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North of England Cancer Network
Radiotherapy NCCG
Constitution
2013
Document Information
Title: Radiotherapy NCCG Constitution
Author: Mr C Walker, NCCG Chair
Circulation List: Radiotherapy NCCG
Contact Details: Mr C Walker, NCCG Chair
Telephone: 01138 252971
Version History:
Date: 14.06.13 Version: v2.2 Review Date: May 2014
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The Constitution has been agreed by: Position: Network Radiotherapy Group Chair Name: Mr C Walker Organisation: South Tees Hospitals NHS FT Date Agreed: 14.06.13 Position: Medical Director Name: Dr M Prentice Organisation: Cumbria, Northumberland, Tyne and Wear Area Team Date Agreed: 03.10.13 Position: Trust Lead Clinicians of the Trusts in the Network for: Division of Responsibility and Accountability across Radiotherapy
Departments (11-1E-103t) and Agreed List of Single Named Head of Service for each Radiotherapy Department in the Network (11-1E-131t)
Name Organisation Mrs M Robertson City Hospitals Sunderland NHS FT Mr J Macdonald Co Durham & Darlington NHS FT Mr K Clark Gateshead Health NHS FT Mr R Bliss Newcastle upon Tyne Hospitals NHS FT Dr J Nichol North Cumbria University Hospital NHS Trust Dr R Stirling Northumbria Healthcare NHS FT Mr M Tabaqchali North Tees & Hartlepool NHS FT Professor P Kane South Tees Hospitals NHS FT Dr O Schulte South Tyneside NHS FT Date Agreed: 03.10.13 Radiotherapy NCCG agreed the Constitution on: Date Agreed: 14.06.13 Review Date: May 2014
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Contents Page INTRODUCTION ............................................................................................................... 5 11-1E-103t ......................................................................................................................... 5 Division of Responsibility and Accountability Across Radiotherapy Departments .............. 5
11-1E-104t ......................................................................................................................... 5 Cross Department Treatment Arrangements – External Beam Radiotherapy Treatment (EBRT) ............................................................................................................................... 5 11-1E-105t ......................................................................................................................... 5 In Vivo Dosimetry Development Proposal (EBRT) ............................................................. 5 11-1E-107t ......................................................................................................................... 5 IVD Implementation Programme (EBRT) ........................................................................... 5
11-1E-108t ......................................................................................................................... 5 Treatment Protocols (Generic) ........................................................................................... 5
11-1E-109t ......................................................................................................................... 6 Consistency with National Dose/Fractionation Recommendations (EBRT) ....................... 6 11-1E-110t ......................................................................................................................... 6 Off Protocol Procedure ...................................................................................................... 6
11-1E-124t ......................................................................................................................... 6 Brachytherapy - Cross-Department Treatment Arrangements ........................................... 6
11-1E126t .......................................................................................................................... 7 Network Radiotherapy Configuration (Generic) ................................................................. 7 11-1E-127t ......................................................................................................................... 8 The Network Radiotherapy Group ..................................................................................... 8
11-1E-128t ......................................................................................................................... 8
Development Proposal (Generic) ....................................................................................... 8 11-1E-129t ......................................................................................................................... 9 Capacity Expansion Programme - Risk Assessment ......................................................... 9 11-1E-130t ......................................................................................................................... 9 Capacity of Expansion Programme – Implementation Programme ................................... 9
11-1E-131t ....................................................................................................................... 10 Heads of Service (Generic) .............................................................................................. 10 Appendix 1 - IVD Proposal ............................................................................................... 11
Appendix 2 - IVD Implementation Programme ................................................................. 19 Appendix 3 - Treatment Protocols ................................................................................... 20 Appendix 4 - Off Protocol Procedures.............................................................................. 27
Appendix 5 - Terms of Reference .................................................................................... 30 Appendix 6 - NCCG Membership List .............................................................................. 35
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Appendix 7 - Capacity of Expansion Programme – Risk Assessment ............................. 36 Appendix 8 - Head of Service Job Description & Job Plans ............................................. 39
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INTRODUCTION The Radiotherapy NCCG is made of health professionals from organisations across the North of England Cancer Network covering a population of 3.06 million. This document outlines the Radiotherapy Constitution and Terms of Reference and will be reviewed on an annual basis. 11-1E-103t Division of Responsibility and Accountability Across
Radiotherapy Departments
Cross Reference
There is no staff shared between the 3 Centres.
11-1E-104t Cross Department Treatment Arrangements – External Beam Radiotherapy Treatment (EBRT)
Patients will not normally change treatment delivery from one department to another. In any exceptional circumstances where this may be required the route will be via consultant to consultant referral.
11-1E-105t In Vivo Dosimetry Development Proposal (EBRT)
Development proposal for the network-wide use of IVD was completed and agreed at the Network board, as part of proposals for local development, in October 2010 and updated in July 2011. See Appendix 1 for IVD Proposal.
11-1E-107t IVD Implementation Programme (EBRT)
A strategy and timetable has been developed for the implementation of IVD across the Network’s Radiotherapy Centres. See Appendix 2 for IVD Implementation Programme.
11-1E-108t Treatment Protocols (Generic)
The single network list of acceptable treatment protocols, including palliative treatment, for all radiotherapy modalities used in the network will be reviewed annually by the Radiotherapy NCCG. See Appendix 3 for Treatment Protocols.
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11-1E-109t Consistency with National Dose/Fractionation
Recommendations (EBRT)
Cross Reference
The treatment protocol list conforms to the current RCR Grade A recommendations for fractionation in external beam therapy for radical and palliative treatments. See Appendix 3 for Treatment Protocols.
11-1E-108t
11-1E-110t Off Protocol Procedure
Authorisation procedures for all modalities for departments to carry out off protocol treatments in exceptional circumstances. See Appendix 4 for Off Protocol Procedures.
11-1E-124t Brachytherapy - Cross-Department Treatment Arrangements
No cross cover arrangements in place. If this was required, a Consultant to Consultant referral would be made.
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11-1E126t
Network Radiotherapy Configuration (Generic)
Cross Reference
Centre Location Modalities & Treatment
Population
Freeman Hospital High Heaton Newcastle NE7 7DN 0191 2336161
External beam therapy, brachytherapy, IMRT
Newcastle (292,200) North Tyneside (198,500) Northumberland (312,000) Gateshead (191,700) South Tyneside (153,700) Sunderland (283,500) plus Easington 55,700) Co Durham - North (237,854) Children (3.06 million)
James Cook University Hospital
Marton Road Middlesbrough TS4 3BW 01642 850850
External beam therapy, brachytherapy, IMRT
Co Durham – South (217,246) Darlington (100,800) Middlesbrough (142,400) Redcar & Cleveland (137,400) Hartlepool (91,300) Stockton on Tees (192,400) North Yorkshire & York (133,165)
Cumberland Infirmary
Newtown Road, Carlisle CA2 7HY 01228 523444
External beam therapy, brachytherapy, IMRT
Cumbria (321,854)
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11-1E-127t The Network Radiotherapy Group
Cross Reference
The Network radiotherapy group includes the representatives listed below:
head of service of each radiotherapy department in the Network
medical physics expert, from each radiotherapy department in the Network
user representative – Margaret Warner, user representative – recruitment is underway for further representation
In instances when user representation is non-compliant, the NHS member nominated with specific responsibility for users’ issues and information for patients and carers will liaise directly with the designated Network Service Improvement Facilitators, who have responsibility for patient and user involvement.
Please see Appendix 5 for NCCG Terms of Reference.
Please see Appendix 6 for NCCG membership list.
Annual Report
11-1E-128t Development Proposal (Generic)
Work Programme
The NECN appointed a Project Manager in February 2012 for the development of Radiotherapy Services. The job purpose being to scope the potential range of service models and procurement routes for the provision of a Satellite Radiotherapy Service within the network. Following on from the work of the NECN radiotherapy group, a partnership has been developed between the NECN and North of England Procurement Service. The first stage will be the testing of the market for potential bidders to supply the Network with a Satellite Radiotherapy unit. Increase in radiotherapy demand within the NECN has most recently been confirmed using Malthus: from 2011 – 2016 a predicted increase in fractions to be delivered equals 16,000, this equates to the workload of two linear accelerators per year. The capacity expansion programme has the approval of the NECN board with the final approval by the North of England Specialised Commissioning Operational Group and Chief Executives of the NECN PCOs being sought with a presentation of a Project Paper on the 19 June and 28 June 2012 respectively. A presentation was given to North of England Specialised Commissioning on 13 July 2012.
