretariat is provided by Macmillan. Audience: This document was written for local and specialist commissioners of cancer services and commissioners of urgent care and will have particular relevance for cancer alliances, acute care providers and specialist cancer Trusts. Groups consulted: This document was produced by the NHS E Chemotherapy Clinical reference Group and Acute Oncology Expert Advisory Group whose members represent a wide range of disciplines and geographical perspectives. The quality surveillance team were also consulted and involved in the development of the outcome measures. Purpose: The purpose of this document is to inform cancer and urgent care commissioners (specialist commissioning and local clinical commissioning Groups) and Providers of the requirements for establishing effective Acute Oncology services and outcome metrics and to recognise Acute Oncology as a vehicle to continuously improve the quality, safety and delivery of seamless urgent cancer care across primary, secondary and tertiary boundaries




Contents 1. Executive Summary………………………………………………………………… 5

1.1 Key priorities……………………………………………………………………. 6 1.2 Key outcome measures……………………………………………………….. 6 1.3 Key responsibilities……………………………………………………………. 6

2. Population needs 2.1 National/local context ad evidence base…………………………………….. 6 2.2 Acute Oncology……………………………………………………………........ 7 2.3 Opportunities, 5 year view and Cancer Strategy/Urgent care….………….. 7

3. Process and Outcome measures.………………………………………….……... 8

3.1 Inpatient…………………………………………………………………………. 8 3.2 Admission avoidance………………………………………………………….. 9 3.3 Data and information management………………………………………….. 9

4. Scope………………………………………………………………………………… 10 4.1 Acute Oncology and Haemato-Oncology.…………………………………… 10 4.2 Population covered…………………………………………………………….. 11 4.3 Acceptance criteria…………………………………………………………...… 12 4.4. Exclusion criteria………………………………………………………………. 12 4.5 Service description and care pathway……………………………………….. 12 4.5.1 The acute oncology patient pathway………………………………………. 12 4.5.2 Community presentation and cancer patient triage………………………. 12 4.5.3 Patient information…………………………………………………………… 13 4.5.4 Emergency Department (EDs)……………………………………………… 13 4.5.5 Acute Medical Units (AMUs)………………………………………………… 14 4.5.6 Inpatient care…………………………………………………………………. 14 4.5.7 Discharge planning………………………………………………………….. 14 4.5.8 Clinical trials………………………………………………………………….. 14 4.5.9 Carcinoma of Unknown primary……………………………………………. 14 4.5.10 Acute Oncology and Metastatic spinal cord compression (MSCC)…… 15

5. Service model……………………………………………………………………….. 15

5.1 SACT/Radiotherapy treatment centres (Tertiary Cancer Referral Centres) 15 5.2 Acute Hospitals without dedicated specialist oncology beds……………… 15 5.3 Acute Hospitals with dedicated specialist oncology beds………………….. 15 5.4 Core Minimum Requirements for the AOS…………………………………… 16 5.4.1 The AOS and Staffing……………………………………………………….. 16 5.4.2 The Acute Oncology Team (AOT)………………………………………….. 16 5.4.3 Weekly review meeting……………………………………………………… 17 5.4.4. The Trust Acute Oncology Group…………………………………………. 17 5.4.5. The Network Acute Oncology Group……………………………………… 18 5.4.6 Acute Oncology Training and Education………………………………….. 18

5.4.7 Acute Oncology and Specialist Palliative Care……..…………………….. 18 5.4.8 Acute Oncology and Pharmacy…………………………………………….. 19




6. Interdependencies with other services/providers………………………………... 19 6.1 Co-located services…………………………………………………………….. 19 6.2 Interdependent services………………………………………………………. 19 6.3 Additional key relationships…………………………………………………… 19 7. Applicable service standards………………………………………………………. 20 7.1 Applicable national standards e.g. NICE…………………………………….. 20 7.2 Applicable standards set out in Guidance and/or issued by a competent

body (e.g. Royal Colleges)……………………... …………………………….. 20 8. References………………………………………………………………………….. 20




Executive Summary

Cancer emergency care places an enormous pressure on the NHS urgent care services and is frequently associated with poor patient experience and poor outcomes. One in five cancers are diagnosed following an emergency presentation, the number of older people living with cancer has grown by 23% over a 5 year period and 9.2million bed days are utilised for advanced cancer and end of life care. Emergency care represents a complex mix of late presentation of new cancers, complications of cancer therapy, complications of cancer and associated comorbidity in an aging population. Sustainable system change needs to be viewed in the context of the wider national urgent care strategy ensuring cancer patients receive the right care in the right place with the right expertise, delivered 24hours a day.

