Cancer summit: 29 March 2023

A Healthier Wales set out the policy direction and the cancer quality statement describes the outcomes and standards we would expect to see in high quality patient focussed services. The quality statement for cancer sets out 22 planning and accountability expectations to be delivered consistently across Wales.

There are 22 national optimal pathways setting out what the optimal journey for patients are on those pathways. It is the expectation of Welsh Government that health boards cancer services align themselves to these optimal pathways reducing variation and ultimately reducing waits for patients.

Welsh Government published a Planned Care Recovery Plan, in April 2022. The cancer section of the recovery plan is very clear about the actions needing to be taken now to increase activity. Our approach for cancer recovery focuses on reducing the backlog of those who are waiting too long on their cancer pathway and ensuring there is clear communications in place with patients throughout their cancer pathway, but also works towards a more sustainable approach to transformed pathways which will deliver robust, efficient, and timely pathways and services for future cancer care.

The Wales Cancer Network, now part of the NHS Executive, published a cancer improvement plan to further support service in February 2023.

A cancer summit was held in March 2023 to:

1. follow-up on progress against commitments made at the October summit
2. reinforce the need for sustained focus over next 8-10 months
3. hear updated commitments from health boards and trusts
4. focus on 3 of the most challenged cancer sites; Gynaecology, Urology and Lower GI

The Deputy Chief Executive of NHS Wales welcomed executive, operational, and clinical leads from across Wales and set out the expectations of the day, highlighting where progress has been made since October 2022 and actions put in place to reduce the backlog of waits for cancer treatments.

The NHS Executive’s National Clinical Director for Cancer gave a presentation of the key service challenges facing NHS Wales. The key points were:

• The NHS is seeing increasing numbers of referrals and has responded by investigating and treating more patients than ever before. Current business intelligence capabilities have been improved significantly.
• The Cancer Network is working closely with NHS organisation and national teams to support NHS delivery and has brought forward a national cancer improvement plan. Further planning support is available to all health boards.
• Performance remains very challenged, and this has implications for patient outcomes, including  significant variation between health boards and between cancer sites. Need to focus on reducing variation and taking opportunities to work more regionally.
• Services are reliant on waiting list initiatives to try to keep pace and recover.
• We need to develop sustainable solutions and to look at whole pathway commissioning.
• The Diagnostic Programme is progressing in support of improving access to cancer investigation.
• There are many good examples of service development to celebrate such as the introduction of rapid diagnostic clinics, accelerate imaging pathways, lung cancer genomics, symptomatic FIT, and trans-nasal endoscopy.
• NHS staff are working incredibly hard and effective system leadership is required to improve services.

The NHS Executive’s Director of Performance and Assurance gave a presentation on progress against the key commitments made at the previous summit. This included backlog and performance trajectories for all cancer patients, and variation between health boards and cancer types. The key points were:

• Health boards are treating more patients and have started to reduce their backlogs, although this needs to be increased and maintained.
• Waiting list volumes remain high, particularly for diagnostic investigation.
• New outpatient waits have been growing since the end of January.
• Short term performance will be impacted by the focus on backlog reduction.
• New patient activity also needs to keep pace.
• A focus on diagnostic access has the greatest potential to support recovery.

The Minister for Health and Social Services addressed the summit and thanked everyone present for the work they are doing to recover and improve cancer services.

The minister reinforced the level of priority required to cancer service planning and delivery. The minister recognised some progress since the last summit and the impact of focusing on the backlog has on cancer performance. The minister reiterated that the quality statement for cancer sets out the national expectations to recover services following the pandemic and work towards achieving the performance target. To do this
the NHS should implement the national optimal pathways locally, invest in its workforce capacity at all stage of the pathway, and reconfigure its more fragile services where necessary working across units, or across the health board, or across a region.

The minister also stressed the importance of supporting people who are waiting for investigation and treatment.

The minister asked those present to recover cancer services as quickly as possible and in line with agreed trajectories. Available capacity should be prioritised accordingly, and the backlog must be brought down.

Cancer services should be properly reflected as a national priority in local planning, and this should include focus on implementation of the national pathways, pathway reform and access to first outpatient and diagnostic.

For Aneurin Bevan University Health the main challenge has been the wait time from referral to the start of the pathway. A target has been set to see 75% of patients within 14 days, this will ensure that patients flow quicker through the pathway. Workshops have been undertaken, aligned with the themes of this summit and have prioritised activity. A live forecast and demand profile for teams to plan for future demand has been created. Pathology reporting has been outsourced. Wait times are now starting to reduce and those waiting over 104 days are now falling.