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11-1E-129t Capacity Expansion Programme - Risk Assessment
Cross Reference
Risk assessment of proposed changes of the Network radiotherapy configuration. In addition:
The NECN Board receives an update on risks via risk register at each meeting.
Radiotherapy NCCG report on progress of the expansion programme at each meeting.
Procurement milestones agreed for current phase of implementation programme only. Delivery milestones have been developed; to be agreed by commissioners.
See Appendix 7 for Capacity Expansion Programme – Risk Assessment.
11-1E-130t Capacity of Expansion Programme – Implementation Programme
The potential procurement timetable and milestone of the Capacity Expansion Programme are enclosed within Appendix 1 of the Work Programme. The expansion programme was agreed at the NECN Board Meeting of the 3 February 2008 with a more recent presentation of progress given to the Board on the 17 April 2012. The outcome being the Chair advising the programme should be brought to the attention of the North of England Specialised Commissioning Operational Group and PCT Chief Executives; this is to occur on the 19 June and 28 June respectively. Finally a presentation will be given to North of England Specialised Commissioning on the 13 July 2012. This timetable will be finalised following the presentation of a Project Paper to the above groups. See Appendix 1 for Progress Report, Capacity Expansion Programme in Work Programme.
Work Programme
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11-1E-131t Heads of Service (Generic)
Cross Reference
Agreed list of single named head of service and responsibilities. for each radiotherapy department in the network. NB: Each head of service is a consultant clinical oncologist and has direct patient care PAs in radiotherapy as well as specified time for the role of head of service in their job plan.
Site Head of Service
Newcastle Dr I Pedley
Middlesbrough Dr A Rathmell
Carlisle Dr S Singhal
See Appendix 8 for Job Plans.
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Appendix 1 - IVD Proposal
North of England Cancer Network Radiotherapy NCCG
In-vivo Dosimetry Development Proposal – July 2011 Executive Summary There is currently very limited in vivo dosimetry being undertaken at the three radiotherapy centres within the NECN It is proposed that IVD using EPIDs and 2D dose predictions from treatment planning systems should be implemented as a system appropriate for modern radiotherapy techniques. A commercial product ‘Dosimetry Check’ is available for purchase. In the long term IVD using EPIDs, cone beam imaging and 3D dose predictions from treatment planning systems should be implemented as an IVD system appropriate for modern radiotherapy techniques. Funding for these developments has to be agreed with North East Specialized Commissioning Group (NESCG) before any system can be implemented. Introduction In 2006 the report on the ‘Beatson Incident’ (ref 1) was published. In the section of the report titled ‘Additional actions recommended by the Head of Health Physics’ was a recommendation that ‘Consideration should be given to the use of in vivo dosimeter to measure the radiation dose delivered in the first fraction for those treatments where an independent check of dose cannot be carried out by other means’. In the ‘Annual Report of the Chief Medical Officer for 2006’ (ref 2) the CMO stated that cancer networks and primary care trusts should be asked to include the phased introduction of in vivo dosimetry(IVD) into their forward plans for radiotherapy. These two reports formed the basis for recommendations in ‘Towards Safer Radiotherapy’ published in 2008 (ref 3), which included the following recommendations:
Each radiotherapy centre should have protocols for in vivo dosimetry monitoring. In vivo dosimetry should be used at the beginning of treatment for most patients. Patients should only be excluded from this procedure according to clear departmental protocols.
Each radiotherapy centre’s protocols for in vivo dosimetry should specify action levels and the procedures to be followed for results outside the tolerance range.
It is stated within the ‘Manual for Cancer Services 2008 Radiotherapy Measures’ that ‘any IVD protocol is required to apply only to multifraction, megavoltage external photon therapy which has been forward planned or planned from tables. It is at the department’s discretion whether this is extended to other situations such as single fraction treatments and inverse planned IMRT.’
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Current position within NECN In vivo dosimetry is in an interim stage of development. There has been much work performed in this area within the network over a number of years but as yet a cost effective solution has not been achieved. Cumberland Infirmary Carlisle In-vivo dosimetry is not in standardised daily clinical use and has been an ‘on request’ option for many years. Sun Nuclear RF-IVD and RF-IVD2 with three QED diodes and three ISORAD diodes are available in the department. A portal dosimetry license for IMRT field fluence measurements using EPID images on the Varian oncology management system has been purchased. The portal dosimetry system would require additional 3rd party software to enable transit dosimetry measurements. Both of these systems are highly labour intensive and expensive and require commissioning. James Cook University Hospital, Middlesbrough In vivo dosimetry is not currently available at JCUH. The short term use of single use IVD’s was investigated however these are no longer commercially available. Northern Centre for Cancer Care, Newcastle upon Tyne. Thermo luminescent devices (TLD) are used for Total Body Irradiations, Total Skin Electron Irradiations and to monitor dose to radiosensitive organs when requested by a clinical oncologist. Choice of IVD For many years the use of TLD or semi-conductor diodes to measure point doses at the entrance or exit point of radiation fields have been the accepted methods of IVD. These are most appropriate for multifraction, megavoltage external photon therapy which has been forward planned or planned from tables. With modern intensity modulated fields the variation in dose across a field can be significant and lead to false positive results when point doses are measured. For intensity modulated radiotherapy an appropriate technique would be a 2D approach comparing planar exit dose distributions from electronic portal imaging devices (EPID)s with predicted dose distributions from the treatment planning system. The ultimate in vivo dosimetry is the use of mega-voltage or kilo-voltage cone-beam CT and EPID dosimetry. This would enable the 3D reconstruction of the patient in the treatment position using the cone beam imaging and the dose distribution to be re-computed from the doses measured on with the EPID. This data can then be used to compare the delivered with the predicted dose in 3 D. (Ref 4) Strategy There is currently limited IVD being undertaken within the network and in recent years there has been significant difficulties in recruiting staff to fixed term posts. As a short term initiative to comply with the requirements it had been proposed that the network support the implementation of single use devices for multifraction, megavoltage external photon therapy which has been forward planned or planned from tables. This option was costed
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out and the specialist commissioners approached to fund this option. Unfortunately in the past year the manufacture of these devices has ceased and an alternative has to be sought. One system which is commercially available is a software package ‘Dosimetry check’ which utilises the EPID to assess transit dose. This option will require the purchase and commissioning of the system, but once it is operational the revenue consequences of this option will be less. Summary costs are detailed below.
Centre
Initial Cost Cost per annum
Dosimetry Check
OMP module
Staff Total Maintenance
Staff Total
CIC £118,378.80
£22,969.33
£141,348.13
£12,437.88 £4,305.00 £16,742.88
JCUH £211,388.40
£20,000
£22,969.33
£254,357.73
£22,338.84 £17,004.75
£39,343.59
NCCC £167,817.60
£20,000
£22,969.33
£210,786.93
£18,581.76 £30,479.40
£49,061.16
This would result in the implementation of the medium term strategy identified last year. I.e. to implement 2D dosimetry utilising EPIDs on at least one linac at each centre. This would facilitate IVD for all patients including those being treated with modern treatment techniques. The original estimates which were presented to the North East Specialized Commissioning Group (NESCG) were for the ‘One Dose’ system which had relatively inexpensive initial costs, but recurrent costs of £320K per annum. See Appendix 1 for a detailed breakdown of costs. Implementing the proposal to use ‘Dosimetry Check’ at each centre means a larger initial cost £606,493, but then reduced costs per annum of £105,147.63. When compared to the ‘One Dose’ system, the ‘Dosimetry Check’ system would be cost neutral after three years and then save £214,852 per annum in subsequent years. Consideration should be given to the following:
OSL who are marketing ‘Dosimetry Check’ would be prepared to negotiate favourable terms for the three network centres if a joint purchase was made.
Stagger the implementation of ‘Dosimetry Check’ over two years, the experience gained in one centre could then be shared with the other two and implementation would be more rapid, with lower personnel costs.
CIC commission the diode system, which would require additional personnel, or wait until a full Varian solution is available for purchase.
JCUH wait until an Elekta solution is available for purchase. The long term strategy of the network is to implement 3D dosimetry utilising EPIDs and 3D cone beam imaging on at least one linac at each centre as the technology becomes available and extending the use of 2D IVD using EPIDs to all linacs within a centre. Outline implementation programme for IVD The following all have to be agreed and implemented:
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Develop an implementation programme for IVD, taking account of the changes in equipment availability.
Funding transferred to the individual trusts to purchase ‘Dosimetry check’ or equivalent and recruit the required staff.
Purchase and commission ‘Dosimetry Check’
Clinical introduction of the routine use of ‘Dosimetry Check’. This will require a staged introduction of IVD within each centre.