An effective acute oncology service (AOS) will enhance patient experience and clinical effectiveness and ensure that equitable, safe, high quality emergency care is consistently provided for non-elective/emergency adult patients with known or suspected cancer. Acute Oncology services are a vehicle to deliver continuous improvement in emergency and unplanned cancer care but services remain patchy across England despite national recommendations in 2009.

Every hospital with an emergency department (ED) or specialist oncology beds should ensure they have a fully functional and constituted acute oncology service responsible for emergency cancer care including metastatic spinal cord compression (MSCC)The overarching aim of the AOS is to:

Ensure timely and equitable access to specialist oncology review and advice for all cancer patients who present with a cancer-related emergency

Develop standard, evidence based management protocols and pathways to ensure safe, high quality and effective treatment for emergency cancer care

Conform to national standards and guidance and ensure local audit is conducted to ensure these standards are met

To deliver a standard training and education programme in emergency cancer care to staff involved in the care of acute oncology patients to ensure safe high quality care is available 24/7

To ensure primary care teams and patients a range of options for emergency cancer care review (advice and triage, fast track clinics, ambulatory pathways, Multidisciplinary Diagnostic Centres, telehealth) reduce inappropriate ED presentation.

To improve the safety and effectiveness of unplanned cancer inpatient care and reduce variation in hospital length of stay following emergency presentation

To develop effective communication pathways and record keeping to ensure that all those involved in the patients care are informed regarding emergency presentations and actions taken




1.1 Key Priorities:

To establish a robust and fully functional AOS in every hospital with an emergency department and/or specialist oncology beds

To align acute Oncology services with the urgent care strategy

Awareness and reducing ED presentation

Commissioned service that provides public and professional awareness of urgent cancer symptoms and a range of options for accessing emergency and unplanned care via expert advice 24hrs, 7 days a week

Reducing variation in practice

Commissioned service that provides timely access to specialist care and information and optimises the safety and quality of care for those requiring unplanned emergency care

Commissioned service that reduces variation in hospitalisation, patients outcomes and patient experience

Best Practice

Commissioned service that ensures care is delivered according to the best evidence-based guidelines and relevant NICE guidance including Carcinoma Unknown Primary, Neutropenic Sepsis and Metastatic Spinal Cord Compression.

Commissioned services that ensure coordination and seamless care for patients requiring emergency and unplanned cancer care including onward referral to appropriate allied services

1.2 Key Outcome measures

Admission avoidance

Hospital Length of stay

30 day readmission rate

Mortality within 30 days of systemic anticancer therapy (SACT)

Neutropenic Sepsis mortality

MSCC outcomes

Patient experience

Emergency admission/presentation of new cancers




1.3 Key Responsibilities:

Commissioners: Commissioning a fully constituted, Acute Oncology team with appropriate competencies and staffing to provide 7day services

Acute Oncology Team: Clinical service delivery, review with 24hrs, delivery of AO induction education, collection of data

Acute Oncology Steering Group: Trust compliance with Quality Surveillance measures, implementation of pathways, protocols, production of outputs, competency sign off

Network Steering Group, population based –MSCC coordination, development and sign off of standardised protocols, Trust performance management based upon submitted outputs, education of AOTs

Specialist Oncology Services: Take leadership and responsibility for supporting robust Acute Oncology Services and pathways across a network footprint, thus ensuring seamless care and timely specialist oncology intervention across health care boundaries

Urgent care commissioners and providers: awareness and consideration of the specific needs of cancer patients who present in the emergency setting and the key role of Acute Oncology services.

2. Population Needs

2.1 National/local context and evidence base

Emergency admissions place an enormous burden on patients and the NHS. Over the last decade, emergency admissions have increased by 31% and attendances at Emergency departments have increased by more than 2 million to 16 million per annum1 Emergency presentation linked to cancer has doubled with 300,000 unplanned admissions per year2 and often associated with poor patient experience, poor coordination of care, poor communication and fragmented patient pathways3,4 . Following admission, there is wide variation in hospital length of stay for these patients with an average of 9.6 days1. It is estimated that the NHS could save in the region of 566,000 bed days, equating to £113million, if this variation was reduced to meet the best performing quartile. A publication from a single Cancer network on over 3000 AO admissions reported that approximately, 50% of admissions are a consequence of cancer progression or associated comorbidity, 30% a consequence of cancer treatment and 20% represent an emergency presentation of a new cancer diagnosis5. In England, 24 per cent of all new cancers, around 58,400 cases a year, are diagnosed through an emergency presentation associated with reduced 1 and 5 year survival6. Finally, emergency presentation following chemotherapy is increasing as a consequence of advances in new systemic anticancer therapy (SACT) and the greater use of multiple lines of palliative SACT.




