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NB *47 NP and 173 FU patients (UGI) seen on Mondays

*45 NP and 144 FU patients (Lung) seen on Fridays

2.2. Data produced by Dr Derneddes data (Appendix A)

Clinic Cancer type Newpatients in

6 months

Follow uppatients in

6 months

Newpatients /

year

Follow uppatients /

year

Mon am Dr Dernedde UGI 43 205 86 410

Mon pm Dr Epurescu LGI 39 121 78 242

Ovarian 14 45 28 90

Wed Dr Harnett Breast 114 340 228 680

Wed Dr Wade Urology 57 257 114 514

Gynae 28 127 56 254

Fri Dr Martin / Dr Dernedde Lung 69 397 138 774

Totals 728 2964

2.3. The NNUHFT Oncology Notes System

2.3.1. Analysis of the Notes system, which collates data on patients attending both the NNUHFT

and the JPUHFT, confirms that there were 3201 new patients registered, 3149 of which were

seen (or had major annotations). Whilst this estimate can be challenged, with possible over

estimates (due to registrations from telephone calls and ward referrals not seen in oncology) or

under estimates (due to recurrences, 2nd primaries seen as New patients), the view of the

Oncology Clinical Director is that this is an accurate assessment of New patient workload for

the two Trusts.

2.3.2. A more detailed breakdown of these 3149 New Patients / year, across cancer body site andConsultant is shown in Appendix B

2.3.3. An estimate of the number of New patients for the JPUHFT has been calculated by dividing

the total number of registered New patients on the Notes system by 3 (population served by

the JPUHFT is 33% of the total served by both Trusts). An assumption has been made that the

mix of cancer types will be consistent across the Network population.

Cancer Type Numbers of New patients / year

across both NNUHFT & JPUHFT

Estimated numbers of New Patients

across the JPUHFT catchment

Head and Neck 174 (includes Kings Lynn) 40

Lung 446 149Upper GI 274 91

Brain 76 25

Breast 683 228

Skin 120 40

Sarcoma 38 13

Haem (including eye) 120 40

Urological 489 163

Lower GI 351 117

Gynaecological 176 55

Carcinoid 8 3Unknown 71 27

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3. Oncology OP Capacity

3.1. The current clinic schedules and numbers of New patient / Follow Up Patients slots currently

available are shown below. NB Some clinics have Staff Grade support.

Day Session Consultant

New

Slots

Follow Up

Slots

Monday AM Dr Dernedde 2 8

PM Dr Epurescu 3 6

Wednesday AM Dr Harnett 3 9

PM Dr Harnett 2 3

Wednesday AM Dr Wade 3 9

PM Dr Wade 6 16

Friday - Weeks 1, 3, 4, 5 AM Dr Martin 4 18

Friday - Weeks 1, 3, 4, 5 PM Dr Martin 4 18

Friday - Week 2 AM Dr Martin 3 13Friday - Week 2 PM Dr Martin 3 13

Friday PM Dr Dernedde 2 8

Totals 35 121

3.2. The total capacity:

3.2.1. The theoretical capacity (based on 52 weeks / year) = 1820 New Patient slots / year and

6292 Follow Up slots / year

3.2.2. Being more realistic, assuming each consultant is operational for 42 weeks / year (based on6 weeks Annual Leave + 4 weeks Study Leave), the actual total capacity available = 1470

New Patient slots and 5082 Follow Up slots / year.

3.2.3. Comparison of the OP activity presented in 2.1, 2.2 and 2.3.3 with the realistic capacity

available (3.2.2) gives an appreciation of the level of mismatch between demand and capacity.

The comparison is shown below

Data source New Patient slots

required

New Patient slots

available based on 42

weeks / year

Difference (+/-)

From PAS data 732 1470 +738From Dr Dernedde data 728 1470 +742

From Oncology Notes

data

991 1470 +479

Follow Up Patient slots

required

Follow Up Patient slots

available based on 42

weeks / year

Difference (+/-)

From PAS data 3006 5082 +2076

From Dr Dernedde data 2964 5082 +2118

3.3. Utilisation of New Patient and Follow Up Patient capacity.

3.3.1. Analysis of the PAS data allows us to determine how many of the New and Follow slots

were used on each day. The results for each consultant are show in the dot plots below.

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E.g. there were 5 occasions in which 4 New patient slots were used and 8 occasions when 13 FU

slots were used.

NB The number of occasions in which no New or Follow Up slots were used confirms that in most

cases Oncologists have provided cover for at least the assumed 42 weeks / year.

211815129630

Dr Harnett - New

Dr Harnett - FU

Numbers of Patients Attending New & FU Clinics / Day- Jan to June 09

42363024181260

Dr Martin - New

Dr Martin - FU

Numbers of Patients Attending New & FU Clinics / Day - Jan to June 09

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121086420

Dr Epurescu - New

Dr Epurescu - FU


1815129630

Dr Wade - New

Dr Wade - FU


121086420

Dr Dernedde - NP

Dr Dernedde - FU

Data

Number of Patients Attending New and Follow Up Clinics / Day Jan to June 09

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4. Current Waiting Time Performance

4.1. Waits for New Patient appointments

4.1.1. The number of days wait between referral and initial OP appointment for each of the visiting

consultant oncologists between January and June 09 are shown in the graphs below.