The initial programme would extend to include a range of treatment situations over an agreed period of time.
Auditing of IVD results and clinical effectiveness of the system
Report to Radiotherapy CCG on audit and clinical effectiveness IVD using EPIDs.
Individual radiotherapy centres to monitor the availability of technology for 3D dosimetry using EPIDs for clinical implementation and inform the Radiotherapy CCG when it is available.
Network to inform the North East Specialized Commissioning Group (NESCG) of the availability of the modern technology
Funding for the strategy to be identified
Funding transferred to the individual trusts to implement the medium term strategy.
Commissioning and clinical introduction of the routine use of EPIDs for 3D dose reconstruction
Auditing of IVD results and clinical effectiveness of EPIDs for 3D dose reconstruction.
Conclusion ‘Dosimetry check’ would provide a network wide solution to the implementation of IVD. The initial capital outlay is significantly more than for the single use dosimeters costed last year. The on-going revenue costs would be significantly less. The purchase of ‘Dosimetry Check’ compared to the original proposal would be cost neutral after three years and in subsequent years cheaper. A decision on whether to proceed with a network wide purchase of ‘Dosimetry Check’ should be made and an implementation strategy matched to the available funds developed.
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References Ref 1: Scottish Executive ‘Unintended overexposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006’. Report of the investigation by the Inspector appointed by the Scottish Ministers for the Ionising Radiation (Medical Exposures) Regulations 2000 Ref 2: Annual Report of Chief Medical Officer 2006. Donaldson L. Department of Health, 2006. Ref 3: ‘Towards Safer Radiotherapy.’ RCR REF No. BFCO (08)1. The Royal College of Radiologists, April 2008 Ref 4: A literature review of electronic portal imaging for radiotherapy dosimetry. W. van Elmpt, L. McDermott, S. Nijsten, M. Wendling, P. Lambin, B. Mijnheer. Radiotherapy and Oncology, Vol. 88, No. 3. (September 2008), pp. 289-309. Ref 5: Can we afford not to implement in vivo dosimetry? Williams M V and McKenzie A. British Journal of Radiology 81 (2008), 681-684.
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Appendix 1 – Calculation of costs for implementing ‘Dosimetry Check’ NCCC CIC JCUH
Dosimetry Check
Dosimetry Check™ Pre-Treatment Verification £55,857.00 £55,857.00 £55,857.00
Dosimetry Check™ Transit Module £23,939.00 £23,939.00 £23,939.00
Installation and training £10,473.00 £10,473.00 £10,473.00
Additional workstation £18,154.00 £9,077.00
Dose kernel £25,136.00
Dose kernel deconvolution £31,425.00 £8,380.00 £48,185.00
Inclinometer required for Elekta linacs £3,490.00
£139,848.00 £98,649.00 £176,157.00
VAT £27,969.60 £19,729.80 £35,231.40
Total cost £167,817.60 £118,378.80 £211,388.40
Software module from Nucletron for OMP £20,000.00 £20,000.00
Staff to commission (band 8B, 4 months) £22,969.33 £22,969.33 £22,969.33
Cost to implement £210,786.93 £141,348.13 £254,357.73
IVD
Palliative pts requiring IVD per annum 1200 100 1000
Rad/adj plans requiring IVD per annum 3048 500 1370
Staffing
Estimate time to position IVD 2 2 2
Estimate time to compare data 10 10 10
Total time required per annum (min) 50976 7200 28440
Assume 10% repeated (min) 56073.6 7920 31284
Total time required per annum (hrs) 934.56 132 521.4
1 band 6, radiographer per hr £21.25 £21.25 £21.25
Total cost per annum £19,859.40 £2,805.00 £11,079.75
10% require investigation for anomalies 425 60 237
Total time required per annum 425 60 237
1 band 7 physicist £25.00 £25.00 £25.00
Total staffing cost per annum £10,620.00 £1,500.00 £5,925.00
Costs per annum
Maintenance cost of Dosimetry Check £16,781.76 £11,837.88 £21,138.84
Maintenance cost or workstations £1,800.00 £600.00 £1,200.00
Staffing costs £30,479.40 £4,305.00 £17,004.75
Total staffing and maintenance cost £49,061.16 £16,742.88 £39,343.59
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Appendix 2 - Calculation of costs for single use IVD NCCC CIC JCUH
IVD
Palliative pts requiring IVD per annum 1200 100 1000
Rad/adj plans requiring IVD per annum 3048 500 1370
Number of fields per radical patient 3 3 3
Total IVD required per annum 11544 1700 6100
Assume 10% repeated 12698 1870 6721
Cost per IVD inc VAT £11.53 £11.53 £11.53
£146,412.55 £21,561.10 £77,493
Staffing
Estimate time to position IVD (min) 5 5 5
Estimate time to readout IVD (min) 10 10 10
Total time required per annum (min) 63720 9000 35550
Assume 10% repeated (min) 70092 9900 39105
Total time required per annum (hrs) 1168.2 165 651.8
1 band 6, 1 band 5 radiographer per hr £38.31 £38.31 £38.31
Total cost per annum £44,753.74 £6321.15 £24,978.12
10% require investigation for anomalies 425 60 237
Total time required per annum 425 60 237
1 band 7 physicist £25.00 £25.00 £25.00
Total staffing cost per annum £10,625 £1500 £5,925
Total staffing and dosemeter cost £201,791.29 £29,382.25 £108,396.12
Note. No account has been taken of the increase time required for each measurement and the impact on the throughput of the linac.
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Appendix 2 – Indicative costs of 2D and 3D IVD using EPIDs CIC- software is available from Varian at CIC to compare dose form EPIDs with dose calculated on the TPS. Personnel would be required to commission the facility and deliver the routine clinical service. Initial investigations suggest that this is not yet a clinically useable system. JCUH - The software required to utilise EPIDs for IVD is still under development by Elekta. The software from Nucletron to obtain the data from OMP is due for release around March 2011, the current indicative price is £10K - £20K. Personnel would be required to commission the facility and deliver the routine clinical service. NCCC – The software required to utilise EPIDs for IVD is due for release by IBA at ASTRO 2011. The current indicative price is £6 – 10K per linac. The software from Nucletron to obtain the data from OMP is due for release around March 2011, the current indicative price is £10K - £20K. Personnel will be required to commission the facility and deliver the routine clinical service. It should be noted that once the 2D or 3D IVD devices were commissioned there would be no on-going cost for any dosemeters. All the IVD options would have to be commissioned and maintained. As an indicative costing it is estimated that the commissioning would take 1WTE clinical scientist at band 8B 1 year to commission the equipment on each site. (£68,908 per site) The staffing required to deliver the clinical service would be at least that required for single use IVD as detailed in Appendix 1.
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Appendix 2 - IVD Implementation Programme Commissioning and Clinical Implementation of ‘Dosimetry Check’ within the NECN
Radiotherapy Centres
Report for the NECN Radiotherapy Group
An initial strategy meeting was held on 23 March 2012. This has been followed up with two Tele Conferences. On each occasion there has been representation from OSL, Clatterbridge Centre for Oncology, Carlisle, Newcastle and Middlesbrough, with people from all staff groups attending. The timeframe for implementation is as follows:
Cumberland Infirmary, Carlisle. Installation, commissioning measurements week beginning 21 April 2012. Commissioning has progressed well this week and data has been acquired on seven patients. It is planned to continue using the software for pelvic patients.
James Cook University Hospital, Middlesbrough. Initial measurements week beginning 14 April 2012. Some issues have been identified and will need to be resolved before the commissioning week due 12 Sept.
Northern Centre for Cancer Care Initial commissioning measurements week beginning 11 or 18 June. Full installation and commissioning weeks beginning 28 August 2012.
Further developments It has been agreed to develop a specification of an output report from Dosimetry Check to enable easy reporting to the NECN and statistical analysis of multiple patient datasets. A policy on the storage of the additional data needs to be agreed between the three NECN centres.