2.2 Acute Oncology Acute Oncology service provision was identified in 2009 as a key recommendation of the National Chemotherapy Advisory Group (NCAG) for improving quality and safety of emergency care for those patients with previously undiagnosed cancer and complications of cancer or treatment7. The report addressed concerns raised by the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD)3, national peer review appraisals and the National Patient Safety Agency8 The role of AOS has since been consolidated with the publication of NICE guidance concerning CUP, Neutropenic Sepsis and MSCC9. A baseline impact assessment by the Department of Health concluded that the establishment of Acute Oncology would be cost neutral as a consequence of improved efficiency in bed utlisation7. Despite some progress in recent years, national peer review10 (2013/14), the 4th annual report of the Cancer Strategy11 and Achieving World-Class Cancer Outcomes12 have all highlighted particular concern in relation to the implementation of AO and CUP services with many areas of non-functioning and non-compliant services due to lack of staffing, lack of training and lack of robust emergency cancer pathways including MSCC. 2.3 Opportunities, 5 year view and Cancer Strategy/Urgent care Following the NCAG recommendations, AOS have largely focused on improving inpatient care. Despite many challenges, peer review has identified many areas of good practice highlighting improved quality of care and reduced Length of stay. Moving forward, AO represents a vehicle to deliver seamless emergency cancer care and admission avoidance in line with the Future Hospital commission123 and Emergency Care strategy1 and NHS 5 year view134. Acute Oncology represents one aspect of emergency or unplanned cancer care and Acute Oncology Services should connect to the whole urgent and emergency care system with the aims of supporting self-care, supporting admission avoidance and ensuring emergency cancer patients receive the right care in the right place with the necessary facilities and expertise, available 24 hours per day. Acute Oncology services should ensure that their expertise should extend to community services to facilitate the dialogue between primary and secondary care staff and to promote education, service redesign and the timely flow of patient information. In this context, Acute Oncology services are uniquely placed to support multidisciplinary diagnostics centres (MDC) and novel pathways for vague symptoms12

3. Process and outcome measures

3.1 Inpatient Care

An effective AOS will:

Ensure AO review by specialist teams with defined competencies within 24hrs of admission, 7 days a week

reduce Hospital length of stay (LOS)

reduce 30 day readmission

Improve safety and quality of emergency care with development and




implementation of AO pathways, protocols and staff training

Responsible for improving outcomes and reducing mortality for Neutropenic Sepsis in line with published NICE guidance.

Improve patient experience

Responsible for implementing the Metastatic spinal cord compression (MSCC) pathway in line with published NICE guidance

Support the MUO/CUP patient pathway in line with national guidance

Provide regular emergency cancer intelligence delivered by an agreed minimum dataset

3.2 Admission Avoidance

An effective AOS will:

Deliver services to promote admission avoidance & reduction in emergency admissions by:

Supporting 24/7 advice lines for health professionals and cancer patients

Developing options for rapid access and ambulatory care

Supporting Carcinoma of unknown primary (CUP) services in line with published NICE guidance and including options for fast track review in cases of suspected cancer/vague symptoms that require urgent oncology review.

Developing community/outreach AO services to support primary care

Support site specific teams to develop and deliver patient information, education and self-help concerning emergency contingency planning

3.3 Data and Information Management: An AOS will maintain the agreed minimum dataset and have an explicit data and information strategy in place that covers: types and quality, data protection, confidentiality, accessibility, transparency, analysis use, dissemination and, risks.

