Urological cancers Why we need change A case for change

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Urological cancers Why we need change A case for change

Transcript Of Urological cancers Why we need change A case for change

Urological cancers Why we need change
A case for change for specialist urological cancer surgical services
January 2013

Contents Foreword................................................................................................................................3 1. Background........................................................................................................................4 2. Context: who’s who ............................................................................................................5 3. Urological cancers..............................................................................................................6 4. Current services.................................................................................................................8 5. Why we need change.........................................................................................................9 6. How we can improve services ..........................................................................................12 7. The patient pathway.........................................................................................................13 8. What this means for patients............................................................................................15 9. Expected benefits ............................................................................................................16 10. Locations .......................................................................................................................17 11. How will we know that things are better?........................................................................19 12. Next steps......................................................................................................................19 Glossary...............................................................................................................................20 Appendix 1: Service specification for surgery for prostate, bladder and kidney cancers .......21
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Foreword

Across North East and North Central London and West Essex – a population of 3.5 million – around two people a day require complex surgery to treat kidney, bladder or prostate cancer1. These patients require specialist, once-in-a-lifetime surgery to give them the best chance of controlling their cancer and reducing the risk of long-term side effects.

We have a highly-skilled and experienced workforce, passionate and committed to delivering the best care to the populations that we serve. However, the way in which services are currently arranged does not maximise the delivery of the highest quality of care, research and training that we are capable of.

We want to change this.

We need to diagnose urological cancers earlier, whilst also improving the care and support of people who have finished their treatment and are either living with their cancer, in remission or recovery. We also need to change the way that we organise hospital care. National and international evidence demonstrates a clear link between higher surgical volumes and better patient outcomes.

Specialist radiotherapy and complex chemotherapy are already concentrated in a small number of specialist centres. We believe that the same should be true of specialist surgery for kidney, bladder and prostate cancers.

We believe that the creation of single specialist centres and high quality local units will provide our patients with high quality diagnostic and therapeutic care and expand opportunities to develop research that benefits patients. This would put us in a position to be among the best in the world – both in the quality of our care and the opportunities for patients to take part in research and access new treatments. We aim to make changes that will be durable for a generation to create a platform that can support future innovation.
We know, however, that specialist treatment is only a small part of a urological cancer patient’s care. The vast majority of patient care would always take place at local hospital units and GP surgeries.

Specialist centres would help put us among the best in the world
Specialist treatment is only a small part of a urology patient’s care

Patients tell us that, where they are cared for in different hospitals, they want their care to be joined up and to the same high standards wherever they are. We understand this and are committed to making it happen.

In this document we make the case for changing urological cancer services across North East and North Central London and West Essex and describe how we believe we can radically improve patient outcomes and patients’ experience of care.

1 2010/11 complex surgery for kidney, bladder and prostate cancers
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Our proposals build on an established clinical case for change – the Model of Care for Cancer Services2, 2010 - a review of cancer care undertaken for the whole of London in 2009/10 by NHS Commissioning Support for London. This made a compelling argument to improve cancer services in the capital where access to and outcomes from cancer care were unequal and mortality rates from cancer were higher in London than the rest of the UK.
The Model of Care proposed integrated cancer systems as an organising principle for cancer care, and it set parameters for changes to cancer services that we are now acting on locally in North East and North Central London and West Essex. The review showed strong evidence that specialist hospitals and surgeons that treat more urological cancer patients achieve better outcomes for high risk surgical procedures and recommended that minimum thresholds for surgery be set. The review involved, engaged with, and received support from, clinicians, local authorities, patient and public representatives and other groups across London.
Developed by our partners across London Cancer, this case for change builds on the framework of the Model of Care, with the aim of bringing globally excellent cancer services to our patients in the most efficient and equitable way.
We welcome your views, feedback and comments on our recommendations for improving urological cancer surgical services.
Professor Mark Emberton and Mr John Hines Urological Cancer Pathway Directors and Consultant Surgeons
1. Background
Over recent months, clinicians in north east and north central London and west Essex have been working together to consider how we can deliver the best possible urological cancer services that our local populations deserve.
Clinicians representing all the hospitals in the area – together with GPs, nurses, health professionals and patient representatives – have developed this case for change for how we believe we can achieve better outcomes for patients.
This case for change focuses on improving specialist surgery for urological cancer, specifically bladder and prostate cancer and kidney cancer, and the most specialist aspects of the surgical treatment.
2 http://www.londonhp.nhs.uk/wp-content/uploads/2011/03/Cancer-model-of-care.pdf
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2. Context: who’s who

London Cancer As a recommendation of the London-wide Model of Care for Cancer Services, the NHS cancer care providers of North East London, North Central London and West Essex are working together in an integrated cancer system known as London Cancer. London Cancer’s aim is to drive superior outcomes and experience for our patients and population of 3.5 million. London Cancer formed in April 2012.

London Cancer’s aim is to make big improvements in cancer services. It will do this by giving clinicians the power to lead improvement programmes and placing patients’ outcomes and experience at the heart of cancer care.