Gill Lawrence Steve Mattock
Chris Walker April 2012
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Appendix 3 - Treatment Protocols
RADIOTHERAPY NCCG
PROTOCOL LIST (GENERIC)
Document Information
Title: Protocol List (Generic)
Author: Dr A Branson, NCCG Chair
Circulation List: Radiotherapy NCCG
Contact Details: Mr Chris Walker
Telephone: 0191 2754743
Version History:
Date: 24.02.12 v1.1 May 2014
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Network Protocol List It is intended that this list will encompass the basic details of treatment protocols in use across the NECN. It is accepted that certain techniques may not be available at all 3 centres, however where possible common conditions will be treated in the same fashion throughout the network. Details of the finer points of technique will differ across the centres according to the equipment in use. Introduction of new techniques and significant changes to existing ones may be initiated either by local radiotherapy multi- professional teams or NSSGs. However they should always be discussed at the NSSG at the first available occasion and the NRG be made aware if the technique is to be adopted so that the Network protocol list can be updated. No new technique should be routinely used beyond 3 months without NSSG discussion and ratification by the NRG. Tumour localisation and planning techniques Except where otherwise specified multifield treatments will be planned using cross sectional imaging (CT +/- MRI). Palliative single and parallel opposed field will be planned using either virtual or conventional simulation techniques. Retreatment All retreatment is defined as off protocol and must be ordered according to the Off Protocol Procedure.
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CANCER SITE/STAGE INDICATIONS RAD/PALL /ADJ
TECHNIQUE DOSE/FRACTIONATION RCR GRADE A
ANUS All pts suitable for
treatment with curative intent
RAD POP followed by 3-4 field planned
Ph I 30.6 GY/17# Ph II 19.8Gy/11# With mitomycin and 5 FU
BILE DUCT Localised
inoperable PS0-2 RAD ADJ
Conformed field technique Conformed field technique
45-50.4GY/25-28# +5FU 45-50.4GY/25-28# +5FU
BLADDER Stage I Local recurrence
not suitable for cystectomy
RAD 3-5 fields planned 64Gy/32#/6.5 weeks 55Gy/22# (T2-T3A NoMo)
Stage II – III Not suitable for cystectomy
RAD 3-5 fields planned 64Gy/32#/6.5 weeks
Stage IV Symptomatic primary/metastases
PALL 2-4 fields possibly planned
30Gy/ 5 weekly #/5 weeks 20Gy/5#/1 week 21Gy/3# 8days
A
BRAIN
Low grade Incomplete resection (good PS) Complete resection/high risk (progressive)
RAD RAD
Conformal plan
54 Gy /30# /6 weeks
High grade Good prognosis/good PS
RAD Conformal plan 60 Gy /30# /6 weeks A
Post resection Poor prognosis/good PS Poor prognosis/poor PS/biopsy only
HD PALL PALL
Conformal plan POP
60Gy/30# 40 Gy /20# /4 weeks 30 Gy /10# /2 weeks30Gy/6# 3x week15Gy/6# 2x week 20Gy/5#12Gy/2#
A
MENINGIOMA Atypical Post surgery
incomplete RAD Individual
conformal plan 60Gy/30# 57.6Gy/32# 54 Gy /30# /6 weeks 52.2Gy/29#
PITUITARY ADENOMA
Post resection RAD 3 field plan
50.4/28#/ 5 ½ weeks 45 Gy/25#/ 5 weeks
CRANIOPHARYNGIOMA
Post resection RAD 3 field plan 50.4/28#/5 ½ weeks 45 Gy/25# /5 weeks
BREAST DCIS WLE ADJ + boost 2 field half beam
block 40Gy/15# boost not normally used If boost indicated 10Gy/5# electrons
Stage I – III Mastectomy >4 nodes or high risk Supremo Trial if appropriate WLE without nodal irradiation WLE with nodal irradiation
ADJ ADJ + boost ADJ + boost
3-4 field half beam blocks 2 field half beam block 3-4 field half beam block or Casebow (large breasts)
45 Gy/20# 40Gy/15# 40 Gy/15#, boost 10 Gy/5# (e¯) 45 Gy/20#, boost 10 Gy/5#(e¯) 45 Gy/15#, boost 10 GY/5#(e¯)
Stage IV Focal symptoms PALL
Ant + post Single fields
8 Gy/1# (bone mets) 20 Gy/5# 20Gy/4# 30 Gy/10# (good prognosis
A A A
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whole brain)
CERVIX Surgery – nodes
+/margins Unsuitable for surgery
ADJ RAD
4 field brick 4 field brick
45Gy/25#/5 weeks or 44Gy/22#/4½weeks + concurrent Cisplatin + vaginal brachytherapy boost 15 Gy/2#/2 weeks 45-50Gy/25#/5 weeks +cisplatin Brachytherapy (HDR) 7Gy x2- 3/ 2-3 weeks
Stage IIB – IVA RAD 4 field brick 50Gy/25#/5 weeks + concurrent Cisplatin Brachytherapy (HDR) 7Gy x2- 3/ 2-3 weeks
Stage IVB Focal symptoms PALL Ant and post 20Gy/5#/1 week COLON Focal symptoms PALL Ant and post 20 Gy/5# / 1 week CORPUS UTERI (ENDOMETRIAL)
Stage I - III Post-operative ADJ 4 field ‘pelvic brick’
44 Gy/22# /4-5 weeks45Gy/25#/5 weeks +/- Vaginal brachytherapy 4Gy x 2# /2 weeks
Focal symptoms PALL Ant and post fields
20 Gy/5# /1 week
HEAD & NECK LARYNX Stage I – II Early stage III(nonbulky)
Radiotherapy choice (maj)/not suitable for larynx preserving surgery
RAD Lat POP 6 MV 5x5
55 Gy /20# /4 weeks 50Gy/16#
Late III – IV Post-operative (laryngectomy)
RAD Lat POP 6 MV 9x5
55 Gy /20# /4 weeks 63Gy/30# 65Gy/30#
ORAL CAVITY Stage I-II adverse
pathology post operative
RAD 3D conformal planning
65 Gy/30# +/- chemo 63Gy/30# +/- chemo 60 Gy /25# /5 weeks
A
A
OROPHARYNX Not suitable for
surgery RAD 60 Gy /25# /5 weeks
HYPOPHARYNX Stage III-IV post-
operative Not suitable for surgery
RAD RAD
Lat POP 50 Gy /20# /4weeks 55 Gy /20# /4weeks 55 Gy /22# /4 ½ weeks
MAXILLARY AN ETHMOIDAL SINUS
RAD PALL
Conformed field technique
63-65GY /30# +/-wkly Cisplat 30Gy/10#
A
SCC IN NECK Part of primary
therapy or post-rad neck dissection
Ant and post (spinal shielding)
55 Gy /22# /4 ½ weeks 50 Gy /20# /4 Weeks
NASOPHARYNX Stage I
Stage II - III Stage IV + chemo
RAD RAD PALL
3D conformal Wide field : 2 phases (including both necks)
65Gy/30# 63Gy/30# 55 Gy / 20# / 4 weeks 60 Gy /30# /6 weeks 30Gy/10(Pall)
UNKNOWN PRIMARY Post-operative to
neck ADJ ADJ
Ant and post (spinal shielding)
63Gy/30#/6 weeks- high risk 60Gy/30#/6 weeks moderate
24
Widefield 2 phases risk 50 Gy / 20# / 4 weeks nodal/tumour involvement
SALIVARY GLAND Post-operative
Inoperative RAD RAD
Wedge pair/electrons
65Gy/30#/6 weeks 63Gy/30#/6 weeks 60Gy/30#/6 weeks 55Gy/20#/ 4 weeks 50Gy/20#/ 4weeks 50 Gy / 25# / 5 weeks
LIP Radiotherapy
choice(cosmesis) RAD 50 Gy / 15 # / 3 weeks
50 Gy /20# /4weeks
LYMPHOMA HODGKINS Stage I – IIA RAD Ant and post
involved field 30Gy/15#/3 weeks 35 Gy/20 #/4 weeks
Stage IIB - IV Bulky Non bulky – incomplete response to chemotherapy
RAD RAD
Involved nodes, 3D conformal Involved nodes. 3D conformal
30Gy/15#/3 weeks 30 Gy/20 #/4 weeks 35 Gy/20 #/4 weeks
NON-HODGKINS Low grade Suitable RAD Ant and post
involved field 30Gy/15#/3 weeks 24 Gy/12 #/4 weeks
Intermediate Stage I – II RAD Ant and post involved field
35 Gy/20 # /4 weeks
Stage III – IV incomplete response to chemotherapy
RAD Ant and post involved field
40Gy/20#/4 weeks 35 Gy/20 #/4 weeks 30Gy/15#/3 weeks
Brain Lymphoma 40Gy/20#/ 4 weeks followed by boost 14Gy/10#/2 weeks
Mycosis Fungoides Incomplete response to topical/PUVA
RAD Single electron field
20-24Gy/10-12#/2-2½ weeks
Advanced RAD Single electron field
20 Gy/ 10 #/2 weeks
KIDNEY Metastatic Pall No Protocol MELANOMA Local control Pall Single electron
field (usually)
24 Gy/3#/21 days
Cutaneous Head & Neck – high risk
ADJ