- Number of emergency admissions for cancer-related problems by acute oncology category and tumour type;

- Type I: First diagnosis of cancer is made in the emergency setting - Type II: Complications of non- surgical therapies - Type III Patients with known cancer - Time of referral and time of review by member of the Acute Oncology

Service

- Number of patients reviewed by the AOS

- Length of Inpatient stay for all medical emergency cancer patients

- Readmission rates within 30 days of acute oncology review

- Mortality in neutropenic sepsis according to risk stratification group




(MASCC)

- Time to first antibiotic in suspected neutropenic sepsis

- Compliance with Trust antibiotic protocol in neutropenic sepsis

- Compliance withMSCC measures;

- Audit of MSCC management and outcomes including surgical interventions, functional outcome and survival

- Deaths within 30 days of receiving chemotherapy

- Annual acute oncology patient experience survey

- Triage and assessment outcomes:

- Numbers of patients/professionals contacting 24 hour advice line services

- Numbers of patients managed with advice and/or referral to primary care services

- Numbers of patients managed with telephone follow up or planned outpatient review

- Number of patients asked to attend an ambulatory or assessment unit.

- Numbers of patients asked to attend ED/Acute Medical Unit for assessment

- Numbers of patients admitted for on-going care.

- - Patient advice line experience including complements and complaints

4. Scope

4.1 Acute Oncology and Haemato-oncology

This Acute Oncology (AO) commissioning guidance covers Haemato-oncology as well as solid tumour oncology. All Haemato-oncology services and patients are considered to be subject to this guidance. In many services, established Haemato –Oncology pathways already fulfill the core principles set out within the guidance for AO. The differing work patterns of haematologists and oncologists are recognised and local differences in the delivery of AO by haematologists and oncologists are acceptable as long as the principles set down in this document are adhered to. It is expected that haematologists and oncologists will work together as closely as possible to ensure efficient use of AO resources and for this reason, the membership local AO teams must include both haematology and oncology representatives.

The principal role of the Acute Oncology Service in emergency cancer care is advisory and lies in:

Defining the most clinically appropriate care pathway

Improving patient experience,




Communication with and signposting to appropriate specialist advice and services.

Training and education The overarching aim of the AO service is to:

Ensure timely and equitable access to specialist oncology review and advice for all cancer patients who present with a cancer-related emergency

Develop standard, evidence based management protocols and pathways to ensure safe, high quality and effective treatment for emergency cancer care

Conform to national standards and guidance and ensure local audit is conducted to ensure these standards are met

To support a standard training and education programme in emergency cancer care to staff involved in the care of acute oncology patients to ensure safe high quality care is available 24/7

To develop alternative pathways to hospital admission and reduce variation in hospital length of stay following emergency presentation

To develop effective communication pathways and record keeping to ensure that all those involved in the patients care are informed regarding emergency presentations and actions taken

4.2 Population covered

This service specification relates to the treatment of adults requiring emergency medical care as part of their treatment for cancer, whether curative or palliative and including treatment for solid tumours and haematological cancers. The service outlined in this specification is for patients ordinarily resident in England*; or otherwise within the commissioning responsibility of the NHS in England (as defined in Who Pays?; Establishing the responsible commissioner and other Department of Health guidance relating to patients entitled to NHS care or exempt from charges).

*Note: for the purpose of commissioning health services, this EXCLUDES patients who, whilst resident in England, are registered with a GP Practice in Wales, but INCLUDES patients resident in Wales who are registered with a GP Practice in England.

An Acute Oncology Service should cover at least the following patient groups:

Type I: Patients in whom a first diagnosis of cancer is suspected in the emergency setting Acute Oncology Teams (AOT) have a key role in Malignancy of unknown Origin (MUO) and Carcinoma Unknown Primary (CUP) services but also generic skills and competencies for all new emergency cancer presentations when defining aims and objectives for inpatient care (early access to site specific teams, specialist palliative care, appropriate investigation, treatment options and discharge planning) Type II: Patients with known cancer who present as an emergency with acute complications of non-surgical treatment – including Systemic Anti-Cancer Therapy (SACT) or radiotherapy. Type III a. Patients with known cancer that are acutely ill because of the disease itself: This group represent the largest proportion of emergency patients and often present with




complex issues including comorbidity, progressive cancer and end of life care (EOL) needs. AOS has a leading role in the assessment of specific complications as outlined in national peer review. For many patients, the AOT should outline the care pathway and discharge to appropriate services (eg Specialist palliative care, cancer site-specific teams, primary care) to ensure optimal efficiency and effectiveness of the service. Type III b. Patients with known cancer that are acutely ill because of comorbidity. This group of patients will be managed by admitting physicians but may require AOS input where a cancer diagnosis might impact on the medical management and to support care planning, prognosis and ceiling of care.