We want to work together to deliver big improvements

Representatives of the NHS trusts within London Cancer that provide urological cancer services are involved in developing these proposals:
 Barnet and Chase Farm Hospitals NHS Trust  Barts Health NHS Trust  Barking, Havering and Redbridge University Hospitals NHS Trust  Homerton University Hospital NHS Foundation Trust  North Middlesex University Hospital NHS Trust  Princess Alexandra Hospital NHS Trust  Royal Free London NHS Foundation Trust  University College London Hospitals NHS Foundation Trust  Whittington Health NHS Trust.

Urological cancer pathway board The pathway board is responsible for improving urological cancer outcomes and patient experience for local people. The board is led by the cancer pathway directors and its constitution can be viewed on the London Cancer website3.
Commissioners NHS commissioners are responsible for ensuring that health and social care services meet the needs of the population. The cluster primary care trusts (PCTs) – NHS North East London and the City and NHS North Central London – are leading engagement on this case for change and the proposed model of care developed by London Cancer. From April 2013, the responsibilities of primary care trusts (PCTs) will transfer to the NHS Commissioning Board, clinical commissioning groups (CCGs) and local authorities (for public health).
NHS Commissioning Board The NHS Commissioning Board (NHS CB) aims to improve health outcomes for people in England. As well as overseeing a comprehensive system of clinical commissioning groups (CCGs) with responsibility for commissioning the majority of services, the NHS CB directly commissions a range of primary and specialised services, including specialised cancer services.

3 http://www.londoncancer.org/cancer-professionals/urological/urological-pathway-board-constitution/
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Clinical commissioning groups From April 2013, GPs, as a part of clinical commissioning groups (CCGs), will be responsible for ensuring local health services meet local needs – they will decide, for example, what local services are needed for patients and how care can be best organised. While the NHS CB will have responsibility for specialised services such as complex cancer surgery, CCGs across North East London, North Central London and West Essex will ensure that the whole cancer care ‘pathway’ delivers excellence for patients, from diagnosis to post-treatment support.
Local authorities Local authorities will have new responsibilities for public health, prevention and health promotion. Public Health England will be established from April 2013 and aim to improve people’s health and wellbeing.
3. Urological cancers
Bladder cancer Around 400 cases of bladder cancer are diagnosed each year in our area. Bladder cancer becomes more common as people get older and is more common in men than in women. The symptoms of bladder cancer are blood in the urine and changes in urination. These are also the symptoms of a lot of other less serious diseases.
Eight out of 10 patients diagnosed have early bladder cancer. These early cancers are often limited in size and the degree to which they have spread. They can therefore be treated by relatively simple surgery that can take place in most hospitals.
A much smaller number of bladder cancers, less than 100 per annum, are more advanced and have spread further (metastasised). These often need to be treated with a combination of complex major surgery, radiotherapy and chemotherapy.
Prostate cancer Prostate cancer is the most common cancer found in men – around 1,500 cases of prostate cancer are diagnosed locally each year. However, very complex surgery is only required by a small number of people. In 2010/11, 220 complex operations for prostate cancer took place across the London Cancer area.
Prostate cancer differs from most other cancers in that small areas of cancer in the prostate are very common and may stay inactive (benign) for many years.
Prostate cancer can cause changes in urination, but these symptoms are often subtle when compared to the same symptoms caused by the less serious changes to the prostate gland seen in all men as they get older.
There are many different treatment types and each have different benefits and different side effects. Treatment options include monitoring the cancer (known as active surveillance), treatment with radiotherapy or brachytherapy4, hormone therapy or surgery.
4 See glossary at the end of this document.
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We know that sometimes a patient’s treatment decision can be influenced by the facilities available at different hospitals and the approaches favoured by different teams.
Patients with any new diagnosis of cancer need to be given clear information and unbiased support in making the difficult decision on what course to follow. Due to the range of treatment options, this is particularly important for prostate cancer patients.
If initial treatment fails or if the cancer spreads then treatment focuses on hormone therapy and chemotherapy. These patients should be able to discuss treatment options, impact of treatments and clinical trials of new drugs.
Kidney cancer Kidney cancer is relatively rare and is approximately twice as common in men as in women. Around 400 new cases of kidney cancer are diagnosed each year across north east and north central London and west Essex.
Kidney cancer is most commonly found incidentally while scanning patients for something else. It may also be picked up in outpatient clinics for people with the symptom of blood in their urine. There are relatively few treatment choices for kidney cancer and treatment is most often surgical.
Some surgical operations for kidney cancer are simple whereas others are very complex. All are becoming increasingly reliant on emerging technologies, such as keyhole (laparoscopic) surgery and robotically-assisted surgery.
Surgery should seek to save as much of the kidney as possible. A number of non-surgical treatment options also seek to do this.
If kidney cancer spreads then the aim of treatment is to control the cancer through new targeted therapies5. This often happens within clinical trials.
Other urological cancers While other urological cancers such as penis and testicular cancers are not the focus of this case for change, there are some co-dependencies which we need to consider. For instance, a highly-specialised operation to treat widespread testicular cancer following chemotherapy is carried out by kidney cancer surgeons, so we will take this into account when proposing changes to kidney cancer services.
5 See glossary at the end of this document.
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4. Current services
Bladder and prostate cancer Of around 1,900 cases of all prostate and bladder cancers diagnosed in London Cancer each year, only 350 patients require complex surgery. This is just under 1 in 5 of all patients (18%). There are currently four bladder and prostate cancer surgical centres across North East and North Central London and West Essex6. Each centre serves a population of between 600,000 and 1 million. There are also a number of patients from other parts of London and south Hertfordshire who choose to have their complex pelvic procedure (to treat bladder and prostate cancer) at one of the London Cancer hospitals providing urological surgery. In 2010/11, each surgical centre carried out between 54 and 89 complex operations – a total of 296. This total was made up of 220 operations for prostate cancer and 76 operations for bladder cancer. We also believe that there are up to 50 bladder and prostate patients each year who do not get the complex surgery that they would benefit from. Our challenge is to ensure that everyone who needs specialist surgery should have access to appropriate surgery.
6Since 2010, a substantial number of Whipps Cross cases have taken place at University College Hospital. Since October 2012, by clinical agreement, a temporary arrangement has been in place for Chase Farm patients to be operated on at University College London Hospital in response to an internal audit which demonstrated that optimal outcomes were not being achieved for some patients. This arrangement is not part of the review of urological cancer specialist services being led by London Cancer, but is a temporary local arrangement in response to clinical need.
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Kidney cancer Of around 400 new cases of kidney cancer diagnosed in London Cancer each year, 300 (75%) require surgery. Across North East and North Central London and West Essex, complex kidney cancer surgery is provided in all nine hospitals that treat and care for adult urological cancer patients. In 2010/11, they each did between 10 and 72 operations – a total of 292 operations.
5. Why we need change
National perspective Whilst there have been significant improvements in cancer care in the UK over the past decade, there is further improvement needed to deliver world-class cancer services. While deaths from cancer have fallen, the UK still has a relatively high mortality rate. National and international evidence demonstrates a clear link between higher surgical volumes and better patient outcomes. Specialist centres which have frequently practising specialist teams and full facilities, with high patient throughput, generally have better patient outcomes. In 2002, the National Institute for Health and Clinical Excellence (NICE) published guidance on improving services for urological cancers7 which recommended that patients with cancers that are less common or need complex treatment should be managed by specialist multidisciplinary teams in large hospitals or cancer centres.
7National Institute for Clinical Excellence, Improving Outcomes in Urological Cancers: The Manual, 2002
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London perspective The NHS body responsible for the whole of London reviewed cancer services in the capital in 2009/108.The review included an engagement process with key stakeholders and patient groups from across London and made a compelling argument for the need to improve cancer services in London. The review showed that access to and outcomes from cancer care were unequal across the city and that mortality rates from cancer were higher in London than the rest of the UK.