Stage I – III Non head & neck high risk
ADJ
Stage IV Symptomatic PALL Occular Post-operative RAD Skin nodules PALL Single electron
field 10Gy SE 21Gy/3#
Recurrence at drain site PALL Single electron field
20Gy/4#
LUNG SMALL CELL Limited Good PS RAD Conformal
Sequential consolidation RT
50 Gy/20# + concurrent 4 cycles Cis-Etoposide 40 Gy/15# 45Gy/25# 27Gy/15 followed by Phase 2 -18Gy/10 50Gy/25# PCI 25Gy/10#
A
Extensive
Good PS, Local symptoms
PALL
POP
50-55 Gy/20 #
Extensive Poor PS (symptoms)
PALL
POP
36Gy/12# 25 Gy/10#/2 weeks 20Gy/4#
25
17Gy/2#, 20Gy/5#,single 8-10Gy 17 Gy/2#, single 8-10Gy 25 Gy/5#
NON-SMALL CELL Stage I-II
Good PS. Involved margins post-op Not suitable for surgery Good PS Poor PS Local symptoms
RAD/ADJ RAD RAD RAD PALL
Conformal Conformal Conformal POP POP
50-55 Gy/20 # 55-60 Gy/20 # CHART 54Gy/36# 55Gy/15# 30Gy/10# followed by Phase 2 -25gy/10# Single 8-10 Gy, 17 Gy/2 # 36-39 Gy /12-13#
A
A A
Stage III A Good PS. +ve nodes/margins post op Not suitable for surgery Poor PS Local symptoms
RAD/ADJ RAD RAD PALL
Conformal
55 Gy /20 # 50Gy/25#/ 5 weeks 20Gy/4# 36Gy/12# Single 8-10 Gy or 17 Gy/2# 36 – 39 /12-13#
A
Stage III B Good PS Poor PS. Chemo-radio Local symptoms
RAD RAD PALL
Conformal 55 Gy/20# 50Gy/25#/ 5 weeks Single 8-10 Gy, 17 Gy/2# 36-39 Gy/12-13#
A
Stage IV Local symptoms PALL POP 20Gy/4# 36Gy/12# Single 8-10 Gy or 17 Gy/2#
A
Superior sulcus PS0-2 T3/4 N0-1 RAD 45 Gy/25# OESOPHAGUS Non-metastatic
Involved margins post-op Unsuitable for surgery
RAD RAD
55Gy/ 20-22# 30Gy/15# then 20Gy/10# + cisplat & 5FU weeks 1&5
Metastatic Local symptoms Early tumour (T1)
PALL
50 Gy/25# with Cisplatin/5FU weeks 1 & 5 20 Gy/5# or 40Gy/15# Brachytherapy 10 Gy in single
PANCREAS Localised Inoperable RAD 3 field plan 45 Gy/25# & boost 5.4 Gy/3#
with concurrent Capecitabine or biweekly Gemcitabine 45-50.4Gy/25-28#
Metastatic Symptomatic (primary or mets)
PALL Ant and post
PROSTATE T1-2 Good PS T3-4 Good PS Advanced
+ve margins post-op Radiotherapy choice Radiotherapy choice Focal symptoms (eg bone)
RAD RAD RAD PALL
Conformal POP
64Gy/32# then Ph2 10Gy/5# 52.5–55 Gy/20# or60-66/30-33# 74 Gy/37 (or 55 Gy/20#) 20 Gy/5#, 30Gy/10# Single 8-10 Gy
A
RECTAL CANCER Duke’s A-C (localised)
Operable. Pre-op Margins involved. Post-op
RAD RAD RAD
25 Gy/5# 45 Gy/25 # with Capecitabine (down staging) 45 Gy/28 # with 5FU weeks 1 & 5
A A
Duke’s D (Metastatic) Inoperable. Chemo-radio
PALL 50.4 Gy/28# with Capecitabine 45Gy/25# 50Gy/25# 25 Gy/5# / 30 Gy /10#
26
Local symptoms/pain
Excessive salivation unresponsive to other medical management
Single electron field
8Gy SE
SKIN BCC and SCC ADJ Single
SXT/electron field 18Gy SE 35Gy/5# 27Gy/3# 45Gy/10#
BCC RAD Single SXT/electron field
18Gy SE 35Gy/5# 27Gy/3# 45Gy/10#
SCC RAD Single SXT/electron field
18Gy SE 35Gy/5# 27Gy/3# 45Gy/10#
STOMACH Resection >T1 post-op ADJ 45 Gy/25# with 5FU days 1-4
and 29-31
Advanced PALL 30Gy/10#/2 weeks SOFT TISSUE SARCOMA
All Trojani grades Pre or post op RAD- Post Op Pre Op Unresectable
Conformed technique
50Gy/25# then 10Gy/5# 50Gy/25# 60Gy/30#
TESTICULAR Seminoma Non-seminoma
Stage I Stage IV. Brain mets Stage IV. Brain mets
ADJ PALL PALL
Ant and post para-aortic nodes 2 lateral fields 2 lateral fields
35Gy/20# 20 Gy/10 #/ 2 weeks 20 Gy/5 #/ 1 week 20 Gy/5 #/1 week
VAGINA Stage IB-early IIB
Stage IIB-IVA Stage IIB-IVA+ inguinal nodes
RAD RAD RAD
Conformed technique
44Gy/22# 50Gy/25# 45Gy/25#
VULVA Post op ADJ Conformed
technique 44Gy/22#
METASTASES Bone PALL Direct applied 6
MV 8-10 Gy /single 20 Gy/4#
A
Brain PALL Parallel pair to whole brain
30Gy/10# 20 Gy / 5# 12 Gy / 1or2#
A A
Stoma Haematemesis Gastric bleeding Pyloric stenosis
PALL Ant and post 20 Gy/5#
27
Appendix 4 - Off Protocol Procedures
RADIOTHERAPY NCCG
OFF PROTOCOL PROCEDURE (GENERIC)
Document Information
Title: Off Protocol Procedure (Generic)
Author: Dr A Branson, NCCG Chair
Circulation List: Radiotherapy NCCG
Contact Details: Ann Bassom, Network Co-ordinator, NECN [email protected]
Telephone: 0191 497 1487
Version History:
Date: 09.06.10 Version: v1 Review Date: April 2011
26.07.11 v1.1 March 2012
24.02.12 v1.1 March 2013
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Off Protocol Procedure The Radiotherapy NCCG has developed this protocol to support governance arrangements for off protocol requests. The protocol is in line with the Manual for Cancer Services 2008, Measure 11-1E 110t: Off protocol procedure (Generic). The Radiotherapy NCCG should agree the authorisation procedures for all modalities for departments to carry out off protocol treatments in exceptional circumstances. Procedure For the majority of circumstances radiotherapy will be given according to approved protocols. The reasons for this are: 1. Patients will receive evidence based treatment 2. Radiotherapy staff will be familiar with the treatment reducing risk of error 3. Justification of concomitant exposures for IR(ME)R is made in the protocols. There will be occasions where a patient will require treatment not defined by a protocol. For example; rare conditions, patients whose clinical condition precludes the use of the appropriate protocol, retreatment or significant overlap with previously delivered radiation fields. Processes to be used in the network.
All off protocol treatments will be identified as such at the time of radiotherapy referral/booking.
All off protocol treatment bookings will be authorised by an appropriately qualified doctor. In almost all cases this will be a consultant, where a doctor of a non-consultant grade may authorise any off protocol treatments this must be specified in the quality management system along with the scope of such treatments that may be authorised by that individual.
For all off protocol treatments the concomitant exposures required must be justified by a practitioner as defined by IR(ME)R.
The reason for using an off protocol schedule must be recorded for the purposes of audit.
Departments must ensure that off protocol treatments are properly risk assessed, that clinical governance procedures are followed including medical physics expert advice and any corporate governance and resource implications are considered where appropriate.
Departments may wish to consider grouping off protocol treatments according to the Clinical and Corporate governance requirements. Possible groups could be:
1. Minor variation from standard treatment which could include 1st retreatment of palliative field
2. Moderate variation ie changes in dose/fractionation based on radiobiological calculations
3. One offs for rare clinical situations particularly where the treatment is unfamiliar. For Group 1 : Authorisation by a consultant or other doctor accredited in the
QMS and justification of concomitant exposures must occur.
29
The reason for use off protocol treatment must be recorded For Group 2: In addition to the above, clinical governance approval should be
demonstrated by counter-authorisation by another consultant and/or medical physics expert as appropriate. A list of consultants who may counter-authorise off protocol treatments along with which disease types must be kept in the QMS.