4.3 Acceptance Criteria

Referrals to the AOS should sent electronically and be triaged daily to ensure timely review by the most appropriate team member. To ensure that all appropriate type II and type III patients are able to access AO services, Trusts should implement electronic recognition and alert systems that would automatically inform the AOS at the point of a patient’s unplanned attendance. Patients who attend hospital, as an emergency/unplanned event when receiving SACT or radiotherapy should trigger an electronic alert in the admitting area that will inform the acute care team of their special circumstances.

4.4 Exclusion Criteria

Management of cancer in children and young adults treated within the children’s services (see separate service specification B15/S/B).

Elective admission of known cancer patients

Emergency admission requiring primarily surgical input

Type III cancer patients managed by site specific teams or specialist palliative care:

4.5 Service description/care pathway (QS measure AOS-16-007)

4.5.1 The Acute Oncology Patient Pathway The acute oncology pathway requires a whole system approach towards prevention and contingency planning. There should be regular assessment of risks and systematic adoption of emergency contingency planning for individual patients with cancer. AOS should hold cancer site-specific teams to account according to the quality of patient information and contingency planning.

The acute oncology patient episode begins at the same point for all patient groups at the first contact with a health professional during this acute episode and ends at the point that responsibility for care is transferred to site specific, Specialist palliative or primary care team

4.5.2 Community presentation & cancer patient triage (QS Measure AOS-16-006)

For known cancer patients, with urgent care needs,, access for both patients and health care professionals to urgent telephone advice is essential and may direct patients to appropriate emergency care such as direct admission or ED/AMU attendance or offer




admission avoidance strategies including patient self-management, advice or community review by one of the following: General Practitioner, specialist palliative care team, district nursing services, ambulance service , access to ambulatory care or day-case facility, or urgent OPD review

24 hour advice lines should be available for healthcare professionals and should have links with the on call oncology team.

All cancer patients should be provided with clear information on emergency contact numbers, recognising that these may change during a patient cancer journey.

24 hour dedicated specialist advice lines should be available to all Patients with known cancer who are receiving SACT or radiotherapy.

Healthcare professionals manning advice lines should be trained to: -

Assess and triage patients contacting advice lines

Provide advice and guidance that is underpinned by national algorithms (e.g. UK Oncology Nursing Society triage tool) and provide timely access to senior clinician advice when required.

Direct and link patients to associated services, such as specialist palliative care, general practitioners, and district nursing services or ambulance teams.

Ensure that the patient episode is recorded and communicated to the oncology team responsible for the patients’ management.

Provide timely specialist emergency care advice for cancer related problems for healthcare professionals

Advice line providers should have clear protocols for: -

The provision of patient and professional information regarding the advice line contact numbers and what to lookout for and when to contact the advice lines

Admission and assessment pathways

Continued monitoring and review process for patients who have contacted the advice line

Pathway for rapid review as an outpatient

4.5.3 Patient Information: (QS Measure AOS 16-005)

Health care professionals should have access to key patient information and treatment details 24/7.This information should be made available through hospital-wide electronic medical record systems, which should link, to cancer-specific systems (e.g. Somerset) and community electronic records.

4.5.4 Emergency Department (ED): (Measures AOS-16-005, AOS-16-008 AOS-16-010)

ED attendance is for acutely unwell patients where there is no established diagnosis or




pathway and that require emergency review and management (within 24hours). ED staff should have training and 24-hour access to agreed emergency cancer treatment protocols, appropriate intra venous antibiotics, emergency cancer management pathway algorithms and advice from an AOS service. ED should develop pathways to ensure patients with suspected cancers are referred urgently to the appropriate cancer site-specific multidisciplinary team (MDT) according to existing flows, guidance (eg The National Optimal Lung Cancer Pathway- NOLCP) and nationally agreed 2 week rule pathways. AOS services should facilitate responsive urgent referral pathways for patients with suspected new cancers that do not fit existing 2 week referral criteria. The AOS should be informed of all known cancer-related emergency presentations within 24 hours of presentation.

4.5.5 Acute Medical Units (AMU):

The AOS should develop collaborative working with AMU to provide seamless care for all cancer patients admitted to AMU with the aim of delivering expert care and options for early hospital discharge. This integration should include daily access to AOS team, pathways and protocols. Integration may be facilitated and enhanced by joint posts, link nursing roles, training and AMU core membership of the weekly AO meeting and Trust AO steering group. The AOS should be informed of all known cancer-related emergency presentations within 24 hours of presentation

4.6.6 Inpatient Care: (QS Measure AOS-16-009)

The AOS should be made aware within 24hrs of admission for Type II/III patients or within 24 hours of a suspected diagnosis for Type I patients.