918273645546372819101

100

80

60

40

20

0

-20

Observation

Dayswait

_X=12.6

UCL=46.5

LCL=-21.3

1

1

1

1

Days Wait for Initial OP Appointment - Dr Dernedde

9181716151413121111

60

50

40

30

20

10

0

-10

Observation

DaysWait

_X=13.03

UCL=35.20

LCL=-9.14

1

Days wait for Initial OP - Dr Harnett

464136312621161161

100

80

60

40

20

0

-20

-40

Observation

DaysWait

_X=25.4

UCL=75.9

LCL=-25.1

1

Days Wait for Initial OP Appointment - Dr Epurescu

464136312621161161

40

30

20

10

0

Observation

DaysWait

_X=8.52

UCL=22.93

LCL=-5.89

1

1

1

Days Wait for Initial OP Appointment - Dr Martin

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736557494133251791

40

30

20

10

0

-10

Observation

DaysWait

_X=10.36

UCL=32.95

LCL=-12.23

1

1

Days Wait for Initial OP Appointment - Dr Wade

4.1.2. Waiting times for New patient are seen as important by Oncologists although there is no

national target, the NNUHFT have set an internal target of

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5.1.4. The three data sources used to assess current OP activity have produced very similar

estimates. For the purposes of future planning, the Oncology Notes system has been confirmed

by the Oncology Clinical Director as the most reliable.

5.1.5. The analysis of the Oncology Notes System data does not extend to Follow Up activity so

estimates of Follow Up activity associated with New Patient numbers have been prepared by

two methods:

5.1.5.1. Using New to Follow ratios provided by Dr Dernedde

5.1.5.2. Using a New to Follow ratio of 1:5 (It is estimated (from a Joint Collegiate Council

for Oncology report Dec 2000) that an average DGH population of 250,000 will have

1,000 new cancer registrations each year. If 75% of these were seen by an oncologist, there

would be 750 new cancer patient consultations each year. The ratio of follow-up patients to

new patients is found to be between 3 and 10:1 (Richards, MA and Parrott, JC, 1996) a ratio

of say 5:1 would mean 3,750 follow-up consultations each year.)

Cancer type New Patient

slots required

Conversion used

based on Dr

Dernedde data

FU slots required-

based on Dr

Dernedde

conversion

FU slots required

based on JCCO

guidance

UGI 91 4.7 428 455

LGI / Ovarian 117 3.2 374 585

Breast 228 2.9 661 1140

Uro / gynae 218 4.5 1071 1090

Lung 149 5.2 775 745

Skin / Haem 60 3 180 300

Head & Neck Estimate 100 Estimate 100

Total 863 3489 4415

5.2. Rising incidence of Cancer

5.2.1. Future capacity planning should also take into account the increasing cancer incidence,

estimated at approximately 8% every 5 years (NRAG based on projections of the future

changes to the population profile in terms of age and gender). With this in mind the followingslots need to be available.

Cancer type New Patient slots required

(Additional 8%)

FU slots required

(Additional 8%)

Dr Dernedde

conversion

FU slots required

(Additional 8%)

JCCO conversion

UGI 98 462 490

LGI / Ovarian 126 404 630

Breast 246 714 1230

Uro / gynae 235 1157 1175

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Lung 161 837 805

Skin / Haem 65 194 325

Head & Neck Estimate 110 Estimate 110

Total 931 3878 4765

New Patient

slots required

New Patient slots

available based on42 weeks / year

Diff

(+/-)

931 1470 +539

Follow Up

Patient slots

required

(Dr Dernedde

conversion)

Follow Up Patient

slots available

based on 42

weeks / year

Diff

(+/-)

Follow Up

Patient slots

required

(JCCO

conversion)

Follow Up Patient

slots available

based on 42

weeks / year

Diff

(+/-)

3878 5082 +1204 4765 5082 +317

5.2.2. The Oncologists currently work within three teams:

5.2.2.1. Team A specialising in Head & Neck, Lung, Upper GI and Brain

5.2.2.2. Team B specialising in Breast, Skin, Sarcoma and Haematology

5.2.2.3. Team C specialising in Urology, Lower GI, Gynaecology and Carcinoid

5.2.3. Assuming the Oncologists continue to work within this team structure then these slots need

to be apportioned across the three teams as follows:

Team Number of New patient Slots

required

Number of Follow Up Patient

slots required

Dr Dernedde

conversion

JCCO

conversion

A 259 1409 * *1405

B 311 908 1555

C 361 1561 1805

Total 931 3878 4765

* Includes an estimated 110 Head & Neck follow up appointments

5.2.4. Based on 42 available weeks the gap between slots available and slots required is:

Team Consultant New Patient Slots available

currently

Gap

A Dr Dernedde 168

+229Dr Martin 320

Total Team A 488

B Dr Harnett 210 -101Total Team B 210

C Dr Wade 378

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+143

Dr Epurescu 126

Total Team C 504

Team Consultant Follow Up Slots

Available

Gap (+ / -) Dr

Dernedde

Conversion

Gap (+ / -)

JCCO Conversion

A Dr Dernedde 672 + 575 + 579Dr Martin 1312

Total Team A 1984

B Dr Harnett 504 - 404 - 1051

Total Team B 504

C Dr Wade 1050 - 259 - 503

Dr Epurescu 252

Total Team C 1302

5.3. The business case for Radiotherapy at JPUHFT

5.3.1. This business case has been presented to the JPUHFT Trust Board and Governors and is

currently with local commissioners. A decision has yet to be made and recent guidance

suggests that no decision will be made until waiting time targets for radiotherapy treatment

have been reviewed nationally. The timescale for this is unknown.