For Group 3: In addition to the above corporate governance approval must be given
by the radiotherapy head of service or approved deputy and where appropriate the head of radiotherapy physics or approved deputy. A risk assessment of the treatment should be performed.
Regular audit of off protocol treatments should be performed. (6 monthly). Where it is apparent that an off protocol treatment arrangement is used regularly the clinicians involved will be required to develop an appropriate protocol for approval within 3 months or cease using such treatment. Clinical trials protocols that are different from routine protocols may not routinely be used for non-trial patients or after closure of the trial. When appropriate they may be submitted for approval for routine use. Brachytherapy Exactly the same principles apply to brachytherapy. Where off-protocol treatment is to be used this must be recorded on the prescription sheet along with the classification (if used) and where necessary the fact and nature of the clinical and corporate governance procedures that have been followed.
30
Appendix 5 - Terms of Reference
North of England Cancer Network
Network Site Specific Group (NSSG)/Network Cross Cutting Group (NCCG) Terms of Reference June 2013 1. Role and Purpose of Site Specific Group The role of NSSG is clearly outlined in the Manual of Cancer Services Quality Measures 2013. The NSSG should be multi-disciplinary; with representation from professionals across the care pathway; involve users in their planning and review; and have the active engagement of all MDT leads from the relevant associated organisations. The NSSG should:
• agree a set of clinical guidelines and patient pathways to support the delivery of high quality equitable services across the network
• review the quality and completeness of data, recommending corrective action where necessary
• produce audit data and participate in open review • ensure services are evaluated by patients and carers • monitor progress on meeting national cancer measures and ensure actions
following peer review are implemented • review and discuss identified risks/untoward incidents to ensure learning is spread • agree a common approach to research and development, working with the network
research team, participating in nationally recognised studies whenever possible. Responsibilities of the MDT Lead Clinician The MDT lead clinician should:
• ensure that designated specialists work effectively together in teams such that decisions regarding all aspects of diagnosis, treatment and care of individual patients and decisions regarding the team's operational policies are multi-disciplinary decisions
• ensure that care is given according to recognised guidelines (including guidelines for onward referrals) with appropriate information being collected to inform clinical decision making and to support clinical governance/audit
• ensure mechanisms are in place to support entry of eligible patients into clinical trials, subject to patients giving fully informed consent
• overall responsibility for ensuring that the MDT meetings and team meet peer review quality measures
• ensure attendance levels of core members are maintained, in line with quality measures
• provide the link to the NSSG either by attendance at meetings or by nominating another MDT member to attend
• ensure MDT's activities are audited and results documented
31
• ensure that the outcomes of the meeting are clearly recorded, clinically validated and that appropriate data collection is supported.
NSSG Chair, Roles and Responsibilities The Network Site Specific Group (NSSG) 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 NSSG operates efficiently and effectively to facilitate these developments across the network. Specifically, the Chair should:
• ensure the group is properly represented by all the key stakeholders operating in the care of the specific tumour site
• work with NECN 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 terms of reference for the Group • ensure that systems and processes are in place to:
o review (and update) local and national standards o collect minimum cancer data sets o support accreditation/quality assurance o agree common audits and bench marking o agree R&D programme/common clinical trials o facilitate user involvement in the development of services.
• ensure that any Tumour specific issues of clinical governance are supported by
adequate protocols across the network • organise NSSG meetings at least twice a year • prepare the agenda for and chair NSSG 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 to the wider network as
appropriate • ensure a vice chair is nominated. This would support succession planning and help
in attending various meetings • agree and publish the NSSG Annual Report and work programme • lead discussions with other NSSGs on issues of common interest.
Vice Chair
The NSSG 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 NSSG followed by a selection process.
32
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 the role must be reflected in Job Plan as 0.5 PA per month NECN staff/ team.
Ground Rules for Networking Introduction These ground rules preserve the principles underpinning clinical networking. The principles may be summarised as follows: • they prevent destructive competition between MDTs for their catchment populations • they prevent destructive competition between NSSGs for their associated MDTs • they allow the development of consistent, intra- and inter-team patient pathways which are clinically rational and in only the patients' best interests instead of in the vested interests of professional groups or of NHS statutory institutions. Before a first peer review assessment of any services which, from the networking point of view, come under the governance of a strategic clinical network (SCN), there should be an agreement between the relevant SCNs which describes which provider and commissioner networks come under the governance of each particular SCN. The agreement should delineate the boundaries and list the constituent services and commissioners of those networks. On principle, a single SCN should be agreed as being responsible for the network. This specifies the governance framework within which the networks are placed. Ideally this would apply to all services in a geographical area. However, the arrangements in terms of the governance and ownership of staff and facilities may not be coterminous across different disease sites spread over a similar geographical area. The network function will therefore be reviewed at a disease site specific level. The term 'network' in these measures refers to the disease site clinical network unless otherwise specified. The geographical extent of this and the physical facilities and hospital sites involved should be agreed between the relevant SCNs prior to review, and a named SCN should be considered having ownership and requiring/commissioning the review. This principle becomes especially important for cases of clinical networks for the rarer cancers where catchment areas may overlap those of more than one SCN. NSSGs
• the NSSG should be the only such NSSG for the MDTs which are associated with it • for cancer sites where there is only one level of MDT, the NSSG should be
associated with more than one MDT • for cancer sites where there is a division into more than one level of MDT, i.e. into
local and specialist/supranetwork MDTs, the NSSG need only be associated with one specialist/supranetwork MDT as long as it is associated with more than one MDT for the cancer site overall.
33
Notes: The NSSG need only be associated with one specialist/supranetwork type MDT but may be associated with more than one. Cross Cutting Groups These currently include network groups for:
• chemotherapy • radiotherapy • acute oncology.
These groups need to have working relationships with the hospitals/services system and also the NSSGs /MDTs system, if they are to fulfil their role of acting as leaders of the networking process. Because these groups are service specific, not cancer site specific, it seems most important to lay down ground rules to ensure clarity and co-ordination across a given cross cutting service within a network, and leave ground rules regarding the relationship with NSSGs/MDTs, at a more informal and flexible level. The term 'network' here refers to the networking arrangements and coverage of the service in question. These services are required to have local multi-professional management teams. These are not equivalent to the site specific groups and are treated differently in the measures. The ground rules for MDTs do not apply to them.
• The network group for a given service should be the only such group for that service for all the hospitals/services it is associated with.
• The equivalent reciprocal ground rules to this for hospitals and services would be; any given hospital should be associated with only one network group for any given service, and any service should be associated with only one network service group.
Note: Hospitals and services are mentioned separately because, for the purposes of peer review and data gathering, it has been necessary to clearly define individual services and delineate their boundaries in terms of staff and facilities. Sometimes a declared 'service' may cross more than one hospital. MDTs For MDTs dealing with cancer sites for which the IOG and measures recommend only one level of MDT (i.e.no division into local and specialist or their equivalent. e.g. Breast MDTs):
• The MDT should be the only such MDT for its cancer site, for its catchment area. Notes: The principle of a given primary care practice agreeing that patients will be referred to a given MDT is not intended to restrict patient or GP choice. A rational network of MDTs, rather than a state of destructive competition can only be developed if i) there is an agreement on which MDT the patients will normally be referred to and ii) the resulting referral catchment populations and /or workload are counted, for planning purposes. It is accepted that individual patients will, on occasion, be referred to different teams, depending on specific circumstances.
• This ground rule does not apply to the carcinoma of unknown primary (CUP) MDT or the specialist palliative care (SPC) MDT. This is because, for this ground rule to be implementable, it is necessary to define a relevant disease entity in terms of objective diagnostic criteria which governs referral at primary care level. This is not possible for CUP or SPC, by the nature of these practices.
• The MDT should be the only such MDT for its cancer site on or covering a given hospital site.
34
Note: This is because for patient safety and service efficiency, there should be no rival individuals or units working to potentially different protocols on the same site. This does not prevent a given MDT working across more than one hospital site. Neither does it prevent trusts which have more than one hospital site, having more than one MDT of the same kind, in the trust. This ground rule does not apply to SPC MDTs, since there may be more than one distinctive setting for the practice of SPC on a single given hospital site.
• The MDT should be associated with a single named network site specific group (NSSG) for the purposes of coordination of clinical guidelines and pathways, comparative audits and coordination of clinical trials.