The AOS should provide advice and/or review within 24hours of referral and should ensure transfer of responsibility to site-specific team at the earliest time point.

4.5.7 Discharge planning

The AOS should provide advice and guidance to clinicians and patients on treatment aims, prognosis and care planning. Working with the specialist palliative care team, AOS should support timely discharge planning and communication with primary care and community services.

Patients must be given appropriate after treatment care and follow-up including information on contingency planning for subsequent emergency events, and advice on self-management. 4.5.8 Clinical Trials As is the standard for all areas of health care the importance of evidence based care must be emphasized. Providers should endeavor to participate in any appropriate AO clinical trials and contribute to the development of an evidence base for practice.

4.5.9 AO and Carcinoma of Unknown Primary

All patients presenting with malignancy of undefined primary origin (MUO) should be assessed and managed according to NICE Carcinoma of unknown primary Guidance




(CUP). In some instances, CUP assessment arrangements may be offered as part of AOS if appropriate, or to be a separate entity. In either case, there should be a single service for each Hospital Trust and details governing this pathway should be agreed locally and should be made explicit to all referring disciplines.

4.5.10 AO and Metastatic Spinal Cord Compression (MSCC) (QS Measures AOS-16-011-13)

MSCC assessment and management requires multi professional and multi-agency collaboration and often spanning several organisations. Service provision and individual patient management should be delivered in line with NICE guidance and national cancer peer review. Against this background, the AOS is responsible for delivering peer review measures and has an important role to play in raising awareness, promoting education, supporting seamless care, audit and service development. The metastatic spinal cord coordinator function should link seamlessly with 24/7 emergency cancer triage services.

5 Service model

5.1 SACT and radiotherapy treatment centres (Tertiary Cancer Referral Centres)

AOS within specialist cancer centres should have a role in the clinical assessment and immediate management of emergency presentations as well as ongoing advice and support of acutely unwell inpatients. In such centres, Oncologists and/or Haematologists will retain chief responsibility for the patient. Tertiary Cancer Referral centres should develop clear management protocols for inpatient care and a single point of access for cancer-related emergency presentation ensuring appropriate levels of expertise, timely review by consultant staff in line with national guidance, competencies and treat and transfer policies. Service development should be supported by acute medicine expertise to ensure networked emergency care pathways and joint working. 5.2 Acute Hospitals without dedicated specialist oncology beds Acute medicine and/or, according to local agreement, haematology, supported by site-specific cancer teams, designated key workers and specialist palliative care should retain chief responsibility for the patient. AOS have a key role providing advice and coordinating care for specific cancer presentations, clearly described in the Manual for cancer standards measures for acute oncology and MSCC. In these circumstances, the AOS would not have direct responsibility for care or defined inpatient bed resource.

5.3 Acute Hospitals with dedicated specialist oncology beds In Acute Hospital Trusts where resident oncology is available, oncology may retain chief responsibility if there are designated oncology beds and an explicit protocol defining the patient group. In this instance, policies should clearly define responsibilities and operational arrangements required to ensure seamless care at all times to ensure optimal patient safety, clinical effectiveness, and patient experience.




5.4 Core Minimum Requirements for the AOS

5.4.1 The AOS and Staffing: The diagram below describes the basic structure, links and responsibilities that will need to be developed and demonstrated by those providing Acute Oncology Services. 5.4.2 The Acute Oncology Team (AOT): (measures AOS-16-002/3) The AOT is the core clinical team that is responsible for delivering AOS within the Trust on a daily basis. Membership: the core membership of the acute oncology team is as a minimum;

Consultant Oncologist/deputy Consultant Haematologist/deputy Palliative Care Consultant/deputy Acute Oncology, Specialist Palliative Care and Haematology nursing team Administrative support

The core team should include an identified individual (s) with appropriate competencies (Clinical Oncologist or Therapy Radiographer) who is available for advice on radiotherapy and is able to coordinate urgent assessment for palliative radiotherapy treatment.