5.3.2. It is worth remembering that the case does however include 2 WTE consultant oncologists

and 1 WTE Consultant Radiographer. This should be considered alongside any proposed

additions to the establishment.

5.3.3. Provides future scope for daily on-site presence of oncologists

5.4. Acute Oncology Service

5.4.1. The NCAG report mandates setting up of an acute oncology service in every hospital with

an A&E department. The principle drive for this is to provide assessment and treatment of

patients with complications of chemotherapy but the service is also expected to ensure the

rapid and appropriate management of patients presenting with previously undiagnosed cancer.

5.4.2. At the NNUHFT, the expectation is that the acute oncology service will:

5.4.2.1. Improve outcomes for patients with complications of cancer therapy

5.4.2.2. More efficiently assess patients with complications of known cancer

5.4.2.3. Assist in compliance with NICE metastatic spinal cord compression guidance

5.4.2.4. Provide a more efficient palliative radiotherapy service

5.4.2.5. Help provide better advice for patients with known cancer under other clinical teams

5.4.2.6. Reduce in-patient stay and compliance with NICE guidance for patients with cancer

of unknown primary site

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5.4.3. The proposal under discussion at the NNUHFT includes an additional 10 sessions of

Consultant Oncologist time and 1 WTE Clinical Nurse Specialist covering the acute oncology

service via a dedicated bleep

5.4.4. Discussions regarding an integrated approach to the development of the acute oncology

service across both Trusts have just commenced. The Anglia Cancer Network is also now

beginning to take a co-ordinating role

5.4.5. Arrangements for the JPUHFT are therefore unclear at this stage and may have some

bearing on the JPUHFT oncology establishment later.

5.5. Review of patients on chemotherapy

5.5.1. It has been reported that due to lack of clinic capacity, breast cancer patients on

chemotherapy are not being reviewed by the consultant oncologist, even patients with an

urgent need for review.Waits of 2-3 months (previously even four months) to see a consultantare reportedly not uncommon, whereas all other patients have access to their consultant at the

very next clinic, if problems arise.

5.5.2. There is a view that delays in review of patients present a clinical risk with potential for

serious complaint.

5.5.3. A search of the bookwise electronic booking system in the Sandra Chapman Unit,

between 1st June 08 and 31st May 09, identifies the need for approximately 320 additional

follow up slots if the existing number of breast cancer patients are to be reviewed every third

cycle of treatment. The data that supports this is available in appendix C

5.6. Leadership

5.6.1. Historically there have been excellent consultant links across the surgical and medical

specialties between the JPUHFT and the NNUHFT.

5.6.2. Oncologists employed by the NNUHFT have provided on site services at the JPUHFT,

covering OP clinics three days / week and MDT meetings by video link or on site.

5.6.3. The Medical Oncologist employed by the JPUHFT also has sessional commitments at the

NNUHFT but is usually too busy to attend

5.6.4. There appears however to be confusion over oncology leadership at the JPUHFT specifically who takes clinical responsibility for the services strategic development. There is a

widely held view that this is a significant problem.

5.6.5. Oncologists have described a walk in / walk out service where they dont get known at

JPUHFT. They are keen to be more involved in teaching / giving presentations. There is also

interest in supporting the case for development of Nuclear Medicine at the Trust.

5.7. Outreach services to Beccles

5.7.1. Outreach services were provided up until approximately 2 years ago, with twice monthly

clinics scheduled immediately after the JPUHFT clinic and run by Dr Ostrowski.

5.7.2. It is reported that the Trust has some interest in re-initiating this service

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5.8. Ratio of Medical to Clinical Oncologists

5.8.1. The Joint Collegiate Council for Oncology has recommended a ratio of 2 clinical

oncologists to every 1 medical oncologist but also recognises the important contribution both

specialties make towards comprehensive cancer care. The balance will also be influenced by

the site-specialised interests of the oncologists and the tumour types for which the cancer unitis accredited.

5.8.2. With regard to OP clinic sessions, the ratio at the JPUHFT is 3 medical oncologist sessions

to 6 clinical oncologist sessions.

5.9. The view is that the current establishment of oncologists makes it impossible to cover

consultant absence. If the consultant is absent for any reason then clinics are cancelled. This

reportedly is the norm across the Trust.

5.10. Even without cover, the consultant oncologists provide a service with comparatively short

waits for New Patient clinic slots. These waits do however exceed the local target of < 7 daysset at the NNUHFT. See section 4.1

5.11. During these discussions there have been requests to have cover arrangements for Lower

GI and Urology as well as Breast appointments.

5.12. Suggestions have also included Nurse / Radiographer led Follow up for Breast patients

with there being potential for approximately 400 slots / year to be seen by a Nurse

5.13. There is a view is that the workload for Breast cancer is sufficiently high to warrant input

from a 2nd Consultant, either running clinics side by side with the existing clinic or on another

day. Input to the MDT could be actual or via video link

5.14. Potential for Oncology Clinics alongside other cancer clinics

5.14.1. The Wednesday pm Breast clinic currently runs alongside the surgical Breast clinic new

patients can then if required be referred from the surgeons for an oncological opinion.

5.14.2. There is enthusiasm to run a joint Gynae-oncology clinic between Dr Wade and Mr Nieto

5.15. MDT cover

5.15.1. The importance of oncologist input to MDTs has long been recognised and is a key

recommendation of the Calman Hine Cancer Report.