Note: MDTs which are IOG compliant but deal with a group of related cancer sites, rather than a single site, may be associated with more than one NSSG, but should have only one per cancer site. e.g. A brain and CNS tumours MDT also dealing with one or more of the specialist sites such as skull base, spine and pituitary could be associated with a separate NSSG for each of its specialty sites. For cancer sites for which there is a division into local, specialist and in some cases, supranetwork MDTs, the following apply to the specialist/supranetwork MDTs. The above ground rules still apply to the 'local' type MDTs
• The specialist/supranetwork MDT should be the only such specialist/supranetwork MDT for its cancer site, for its specialist/supranetwork referral catchment area
• The specialist/supranetwork MDT should be the only such specialist/supranetwork MDT for its cancer site on or covering a given hospital site
• The specialist MDT should act as the 'local' type MDT for its own secondary catchment population. If a supranetwork MDT deals with potentially the whole patient pathway for its cancer site, this ground rule applies to the supranetwork MDT. If it deals with just a particular procedure or set of procedures, not potentially the whole patient pathway, it does not apply.
Note: This is in order that the specialist/supranetwork MDT is exposed to the full range of clinical practice for its cancer site. The specialist MDT should be associated with a single named network site specific group (NSSG), (or possibly one per individual cancer site, as above) for the purposes of coordination of clinical guidelines and pathways, comparative audits and coordination of clinical trials. Review Date: June 2015
35
Appendix 6 - NCCG Membership List
RADIOTHERAPY CROSS CUTTING GROUP
1. CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST
Name Designation
Melanie Robertson Cancer Lead Clinician
2. NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST
Name Designation
Debbie Bennett Deputy Radiotherapy Service Manager
Susan Lamb Radiotherapy Service Manager/Deputy Directorate Manager Cancer Services
Gill Lawrence Head of Radiotherapy Physics
Dr Ian Pedley Radiotherapy Clinical Head of Service/ Deputy Clinical Director Cancer Services
3. NORTH CUMBRIA UNIVERSITY HOSPITALS NHS TRUST
Name Designation
Maureen McGuckin Radiotherapy Manager
Steve Mattock Head of Radiotherapy Physics
Sandeep Singhal Consultant Oncologist Clinical Lead 4. SOUTH TEES
HOSPITALS NHS TRUST
Name Designation
Adrian Rathmell Clinical Director for Radiotherapy/Oncology
Dawn Stephenson Deputy Divisional Manager
Fiona Milnes Services Team Leader Radiotherapy
Emma Thompson Research Radiographer
Chris Walker (Chair) Head of Radiotherapy Physics 5. NORTH OF
ENGLAND CANCER NETWORK
Name Designation
Bridget Workman Research Manager
Margaret Warner Patient & Carer Representative
Tony Branson Medical Director
Roy McLachlan Network Associate Director
36
Appendix 7 - Capacity of Expansion Programme – Risk Assessment
Risk No
Author Date
identified Date of
last update
Description Likelihoo
d
Impact
Severity
Countermeasures Owner Status
1 Adrienne Moffett 01/03/10
07/06/12
Risk of insufficient workforce (key sectors or overall) to meet service requirements
H H 9 Develop robust Workforce Plan; undertake risk assessment(s) re key staff groups e.g. Dosimetrists and Physicists and; monitor responses to recruitment processes
Update Workforce planning to be essential part of service specification. National/local vacancy rates to be monitored for professional sectors of workforce.
SR C
2 Adrienne Moffett 01/03/10
07/06/12
Insufficient capital resources due to public sector funding issues/changes in Government Policy
Update Insufficient support from Commissioners
M
H 8
Revise overall approach; delay project (?)
Update Network to present evidence of need for expansion programme.
SR/RMcL C
Document Title: Risk Log Project Manager: Adrienne Moffett
Project Title: NECN Radiotherapy Project Version No 0.3
Author: Adrienne Moffett Date Initiated 04/03/10 Review Date: Dec.2012
** Likelihood = H (High) M (Medium) L (Low) *** Impact H = (High) M (Medium) L (Low) **** Severity = Impact X Likelihood (Using the adjacent grid). ***** Status = Happened (H), Worsening (W), Constant (C), Reducing, (R) Disappeared (D), Sort Risks in descending order of severity
L
IKE
LIH
OO
D
H 3 6 9
M 2 5 8
L 1 4 7
L M H
IMPACT
37
Risk No
Author Date
identified Date of
last update
Description Likelihoo
d
Impact
Severity
Countermeasures Owner Status
3 Adrienne Moffett 01/03/10
07/06/12 Displacement of staff from other
Cancer Centres to satellite M
M 5
Controlled by market forces. SR C
4 Adrienne Moffett 01/03/10
01/03/10
07/06/12
Risk of developing proposals which lead to overcapacity in treatment machines and under use of facilities/workforce.
L M 4 Review data and waiting list trends. Monitor RRR/patient numbers. Close liaison with Commissioners and Providers
Update Review data; use Malthus to forecast local demand of radiotherapy. Develop expansion to meet local forecasts whilst monitoring future planning requirements within the Network.
SR R
5 Adrienne Moffett 01/03/10
07/06/12
Risk of delay in developing proposals due to lack of capacity of key personnel to provide significant input into the procurement
L
M
4
Ensure Project Group capacity through on-going secondment, plus Network support
Update Ensure continuing support for Project Manager through on-going secondment, financial Network support for procurement services and procurement team.
SR R
6 Adrienne Moffett 01/03/10
07/06/12
Risk of technological/prescribing changes impacting on future activity
L M 4 Close liaison Clinical leads
Update Include close liaison with Leads of Cancer Centres
ANB/AR/SS/SR
SL/FM/GB
R
7 Adrienne Moffett 01/03/10
07/06/12
Lack of capacity in Trusts to respond to procurement strategy
L M 4 Close liaison with Commissioners with regard to proposals, timing and funding. Close liaison with Trust
Update Now have named people as part of commissioning team.
SR R
8 Adrienne Moffett 01/03/10
07/06/12
Risk of delays in introduction of activity based tariff across the Network
Update non-mandatory radiotherapy tariff released
L M
4
Monitor progress with Commissioners; identify resources for detailed financial modelling
SR/RMcL R
38
Risk No
Author Date
identified Date of
last update
Description Likelihoo
d
Impact
Severity
Countermeasures Owner Status
9 Adrienne Moffett 01/03/10
07/06/12
Risk of lack of suitable sites (due to cost, location, lack of support services, travel times/patient acceptability)
L M 4 Robust site appraisal; strategic level negotiations
Update Proposed sites to be appraised during procurement process
SR R
10 Adrienne Moffett 01/03/10
07/06/12
Procurement strategy unsuccessful
Update Lack of commercial interest in programme
L H 3 Early and ongoing consultation with Commissioners/Providers/bidders (in line with overall approach)
Update Partnership with North East Procurement. Robust planning and marketing process with development of a procurement team.
SR R
11 Adrienne Moffett 01/03/10
07/06/12
Risk of insufficient support to address infrastructure issues and support services issues
L L 1 I IT Project Manager to address IT/Data/Storage issues; ongoing liaison with Providers and Commissioners
Update Infrastructure and support service will be appraised during the procurement process
SR R
39
Appendix 8 - Head of Service Job Description & Job Plans Job Description, Newcastle Job Description
POST TITLE: Radiotherapy Head of Service JOB PURPOSE: To be responsible the safe delivery of radiation therapy within
the Northern Centre for Cancer Care, the maintenance of high standards and the development and implementation of clinical and corporate strategy relating to radiotherapy within the Directorate. To provide leadership relating to radiotherapy within the Directorate by giving appropriate support, guidance and information to colleagues.
ACCOUNTABLE TO: Chief Executive ACCOUNTABLE FOR: Clinical Oncologists (with respect to radiotherapy)
Radiotherapy service manager, Radiotherapy staff PROFESSIONALLY ACCOUNTABLE TO: Medical Director, Clinical Director, Assistant Medical Director
Cancer Services LIASES WITH: The Medical Director’s Team
Clinical Director RMPD Head of Radiotherapy Physics Directorate manager
MAIN DUTIES Clinical Standards, Safety and Effectiveness
To ensure that the standard of Radiotherapy provided by the Directorate is appropriate.
To ensure the effective working of the quality management system
To investigate all errors and inaccuracies in the planning and delivery of radiotherapy according to the trust policy.
To report via the trust risk management department all errors where required to the appropriate statutory authority.
To work with colleagues to ensure optimal radiotherapy protocols are utilised.
To ensure that all radiation exposures related to radiotherapy (planning, therapeutic and verification) are justified by practitioners as required by IR(ME)R.