Londoners report a poorer experience of cancer services than other areas of England, and services are not always organised to deliver the best outcomes for patients. Despite having the highest population density, London has one of the smallest average catchment populations per hospital for all services. This means that hospitals in London are not able to take full advantage of the advances in medical care and economies of scale as specialist staff, facilities, and patients are spread across a relatively large number of hospitals.

“[A] number of London hospitals seeing a low volume of bladder and prostate cancer patients. [It] is clear that Londoners are not currently being provided the world-class service they
deserve.” Review of services across
the whole of London

The review showed that there was evidence that specialist hospitals and surgeons that treat more urological cancer patients achieve better outcomes for high risk surgical procedures and recommended that minimum thresholds for surgery be set.

This London-wide review made wide ranging proposals for increasing early diagnosis, improving hospital care and taking a new approach to patients living with cancer. The proposals said that common treatments should be available locally to patients, but that specialist surgery should be concentrated.

For bladder and prostate cancer this ambition led to three specific surgical recommendations:  That a maximum of five hospitals across the whole of London should provide complex
bladder and prostate surgery9  That each surgical centre should serve a population of at least two million  That these centres should carry out a minimum of 100 operations for complex bladder
and prostate cancer a year.

For kidney cancer, the clinical papers that form the London guidance concluded that the management of renal malignancies should be confined to specialist urology multi-disciplinary teams.

Engagement on the London-wide case for change and model of care10 was held between August and October 2010. This involved clinicians, local authorities, patient and public representatives and other groups from across London. Letters were sent to 1,600 GP practices across the capital and a further 1,100 stakeholders were informed by email. A stakeholder event was attended by 80 delegates and proposals were met with a high degree of support. Many groups including LINks, local authority overview and scrutiny committees,

8 NHS Commissioning Support for London, Cancer Services: Case for Change, 2009; A Model of Care for Cancer Services, 2010 9 At the time there were more than 10 bladder and prostate centres across London, four in the London Cancer area. 10 http://www.londonhp.nhs.uk/wp-content/uploads/2011/03/Cancer-engagement-report.pdf
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