5.15.2. The table below provides a picture of the MDTs established and the contribution made to

them by Oncologists. This contribution can be from either Trust (video links) and is not

constrained to those visiting the JPUHFT

Cancer

Body Site Day / Time Type of MDT Consultant Comment

Breast Wed On site JPH Dr Harnett

Suggestions have been made

regarding the need for an

additional MDT / week at JPUHFTLung Tues (12-1) Video linked with

NNUH

Dr Martin /

Dr

Covered by NNUHFT team in

absence of Dr Martin

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Dernedde

Colorectal Monday Lunchtime On site JPH

Dr

Epurescu

Radiotherapy patients seen at

NNUH

Upper GI Friday lunchtime

Video linked with

NNUH

Dr

Dernedde

Radiotherapy patients referred to

NNUH. TWR from NNUH also

attends. Radiotherapy referrals

made by UD to TWR

Urology Wed morning On site JPH Dr Wade

No oncologist present at MDT

even though Dr Wade is at the

JPUHFT on Wednesdays.

Specialised urology (penis / testis)

seen at NNUH

Gynaecology Thur lunchtime

Video linked with

NNUH

Dr

Epurescu /

Dr Wade Dr Biswas also from NNUHFT

Head &

Neck Wed morning

Joint MDT with

NNUH Dr Martin

New patients seen at NNUH

Dr Roques / Martin from

NNUHFT

(Thyroid) Mon lunchtime(fortnightly Video linked withNNUH Dr Martin Dr Roques / Martin fromNNUHFT

Lymphoma Tues morning

Video linked with

NNUH

All new patients seen at NNUH

ANH and HMS from NNUHFT

Brain None

No link with

NNUH or

Cambridge

All new patients seen at NNUH

Video links needs to be established

with Addenbrookes

Skin Mon morning

Video linked with

NNUH Dr Harnett

There is a JPUHFT MDT on

Friday pm with no Oncology input

noted at Peer Review

Sarcoma

Informal

developing

Video links with

NNUH / supra-

regional in

development

Dr

Stebbings

Takes place every two weeks on a

Friday HMS

5.15.3. Gaps highlighted through discussion are:

5.15.3.1. Colorectal MDT is attended by a Medical Oncologist only; as such there is no

specific radiotherapy input to the discussion from a clinical oncologist.

5.15.3.2. The JPUHFT Urology MDT meets without input from any Oncology expertise

5.15.3.3. There is no Oncology input to the JPUHFT Skin MDT

5.15.3.4. There are no video links from Addenbrookes to JPUHFT and NNUHFT so although

local patients are managed very competently by the Addenbrookes team, local clinicians

do not have the opportunity to be involved in Brain MDTs

5.15.3.5. The potential need for a second weekly Breast MDT a counter argument exists for

expansion of the existing weekly MDT or a more efficient MDT.

5.15.4. Standards for MDTs

NICE has published Improving Outcomes Guidance for many tumour types which specifies

oncology input to local MDTs:

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5.15.4.1 IOG Skin (p45) Local skin MDT Not every local Skin MDT will have a clinical

or medical oncologist available but if local circumstances allow they should part of

the local Skin MDT arrangements

5.15.4.2 IOG Colorectal (p45) Whenever elective surgery is considered for patients with

rectal cancer, a clinical oncologist should be involved in discussion about each

patient before surgery is scheduled. In view of the current shortage of clinicaloncologists in the NHS, teleconferencing may be appropriate to enable this

discussion to be held. A medical oncologist may also be included in the MDT if

available

5.15.4.3 IOG Breast (p77) Oncologists should devote at least 3 sessions / week to breast

oncology. Newly appointed oncologists should have at least one years experience in

an established breast unit. Where the oncologist is a medical oncologist, a firm link

must be established between the core team and the clinical oncologist from the

centre to which patients are referred for radiotherapy.

5.15.4.4 IOG Urology (p27) Oncologist with expertise in radiotherapy and chemotherapyfor patients with urological cancers. The oncologist, who is likely to be a member of

the specialist urological cancer team from a linked cancer centre, should cooperate

with other specialist oncologists in the network

5.15.5 Peer Review

A peer review team visited the JPUHFT on 22/09/09 and reviewed gynaecological diagnostic

services and skin LMDT. For the skin team they verbally raised a concern regarding the lack of

oncologist attendance at the LMDT held here at the Trust. Whilst there was some disagreement

locally about the need for oncologist input for the type of patients discussed, the peer review team

upheld the measure.

No formal documentation available until the report is finally issued in December 09.

6. Conclusions

6.1. The PAS and Dr Dernedde data sources provide comparable estimates of current OP activity.

The estimates they give though are slightly lower than that obtained from analysis of the

NNUHFT Oncology Notes system.

6.2. It is also possible that a proportion of OP activity has been omitted from the PAS totalspresented in section 2.1, with a number of New Patients and Follow Up patient slots being

provided in review clinic templates.

6.3. Based on JCCO estimates, where they estimate that a population of 250,000 would see

approximately 1000 new cancer cases / year, the NNUHFT Oncology Notes system provides a

reliable data set and has been proposed as the preferred planning tool.

6.4. There is significant variation in the numbers of New and Follow Up slots available to

consultants in their clinic templates. (Refer to section 3.1) The number of New Patient slots can

vary from 2 to 6 per clinic and the number of Follow Up slots can vary from 3 to 18 slots per

clinic.