To participate in annual reviews in support of the Trust’s Clinical Governance Policy and to contribute to the directorate annual Clinical Governance report
To promote and maintain with colleagues a healthy and safe working environment for Directorate staff involved in the delivery of radiotherapy.
40
Performance Standards and Targets
To advise the clinical director on business management matters relating to radiotherapy and contribute to the production of an annual Directorate Business Plan.
To contribute to the achievement of Directorate and Trust performance targets, supporting the Clinical Director, Directorate Manager and other colleagues.
Personnel and Resource Management
To advise the Clinical Director on the resource requirements for the safe and effective delivery of radiotherapy.
To advise on the requirements for medical physics support for radiotherapy including commissioning of treatment machines, imaging equipment and other radiotherapy associated technology, the quality assurance required for the use of all equipment, planning and dosimetry for all radiotherapy techniques in use, support for radiotherapy research and development, maintenance and repair of equipment by the Radiotherapy technology group. Currently this is managed via a service level agreement with RMPD.
Policy and Strategy
To review the configuration of radiotherapy services within the network and advise on opportunities to develop the activity undertaken by NCCC.
To represent NCCC on the network radiotherapy group
To contribute to change and innovation within the Directorate in respect of service delivery and development.
To promote ‘Patient and Public Involvement’ in the design and planning of radiotherapy services.
Teaching, Research and Development
To facilitate an environment that is conducive to the ethos of teaching and education across the disciplines.
To encourage clinical research and development in radiotherapy and in accordance with joint NHS/University priorities.
41
Job Plan – Newcastle
DCC SPA ANR
morning afternoon hours PA hours PA hours PA
PA
comments
Monday 07.00-07.45 Travel to Sunderland 13.00-14.00 MDM colorectal SRH 11 2.75 0 0
07.45-08.45 admin SRH 14.00-16.00 MDM urology SRH
08.45-13.00 Outpatient SRH 16.00-17.45 ward referrals/chemo day
unit SRH
Tuesday 08.00-09.00 admin/ head of service NCCC 14.00-17.00 outpatient clinic NCCC 8 2 1 0.25 0
09.00-14.00 on-treatment review/planning NCCC 17.00-18.00 SPA NCCC
10.00-13.00 Outpatient clinic NCCC
Wednesday 08.00-09.30 admin/head of service NCCC 13.00-15.00 admin NCCC 10 2.5 0 0
08.30 Uro-oncology ward round 15.00-17.00 MDM colorectal Newcastle
09.30-13.00 chemo day unit/clinical trials alternates RVI FH
Thursday 08.00-13.00 outpatient clinic/ward referrals Freeman 13.00-14.00 PSG 14-15.00 planning 11 2.75 1 0.25 0
15.30-17.30 MDM urology Freeman
17.30 -19.00 Admin NCCC
Friday 08.30 -13.00 RT Planning 13.00-15.00 SPA NCCC 6.5 1.625 2 0.5 0
15.00-17.00 Admin/Head of service NCCC
Total 46.5 11.63 4 1 0 0
Overall total 50.5 12.63
Appraisal done 28/2/2012
Mandatory Training will complete by end March
Aim to reduce to 11PAs when new colorectal post appointed
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Job Plan - South Tees
Monday Tuesday Wednesday Thursday Friday
08:00 – 10:00 Theatre 10:00 – 11:30 Planning/ Brachytherapy 11:30 – 13:30 Gynae MDT 14:00 – 17:00 Joint Gynae Clinic 17:00 – 19:00 Admin
08:00 – 09:00 Admin 09:00 – 12:00 Chemo Clinic 12:30 – 13:30 Senior Management Meeting 13:30 – 14:00 Admin or meetings 14:00 – 17:00 F U/Rev Clinic 17:00 – 17:30 Admin 17:30 – 19:00 Urology MDT
08:00 – 08:30 Travel to UHH 08:30 – 09:00 Admin UHH 09:00 – 13:30 Clinic UHH 13:30 – 14:15 Travel from UHH 14:15 – 15:30 Lymphoma MDT 15:30 – 19:00 Admin/Meetings
08:00 – 08:30 Admin 08:30 – 10:00 Ward Round 10:00 – 13:00 Planning 13:00 – 14:00 Admin or meetings 14:00 – 17:00 New Patient Clinic 17:00 – 19:00 Admin, meetings or SPA
08:00 – 08:30 Admin 08:30 – 09:30 Radiology MDT 09:30 – 13:00 SPA or meetings 13:00 – 14:00 Clinical Meeting 14:00 – 19:00 Admin, meetings and SPA including monthly Directorate Meeting
Committee work/meetings (mainly non-timetabled) Trust - Cancer Strategy Group Other network meetings - NECN Board - CDs Meetings - Clinical Leads Group - Senior Medical Staff Committee - Regional Audit - Electronic records Steering Group - SSGs (gynae, lymphoma, urology) - Radiotherapy NCCG Directorate - Senior Staff/Consultants Meetings Divisional (Speciality Medicine)
- Educational Meetings - Divisional Board - Governance Meetings - Divisional Governance - Senior Management Meetings - Divisional CDs - Oncology Modernisation Meetings - Mortality Meetings Ad-hoc - Multiple - Quality System Management Meetings - Radiotherapy Technical Forum “Admin” comprises - Clinical admin
- Management/CD work incl appraisals Chemotherapy - S Tees Locality Chemotherapy Group - Trust Fund admin - NECDAG - General correspondence and emails - NECN Chemotherapy Steering Group
- Chemotherapy Electronic Prescribing Steering Group - Chemo Scheduling Group
43
Job Plan - North Cumbria, Consultant
Commitment Schedule
Day Time Activity PAs DC SPA
Location No. per month
Mon am Admin Gynae MDT Treatment Review
0.25 0.5 0.5
CIC Wkly
pm Brachytherapy List SPA
0.25 0.75
CIC Wkly
Tue am Voluming SPA
0.5 0.5
CIC Wkly
Pm Clinic
1 CIC Wkly
Wed am Clinic 1
CIC Wkly
pm Planning SPA
0.75 0.25
CIC Wkly
Thu am Travel & Clinic 1
WCH Wkly
pm Ward Review, Clinic, Admin & Travel
1
WCH Wkly
Fri
am Admin Ward Round Lung MDT
0.25 0.5 0.5
CIC Wkly
pm Admin SPA
0.5 0.5
CIC Wkly
On-call
Programmed activity summary
Direct Clinical Care 8.5
Supporting professional activities 2
Additional special responsibilities / Management: Lead Oncologist and Clinical Director
1
Other external duties and activities
Total programmed activities 11.5
Agreed on-call rota N/A
Agreed category A or B
Dept. Oncology
Date last Appraised: January 2012
Job plan start date: Sept 2009
44
Main duties and responsibilities Medical and Clinical
Direct Clinical Care Annual Hours
Per week
PAs
Ward rounds Outpatient activity Planning activities Multidisciplinary team meetings Surgical Administration Travel
2 14.5 10 3 1 1.5 2
TOTAL 34 8.5
Supporting professional activities
Personal management and development Annual Hours
Per week
PAs
CPD, CME, Teaching Audit/ clinical governance Job planning /Appraisal Research Clinical management
2.0 1.0 2.0 0.5 0.5 2.0
TOTAL 8 2.0
Additional special responsibilities/ Management
Annual Hours
Per week
PAs
Lead Oncologist and Clinical Director of Oncology Unit
TOTAL 4 1.0
Other external duties and activities
Annual Hours
Per week
PAs
TOTAL
Arrangements for Fee-paying work
Private Practice : Occasional patient in dept Fee Paying Work : Occasional category 2 reports etc
45
Objectives Supporting Resources Personal Development Plans Potential barriers to achieving objectives Action plan to resolve issues identified Additional programmed activities
Additional comments if any
Are you undertaking private medical practice as defined in the terms of service : occasional patients seen in dept
Yes
If YES – are you already working an additional PA i.e. more than 10 PAs or contracted commitment for part time staff
Yes
If NO – is an additional PA been requested by the Trust
No
If YES – has this been taken up
Yes / No
1. Deliver service in accordance with the Clinical Oncology Good Practice Guide
2. Enhance Brachytherapy service 3. Explore opportunities for teaching and possible SpR placement 4. Establish robust patient feedback mechanisms to improve and develop
services. 5. Maintain activity level to deliver contracted service
I intend to attend several courses related to Gynecological and Lung Cancers. Besides that I intend to brush up my knowledge of Intensity Modulated Radiotherapy (IMRT) and conformal therapy by attending some workshops / symposium in near future.
* Plan to enhance Brachytherapy services is still waiting clearance from the management.