Since the last summit Betsi Cadwaladr University Health Board has completed the prostate pathway review and had established a task and finish group to implement key changes. This includes the implementation of a straight to MRI service and nurse led clinics. From 1 April the new FIT guidance will be implemented with a particular focus on safety procedures with GPs. The audit of the neck lump pathway has been completed, one stop clinic established and reduced diagnostic times by 14 days at 1 hospital with the intention of rolling out to the other 2 sites shortly. Oncology capacity has increased with the appointment of new consultants, 1 substantive, 2 locum and an additional medical oncologist. There are issues remaining around teledermoscopy with no substantive consultants in the west and therefore the health board is continuing to transfer patients between sites. Referrals are received electronically from the GP, but have to be printed, there is work to be done to review them electronically.

Considerable focus remains on reducing the 62-day backlog. Since September Cardiff and Vale University Health Board have had 3 internal cancer summits, all clinically led, with a focus on reducing the backlog. This focus has worked well with a significant reduction in the number of patients waiting over 62 days, from a peak of around 750 to under 200. The wait for first contact is down to around 15 days, with an aim of 14 days or less by the end of Q1. The aim is to ensure that 85% of patients have a diagnosis by day 28. January performance was 55%, February will be around 62% and 75% by the end of Q1 with a push to 80% by Q2.
The performance at Cwm Taf Morgannwg University Health Board’ is considerably below where it should be.

There has been some reduction in the backlog, and whilst it is at its lowest level since November 2021 at 618 patients, it is still too high. A single neurological MDT with a single pathway is now in place across two tumour sites. The urological service is being reconfigured bringing all the diagnostics onto the Royal Glamorgan site.

The neck lump pathway will be in place by the end of the month. The one stop gynaecology clinic is now live. There has been some positive recruitment, including an additional breast surgeon and additional urologist.

Additional capacity for endoscopy is planned. The breast cancer service currently runs on multiple sites but
will be consolidated for outpatients to the Royal Glamorgan site.

Hywel Dda University Health Board’s commitment following the last summit was to reduce the backlog and the overall size of the PTL. The backlog is roughly 40% of what it was during its peak last summer and the PTL considerably reduced. Surgical volumes are significantly above the pre pandemic levels for cancer patients. The two largest problem areas are urology and lower GI, and plans are in place to increase
capacity. 

Powys Teaching Health Board noted that there is no district general hospital or associated specialist teams, therefore limited diagnostics and minimal treatment for cancer within the health board. There are consistent themes emerging from the clinically led monthly harm review panel, which are mainly radiology and pathology capacity, outpatient capacity, complex pathways where patients are involved with multiple providers and also patient factors. FIT testing has been successfully implemented in all practices in Powys through a variety of pathways. BCUHB have confirmed capacity to accept Mid Powys residents, this will provide RDC access to residents across the whole health board. The approach to cancer tracking is being
reviewed with a focus on provider services and to avoid duplication with activity in other health boards.

Provider services remain fragile within the health board, this is linked to staffing issues which are being addressing through commissioning.

Swansea Bay University Health Board commitment following the last summit was to reduce the number of patients on the PTL, this has reduced by 36%. There have been considerable challenges with gynaecology especially at the front end of the pathway with diagnostics being a significant challenge. Work needs to be undertaken on the lung pathway. Endoscopy has improved with 24% of referrals being seen within 14 days. A dashboard went live in February highlighting tumour site performance.

Insourcing is underway for gynaecology. A new breast consultant starts in April supported by the additional mammogram machine.

Velindre has been specifically focusing on pathways, workforce and regional working. There is some focused work around improvements in response to operational processes to improve all elements of the pathway. On workforce there is a dual approach, one is looking at what can be done in terms of national and regional
programmes and the other is reviewing some of the specialist roles at a more local level. Since the last summit they have undertaken a number of capacity reviews to give a better understanding of demand and capacity management.

Focus on specific pathways

There followed a group discussion on Urology, Lower GI and Gynaecology. Key points included:

• Nicholas William Gill, Cancer Site Group lead for Urology said the main issue is with capacity, the service struggles during periods of staff absences. Nicholas highlighted that high-risk prostate cancer takes significantly longer to go through the pathway due to the number of diagnostic tests required and commented on the difficulty in managing high risk and low risk patients.
• Kerryn Lutchman-Singh, Cancer Site Group pathway lead for gynaecology said it is important that Gynaecology patients get the same standard of care all along the pathway from diagnosis to treatment. They are piloting the ovarian one stop which is showing some encouraging results. It may be possible to implement the same model for Gynaecology.
• Martyn Evans, Cancer Site Group lead for colorectal said in the last year there have been some significant steps for lower GI. The endoscopy capacity is an issue.

The following commitments and actions were agreed and progress against these will be monitored closely:

• Implement the national pathways and reduce the pathway intervals through things like straight to test and same day follow on investigations.
• Longer-term planning is expected to come through in health board plans.
• Continue to improve on time to first outpatient and diagnostic appointment.
• Bring down the volume of patients waiting over 62 days to a safer level and continue to improve performance in line with individual trajectories agreed with the delivery unit.
• 1% tolerance against local pathway volume on 104 day waits that are not patient initiated.
• Focus required on improvements for urological cancer, lower gastrointestinal cancers, and gynaecological cancers.