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6.5. The data presented in 3.2.3 shows that the current total allocation of New and Follow Up slots

in clinics is in excess of what is required for the current demand. Even with the highest

estimate of New patient demand (991 patients from the Oncology Notes System source) there

is an excess of nearly 480 New patients slots (and at least 2000 Follow Up slots) across all

consultant clinics based on 42 operational weeks / year.

6.6. This excess of New and Follow Up slots should not however automatically be assumed to beslots that are available to be used within the time constraints of the clinics. It is obvious from

discussion that clinics often run over time even though slots are not utilised. This implies that

clinic slots are too short.

6.7. Section 3.3 provides useful information on how the allocation of New and Follow Up slots has

been used. If we discount 0 entries (clinic not open) and look by consultant at the most

common number of New patients and Follow Up patients seen / day (or day) alongside the

range, then the results are;

6.7.1. Dr Harnett most commonly sees 4 New patients / day (range 1-8) and 13 Follow Up patients

/ day (range 8 - 21)

6.7.2. Dr Martin most commonly sees 1, 2 or 3 New Patients / day (range 1-6) and 10 Follow Up

patients / day (range 3 - 44)

6.7.3. Dr Epurescu most commonly sees 2 New Patients / day (range 1-5) and 8 Follow Up

patients / day (range 6 -12)

6.7.4. Dr Wade most commonly sees either 3 or 6 New Patients / day (range 1 7) and either 14 or

18 Follow Up patients / day (range 9 20)

6.7.5. Dr Dernedde most commonly sees 2 New patients / day (range 1-4) and 7 Follow Up

patients / day (range 2-13)

6.8. On a daily basis there is a relatively high level of consistency across consultants in the numbers

of New and Follow Up patients actually seen in clinics. Dr Harnett sees slightly fewer Follow

Ups / day than his colleagues (because he does not review breast chemotherapy patients) and

Dr Martin tends to see slightly fewer New and Follow Up patients / day than his colleagues. Dr

Martin has the greatest level of variation in his Follow Up numbers with 4 occasions in which

over 30 patients were seen, once as many as 44 patients.

6.9. Waiting times performance data shown in section 3 ranges between 8.5 and 25 days for NewPatient appointments and between 24 and 149 days for Follow Up appointments. (NB a high

proportion of 0 days waits for Dr Dernedde skews the lower value of 24 days). Whilst not a

national target, there is an internal target at the NNUHFT to see New Patients within 7 days of

referral (unless there are clinical reasons for a longer delay or the patient wishes to defer an

appointment) and there is a view that this should be the aim across both Trusts.

6.10 Discussions with the Oncology Clinical Director regarding which cancer patients should be

seen at the JPUHFT suggest that approximately 87% of New Patients should be seen at their local

Trust with the remaining 130 New patients being seen at the NNUHFT. There appears to be no

formal agreement between the two Trusts that work should be distributed in this way.

6.11 Assuming agreement is reached and that cancer incidence rises by 8% over the next 5 years,

the minimum activity that should be used for service planning is 930 New Patients and 3800 Follow

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Up patient slots (based on Dr Derneddes conversion factor.) On these numbers, and assuming 42

operational weeks / year the total number of slots currently available is actually in excess of what is

required with approx 540 more New Patients slots and 1204 Follow Up slots available than

required. See 6.6.

6.12 There is strong support from the oncologists for the current arrangement of working in three

teams to continue. Although 5.11 suggests that the slot capacity available exceeds that required, itdoes not mean that the capacity is in the right place as far as the teams are concerned. Some

adjustments are required, based on the data available:

6.12.1 Team A could theoretically reduce its New slots by 230 / year and its Follow Up by 575 /

year. What is clear from the data in section 2.1 to 2.2 is that Dr Dernedde is seeing a greater

proportion of the patients seen collectively by team A and yet has approximately 30% of the

total New patient and Follow up slot capacity. Either New / FU slot capacity needs to be

redistributed from Dr Martin to Dr Dernedde or the patient workload needs to be more fairly

distributed. Because of the frailty of Dr Derneddes patients, there is a need to have

sufficient OP slots available for patients to be seen quickly rather than defer them to the

Sandra Chapman Clinic as is currently the case.

6.12.2 Team B needs to increase its New slots by 100 / year and its Follow up by 400 / year

6.12.3 Team C could decrease its New slots by 140 / year and needs to increase its Follow Up by

260 / year.

6.13 If the JCCO advice from Dec 2000 is accepted, then the number of Follow Up slots that

should be available for a population of 250,000 is 4650 (using a conservative New to Follow

Up ratio of 5:1.)

6.14 If we use this JCCO guidance on New to Follow up ratio then:

6.14.1 Team A would need 1405 Follow Up slots / year (580 less than it currently has) includes

110 Follow Up slots for Head & Neck appointments. (Refer also to 6.12.1)

6.14.2 Team B would need 1555 Follow Up slots / year (1050 more than it currently has)

6.14.3 Team C would need 1805 Follow Up slots / year (500 more than it currently has)

6.15 The business case for radiotherapy which includes 2 WTE Clinical Oncologists, presents a

great future opportunity for a 5 days / week oncology presence at the JPUHFT. Success in theradiotherapy case will undoubtedly influence the outcome of this work but at this point in

time, the two cases need to remain separate.

6.16 The number of visiting consultant sessions at the JPUHFT has not increased within the last 8

years

6.17 Plans for the Acute Oncology Service have clearly been discussed separately at each Trust.

Opportunities to integrate these plans are at a very early stage of discussion.