The Network or Alliance Acute

Oncology Group

This group will develop and review Acute

Oncology Services across a regional

footprint

The Trust Acute Oncology Group

This group will develop

and review Acute Oncology Services

within a Trust

The Acute Oncology Team

This is the clinical team

that implement and deliver Acute Oncology

Services within the hospital




An AOS requires strong leadership and engagement with non-surgical oncology services to ensure optimal service development and communication with tertiary, secondary and primary care. Providers must ensure adequate time for this leadership. The overall lead of the AOS should be a team member who is directly responsible for the development, management and ultimate clinical accountability and responsibility of the service Acute Oncology teams will ensure that:

Health care professionals are fully informed of 24 hour access to senior decision making by Consultant Oncology, Haematology and Specialist Palliative Care Physicians.

7 day availability for treat and transfer policy

A fully competent acute oncology team member will assess all patients with a known cancer diagnosis who are admitted as an emergency/unplanned within 24 hours of admission 7 days per week

A fully competent acute oncology team member should review all patients who are admitted as an emergency/unplanned and have a new diagnosis or high suspicion of cancer within 24 hours of referral.

Competency must be assessed and agreed by the trust Acute Oncology Lead Clinician.

Staffing levels of nurses with AO competencies should support 7 day working and ensure availability to provide direct clinical care within 24hours of referral, timely communication, clinical information capture and their key role in education and service development. Furthermore, team effectiveness, coordination of care, communication and data capture are dependent on appropriate levels of administrative support. 5.4.3 Weekly review meeting The acute oncology team should meet weekly at an agreed time to ensure a high level of team working, multiprofessional review of care, good communication, coordinated patient follow up and collection of a minimum dataset The weekly meeting should not delay daily decision making but rather provides multi professional oversight, supporting decision making. All emergency haemato-oncology admissions should be discussed in a weekly meeting either as part of the AOT meeting (with Haematology representation) or as a separate haematology MDT. The weekly meeting should develop links to facilitate communication with community services.

The AO review meeting may act as the CUP MDT in some instances. If this is the case then the group membership should fully comply with peer review measures. 5.4.4.The Trust Acute Oncology Group: (QS measures AOS-16-001, AOS-16-015, AOS-16-016, AOS-16-019 )

Responsibilities: this is an overarching multidisciplinary strategic group responsible for governance, service development and monitoring of the AOS across a hospital trust in line with national guidelines and recommendations. .

Membership: This group should have representation from the AOT, cancer services




management and all disciplines/departments involved with the emergency care pathway for cancer patients.

5.4.5. The Network or Alliance Acute Oncology Group:

Responsibilities: this expert advisory group will develop and review acute Oncology services across a defined clinical network and will support, cross boundary working and equitable service delivery according to national guidelines and recommendations. This group will offer expert opinion and guidance and will lead on AO performance monitoring on behalf of commissioning groups. The group will lead on education and training for AOTs.

Membership: this group will be formed and led by representatives from each trust/organisation that provides an acute oncology service in total or a component of acute oncology services within a clinical network. For example an organisation may provide advice line services or deliver a component of MSCC management as part of an acute oncology service and as such should provide representation of their service to this group. This network AO group should ensure appropriate representation from all AOSs and including Oncology, Haematology, Specialist palliative care, primary care, acute medicine and commissioning. The group should have appropriate levels of administrative and data management support to fulfil its role.

5.4.6 Acute Oncology Training and Education (QS measure AOS-16-004)

Acute Oncology Induction training in referral criteria, contact details, 24/7 triage and 24/7 consultant oncology availability should be made available to Consultants and NCCG medical staff in ED and on the acute medical take and contracted nurses of band 6 and above in the ED and on the acute medical unit. Dissemination and monitoring of Acute Oncology Induction training is the responsibility of provider Learning and Development departments.

The Network AO group should be responsible for developing the induction training package and for training and education of AOTs, ensuring appropriate competencies. All nursing members of the AOT should have completed specific training and competencies in AO presentations and should participate in regular updates, at least on an annual basis.

5.4.7 AO and Specialist Palliative Care

Specialist palliative care has a key role in the delivery of an effective acute oncology service and should provide representation within the AOT. In many instances, Specialist palliative care services may lead the AOS on many aspects of care with specific expertise in symptom control, patient and family support, advance care planning, care in the last days of life and service development. A close working relationship between the acute oncology service and specialist palliative care team is necessary to ensure that patients and families receive appropriate specialist input as part of a cohesive and timely care pathway. 5.4.8 AO and Pharmacy