6.18 There is serious concern that Breast cancer patients undergoing chemotherapy are not being

reviewed as per protocol by an oncologist. (Oncologists at both Trusts are committed toworking to common agreed protocols including FU frequency, but current staffing does not

support this). This reportedly presents a significant clinical risk with a serious risk of

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complaint which it appears could be reduced substantially by providing a minimum of 320

additional follow up slots.

6.19 There are no clinical leadership arrangements obvious to all those involved in delivering the

service. If this continues then it is unlikely that the Trust will develop and implement an

oncology strategy for the Trust which aligns with that of its oncology partner at the

NNUHFT. The absence of an aligned strategy is likely to lead to fragmentation of oncologyservices across the Trusts. There is interest from within the Oncology Service to provide

these clinical leadership arrangements.

6.20 The value of providing outreach services to Beccles is questionable. Although it is a very

patient centred option, it appears that the service was previously withdrawn because the

number of patients attending was small. It is unlikely to be an efficient way of using

consultant oncologist time in future.

6.21 Based on current working patterns of 6 sessions of clinical oncologist time and 1 session

visiting + 2 resident medical oncologist, the JPUHFT complies with the JCCO recommended

ratio of clinical to medical oncologists. The reality is that any shortfall in OP capacity couldbe addressed by employing either medical or clinical oncologists (or even nurse /

radiographers for Follow Up). Given the interest in providing a radiotherapy service in future,

it maybe more sensible to employ additional clinical oncologist sessions.

6.22 The data presented in section 3.3.1 confirms that there were very few occasions in which

weekly OP clinics did not take place. One consultant was available for 46 weeks and the

remaining consultants were available for between 40 and 42 weeks of the year. Ideally, all

consultant absences should be covered by a colleague with the same team, but this has

certainly been impractical in the past. With waiting time performance for New Patients

between 8.5 and 25 days across all consultants, and therefore exceeding the desired target of

seeing New Patients within 7 days, the case for additional consultant cover is strong.

6.23 The advantages (to patients and clinical staff) of running Oncology clinics alongside surgical

clinics have been proposed by at least two of the oncologists. The principle is a good one

although there may be practical difficulties in aligning schedules of the relevant surgeons and

oncologists. If this can be achieved without loss of clinic capacity then it makes sense to do

so. There appears to be particular value in joint clinics for Head & Neck (already taking

place), Skin and Gynaecological cancers.

6.24 The absence of a clinical oncologist opinion at the colorectal MDT and any oncologist

opinion at the urology and Skin MDTs weakens the MDT discussion. Whilst involvement ofa medical oncologist in the colorectal MDT is valued, he can only contribute to chemotherapy

treatment discussions. The fact that an oncologist specialising in urology work is present at

the JPUHFT on the same day as the urology MDT, but doesnt attend, is surprising. (refer to

section 5.15.4)

6.25 Any case for a 2nd breast MDT needs to be driven by the Lead Clinician for Breast at the

JPUHFT. Even if the principle is accepted there will be practical difficulties in releasing time

for all specialties to attend. Interestingly, the NNUHFT has 1 x Breast MDT / week, serving a

population twice that served by JPUHFT.

7 Recommendations

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7.1 For planning purposes, the Oncology Notes System with JCCO conversion and with 8% uplift

for rising cancer incidence, is used. This means that the JPUHFT should be planning on a New

Patient demand of 930 patients and a Follow Up demand of 4765 patients / year.

7.2 Current clinic templates are replaced with templates that provide capacity for the anticipated

demand of New and Follow Up Patients. The actual slots required are:

7.2.1 For Team A 260 New Patient slots and 1405 Follow Up slots / year appropriately

aligned to the relative caseloads of Dr Dernedde and Dr Martin. There is scope for Dr

Dernedde to provide OP consultation alongside Dr Martin on Friday pm using the existing

Op nursing / admin support.

7.2.2 For Team B 310 New Patient Slots and 1555 Follow Up slots / year

7.2.3 For Team C 360 New patient Slots and 1805 Follow Up slots

7.3 The time allocated for New and Follow Up slots is standardised at 30 mins / New patient and 15

mins / Follow Up patient. (This would then be consistent with the standard at the NNUHFT)

7.3.1 This means that the OP time required for the teams is:

Team New

Patient hrs

required

Follow Up

Patient hrs

required

Total OP

hrs required

New Patient

slots (30 mins)

required

Follow Up

slots (15 mins)

required

A

Dr Martin

Dr Dernedde

3.1 8.4 11.5 6 34

B

Dr Harnett

3.7 9.25 12.95 7 37

C

Dr Wade

Dr Epurescu

4.3 10.75 15.05 9 43

7.3.2 Limit the total time for OP clinics to 6 to 6.5 hours / day allowing 1 to 1.5 hours / day for

associated administrative work.

7.4 Accommodate these OP hours required by:

7.4.1 Maintaining the current number of clinic days for team A, re-aligning OP slots appropriatelyto the caseload of Dr Dernedde and Dr Martin and review capacity in 6 months

7.4.2 Providing an additional full days clinic / week (additional 2 x Clinics) for team B

7.4.3 Providing an additional full days clinic / week (additional 2 x clinics) for team C

7.4.4 Uplifting the visiting JPUHFT oncology establishment by 20% to ensure that OP clinics are

always covered during annual and study leave absences and that the New Patient target of

being seen within 7 days is maintained.

7.5 Whilst there may be benefits of using Tuesdays or Thursdays for these additional clinics, anydays where clinic resources are available can theoretically be used.