Providers should ensure full engagement of pharmacy staff with the AOS to support the AOT with 24/7 access to specialist pharmacist advice for chemotherapy regimens prescribed and/or recently administered for a presenting patient, supportive medication needed, advice on and access to palliative care medicines,.. Confirmation of a thorough medication history for newly admitted patients, particularly focussing on identifying oral chemotherapy, chemotherapy adjunctive treatments and chemotherapy supportive medications. Education and training of general medical and nursing staff to raise awareness of oral chemotherapy drugs and supportive medications to understand fully when to refer patients to specialist services. 6 Interdependencies with other services/providers

AOS is a multi-professional service that integrates existing expertise in acute medicine, specialist palliative care, haematology and oncology and community services. The AOS provides outlet for community management, admission avoidance as well as inpatient care across all cancer care providers

6.1 Co Located services The service should be part of a clinical managed network and there should be significant representation from the local service on the network AO group. This service should work closely with its local, regional and national colleagues to ensure continuous service improvement 6.2 Inter dependent services The AOS will be required to set up and maintain formal links across the Tertiary Referral cancer centre, local district general hospitals and community services and to include governance, training and development and networked solutions for patient information and triage purposes. Cross cover arrangements for core AO members should be organised by the AOT and agreed by the AO lead 6.3 Additional key relationships include:

Pathology Services (including histopathology, haematology, and microbiology)

Ambulatory and day care facilities

Inpatient Facilities

Radiology

Pharmacy

Biomedical and clinical research

Clinical Psychology

Counselling service and PALS

Specialist Nursing teams including community nurses

Macmillan nurses,

Social workers

Community services

Hospice services

Ambulance service




7 Applicable Service Standards

7.1 Applicable national standards e.g. NICE

NICE Improving Outcomes Guidance (IOG) – (http://guidance.nice.org.uk/CSG)

NICE Guidance CG104: Metastatic malignant disease of unknown primary origin

NICE Guidance: CG75: Metastatic Spinal Cord Compression

NICE Guidance CG151: Prevention and management of neutropenic sepsis in cancer

National Cancer Peer Review “The Manual for Cancer Services” Measures relating to chemotherapy services, acute oncology services and CUP services

Chemotherapy Reference Group :Chemotherapy Service Specification

Department of Health (2011) Improving Outcomes: A strategy for Cancer 2011

National Chemotherapy Advisory Group (2009) Chemotherapy Services in England: Ensuring Safety and Quality

NCEPOD (2008) “For Better, for worse? A review of the care of patients who died within 30 days of receiving systematic anti-cancer therapy”

Department of Health (2011) Innovation Health and Wealth, Accelerating Adoption and Diffusion in NHS weblink All NICE Technology appraisal recommendations should be incorporated automatically into relevant local NHS formularies in a planned way that supports safe and clinically appropriate practice. 7.2 Applicable standards set out in Guidance and/or issued by a competent body

(e.g. Royal Colleges)

Cancer Patients in Crisis: responding to urgent needs. A joint report by Royal College of Physicians &Royal College of Radiologis

8 References 1. Transforming urgent and emergency care services in England: Urgent and Emergency care Review. End of Phase I Report. (2013). 2. Delivering the Cancer Reform Strategy – National Audit Office 2010. 3. The National Confidential Enquiry into Patient Outcome and Death report “For better For Worse” in 2008.

4. Cancer Patients in Crisis: A joint working party report from the Royal College of Physicians and Royal College of Radiologists (2013).

5. The impact of a new acute oncology service in acute hospitals: experience from

the Clatterbridge Cancer Centre and Merseyside and Cheshire Cancer Network.

Neville Webb H et al, Clinical Medicine 2013, 13, 565-9

http://guidance.nice.org.uk/CSG




6. Routes to diagnosis project. NCIN 2013

7. The National Chemotherapy Advisory Group (NCAG) report “Chemotherapy Services in England; Ensuring Quality and Safety (2009)

8. The National Patient Safety Agency (2008) Oral Chemotherapy alerts

9. The National Institute for Health and Care Excellence guidance in Cancer of

Unknown Primary (CUP), Metastatic Spinal Cord Compression (MSCC) and

Neutropenic sepsis (NS)

10. National Peer review report: Acute Oncology 2012-2013

11. Improving outcomes: A Strategy for Cancer. Fourth Annual Report 2014

12. Achieving World-class Cancer Outcomes: A strategy for England 2015-2020 13. Future Hospital: Caring for medical patients (2013)

14. The NHS Five year forward view (October 2014):

Centres: Freeman, Hammersmith, UCL, Christie, Cardiff, Southampton, Bath

Proposed start date: 31/08/2018

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