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7.6 Scope for Nurse / Radiographer led Breast Follow Up should be investigated alongside the

proposed expansion of Team B clinics (7.4.2). In the long term, the Nurse / Radiographer can

then provide cover for Breast Follow up. (Until the case for radiotherapy at JPUHFT is

approved, this cover should be provided by Nursing)

7.7 Scope for Nurse led follow up for Urology should also be investigated alongside the proposed

expansion of Team C clinics (7.4.3).

7.8 Nursing and Administrative support to the additional clinics needs to be reviewed and increased

if required.

7.9 The demands on Oncologist time associated with in-patient care are unlikely to change in the

short term. No additional resource associated with in-patient care is proposed at this time.

7.10 Responsibility for the oncology teams workload should lie with the team rather than

individual consultants. The recommendation is that secretaries will continue to be book patients into

a specific consultant slots but that unused clinic capacity is at least offered to another consultant

within the team to use where possible.

7.11 If an oncology team is unable to use any of its teams unused capacity then this capacity

should at least be offered to the other oncology teams. It is acknowledged that it will only rarely be

possible for a consultant from another team to use this capacity to see other cancer types.

7.12 The Trust monitors utilisation of clinic slots for each consultant to ensure that slots are used

efficiently and that templates are appropriate.

7.13 The Trust continues to collect data on waiting time performance (particularly for New

Patients) and analysis is carried out as required. A target of

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7.17 Team B takes responsibility for the Skin (BCC and SCC) and Haematology cancers to be

seen at the JPUHFT

7.18 The Trust does not wait until the outcome of the business case for radiotherapy is known

before taking action on Oncology capacity. The shortfall can be addressed now and then the

oncology establishment reviewed again in line with the requirements for radiotherapy.

7.19 Follow up of Breast cancer patients on chemotherapy is maintained according to protocol

within the additional Follow Up capacity proposed.

7.20 No outreach services to Beccles are provided unless the numbers increase significantly, in

which case the situation should be reviewed.

7.21 Support the wish of oncologists to run oncology clinics alongside surgical oncology clinics if

it is practical to do so and out patient capacity is not lost as a result.

7.22 Input to JPUHFT MDT meetings is accommodated within the new schedules proposed in 7.4

7.23 A number of shortfalls associated with MDTs need to be addressed as follows:

7.23.1 A clinical oncologist from Team C should provide input to the Lower GI MDT. If the

additional 1 day clinic for team C took place on a Monday then it is possible that a clinical

oncologist could attend. If this is not possible then attendance through video link from

NNUHFT is a realistic compromise.

7.23.2 A second oncologist involved in the additional Breast clinic for Team B should link into the

existing Breast MDT and possibly a second Breast MDT if that was to be developed. This

could either be by direct attendance or through video link.

7.23.3 An oncologist from Team C to attend the JPUHFT Urology MDT on Wednesday.

7.23.4 If there is a need for a separate Skin MDT on Friday, (rather than a common Skin MDT

across the Trusts) then an oncologist from Team B should participate.

7.24 The full cost implications of these recommendations should be considered by the JPUHFT

Medical Division / Finance team. In summary they are:

7.24.1 2 x additional days of Oncology clinics (4 x clinics) with associated oncologist, nursing

and administrative costs (potentially including secretarial costs within that) based onNNUHFT Job Plans, 4 additional clinics equates to 6 PAs.

7.24.2 Cover for the equivalent of 20% of clinics (based on 10 / 52 weeks / year absence) = 2 PAs

7.24.3 Nursing costs to support 400 Breast Cancer Follow Up slots / year approximately 1 clinic /

week. Potentially Urology Cancer Follow Up could also be included.

7.24.4 1 x PA for clinical leadership

7.24.5 Costs associated with JPUHFT element of the integrated plan for Acute Oncology Service

as yet unknown (potentially this could include additional medical / nurse specialist resource)

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7.24.6 Costs associated with any referral of the 130 New cancer patients (Head and Neck, Skin,

Brain, Sarcoma, Sarcoid and other rare cancers) to NNNUHFT

7.24.7 1 x MDT session for Clinical Oncologist input to Lower GI MDT

7.24.8 Possibly 1 x MDT session for Clinical Oncologist input to Skin MDT

Coaching and Management

Solutions

Garry Shayes

Mobile: 07979 770365 Office: 01362 861109

Email: [email protected]

Web: www.coachingandmanagementsolutions.co.uk
mailto:[email protected]:[email protected]

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Appendix A

JPUH Oncology patient numbers according to clinic statistics

(based on IPM data December 08 May 09)

Upper gastro-intestinal cancer (Monday morning clinic, U Dernedde)

Seen in last6 months

Extrapolated figures for1 year

Patient numbers perclinic

New patients 43 86 1.6

Follow up pat.

(Follow-up in this

clinic + follow-up in

nurse-led clinic)

205

(173 + 32)

410 7.8

Ratio New/FU 1 : 4.7

Lower gastro-intestinal and ovarian cancer (Monday afternoon clinic, D Epurescu)

Seen in last

6 months

Extrapolated figures for

1 year

Patient numbers per

clinicNew patients 54 108 2.0

Follow up pat. 166 332 6.3


Breast cancer (Wednesday all day, A Harnett)

Seen in last

6 months


1 year

Patient numbers per

clinic


Follow up pat. 340 680 13


Urology and gynaecology. cancer (Wednesday all day, R Wade)

Seen in last

6 months


1 year

Patient numbers per

clinic


Follow up pat. 384 778 14.9


Lung clinic (Friday all day, C Martin / U Dernedde)

Seen in last

6 months


1 year

Patient numbers per

clinic

New patients 138* 138 2.6

Follow up pat. 730* 774 14.8

Ratio New/FU 1 : 5.2(* corrected IPM figures, because some patients were seen as new patients by one consultant are booked as new patients twice when referred for

radiotherapy)

Total number of new cancer patients seen in oncology clinics: 730 per yeari

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Appendix B

Estimate of activity in oncology for 1/1/08-31/12/08

1. Oncology Notes Registrations 1/1/08-31/12/08

3201 NPs registered

52 never seen (very brief MDT notes etc all excluded)

3149 seen (or major annotation on Notes)

Coding

Approx 60% had ICD-10 code on Notes assumed correct

Approx 25% had diagnosis on Notes retrospectively coded without reference to main Notes entry

TWR May09

Approx 15% had no diagnosis Notes reviewed and retrospectively coded TWR May 09

Possible errors

Over-estimates other brief MDT notes, registrations from phone calls and ward referrals not seen

in oncology

Under-estimates recurrences, 2nd primaries seen as NPs?

Either incorrect data entry

Summary

TWRf WMCM MRDf ANH HMS RJWg ASB GK h MJOi UD EDE Total

H&Na 97 77 174

Lung 121 229 42 1 1 52 446

Upper GI 42 53 34 56 22 65 2 274

Brain 67 2 2 1 1 3 76

Breast 1 2 0 370 57 1 146 1 4 101 683

Skin 2 9 4 100 3 2 120

Sarcomab 2 33 1 1 1 38

Haemc inc eye 23 95 1 1 120

GU 1 82 1 275 1 103 25 1 489

Lower GI 1 140 86 1 1 122 351Gynae 6 98 11 61 176

Carcinoid 8 8

Unknownd 10 2 5 5 10 1 8 10 3 11 6 71

Benigne 7 4 0 0 111 0 0 0 1 123

Total 348 326 100 489 449 377 296 267 65 138 294 3149

Notes:

a) H&N patients all seen in joint clinic NNUH some registered only at MDT but this figure seem

rightb) Sarcoma all seen in joint clinic

c) Haem now all (myeloma?) seen in joint clinic w haem NNUH

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d) these are true unknown primary cancers

e) Majority are benign soft tissue disease managed by HMS in sarcoma MDT

f) includes 20 patients registered under AB and HBJ (CNS tumours)

g) started May 08

h) started March 08

i) retired May 08. Figures seem low what was happening to his JPUH patients?

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Appendix C

Breast cancer treatment figures obtained from the Bookwise

electronic booking system in the Sandra Chapman Unit

Search criteria: any patients under Dr.Harnett seen between 01.06.08 and 31.05.09

Results:979 visits in total

823 visits for breast cancer specific treatment

(=chemotherapy / bisphosphonates / Herceptin)

123 patients (breast cancer patients only)

Number of treatments and number of necessary clinic appointments as per departmental protocols

(e.g. patients on adjuvant treatment to be seen after every third cycle etc .ii)

Treatment regime Number of treatments Ass. Number of clinic

appointment as perdepartmental protocol

AC 38 19

Capecitabine 188 63

Carbo/Gemcitabine 27 14

CMF 57 18

Doxorubicin 8 4

Epirubicin 36 12

FEC 198 66

Herceptin 117 30

Taxanes 38 19

Taxol weekly 17 3Vinorelbine 43 22

Zometa 56 19

289

Minimum amount of follow-up consultant-led clinics would be 289/year. In addition, patients with problems (disease

progression etc.) should be able to seen in a consultant-led clinic at the nearest available clinic slot (usually next

upcoming clinic). This is at least an extra ~ 30 patients/year. So the total number of clinic slots required for these

treatment patients is ~320/year. Assuming there are 45 clinics per year, this would be 7 follow-up patients per week

(again: absolute minimum! In other UK hospitals, these patients are seen more frequently).

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Appendix D

FU Waiting Times Data

3112802492181871561259463321

400

300

200

100

0

Observation

DaysWait

_X=148.7

UCL=365.1

LCL=-67.7

111

1

Days Wait for FU Op Appointment - Dr Harnett

15413712010386695235181

300

200

100

0

-100

Observation

DaysWait _

X=125.7

UCL=317.9

LCL=-66.4

Days Wait for FU OP Appointment - Dr Epurescu

31628124621117614110671361

400

300

200

100

0

-100

Observation

DaysWait

_X=128.1

UCL=376.7

LCL=-120.6

11

1

Days Wait for FU OP Appointment - Dr Martin

29826523219916613310067341

400

300

200

100

0

-100

Observation

DaysWait

_X=117.7

UCL=322.9

LCL=-87.5

11111

1

Days Wait for FU Op Appointment - Dr Wade

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2802492181871561259463321

200

150

100

50

0

Observation

Dayswait

_X=24.2

UCL=74.7

LCL=-26.4

1111

11

1

111

1

1

111

1

1

1

1

1

1

1

1

11

1

11

1

1

11

1

1

11111

Days wait for Follow Up Op Appointment - Dr Dernedde

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i Not included are approximately 10-20 new cancer patients seen in the monthly joint head and neck clinic of Craig

Martinii Compared with other UK hospitals, these figures represent an absolute minimum of care!

jph - oncology (2)

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