Brighton and Hove Cancer Update
For Brighton and Hove Health Overview and Scrutiny Committee
1.0 Introduction
Brighton and Hove Health Overview and Scrutiny Committee asked for an update on cancer services, specifically in relation to screening, diagnostics and treatments: where we are now and plans for improvement. This follows a previous report in 2019 and will provide an update on current performance in line with national targets, highlight some of the challenges and describe some of the work streams taking place or planned to improve the position for the population of Brighton and Hove.
The previous report in 2019 was based on the CCG Improvement and
Assessment Framework (IAF) for 2018/19. The IAF has now been
replaced with the NHS
Oversite Framework for 2019/20 (which incorporates the former provider
Single Oversight Framework too), and informed assessment of
CCGs in 2019/20. The indicators for cancer remain the
same.
The final overall rating for Brighton and Hove for 2019/20 is Good, this is the same as the previous year.
The four cancer indicators are given in table 1 below along with the Brighton and Hove position and the national benchmark/England average for 2019/20.
Table 1
|
Indicator |
Brighton and Hove |
National Benchmark/ England Average |
|
Cancers diagnosed at an early stage* (Target: 62% by 2020) |
30% |
54.3% |
|
People with urgent GP referral having first definitive treatment for cancer within 62 days of referral (Target: 85%) |
69.6%
|
77.7% |
|
One-year survival from all cancers** (Target: 75% by 2020) |
73.5% |
73.9% |
|
Cancer patient experience (Scored from 1-10 with 10 being best) |
8.7 |
8.8 |
*Data from 2018 **Data from 2018
2.0 Cancer Screening
Cancer Screening is a way of finding out if people are at higher risk of a health problem, so that early treatment can be offered or information given to help them make informed decisions. An effective screening programme will ensure that cancers are diagnosed at an early stage.
All screening was impacted by Covid as the service was suspended between March 2020 and July 2020 as a result of the reduction in secondary care activity during the 1st and 2nd waves.
The three main national cancer screening programmes, commissioned by NHS England/ Improvement with oversight assurance through Public Health England, are bowel, breast and cervical.
In addition, the National Targeted Lung Health Check screening programme that has been piloted in parts of England, is now on the third wave and being rolled out to further sites where lung cancer survival is an outlier compared to the England average.
General Practices and Primary Care Networks work to improve cancer care through the Cancer Direct Enhanced Service (DES) and Quality Outcomes Framework (QOF). The DES aims to improve collaboration and, peer support and promotes improvement through audit and learning whilst the QOF aims to focus practices on quality improvement projects.
The Clinical Commissioning Groups (CCG) have been engaging directly with PCNs and practices with the support of Cancer Research UK on the delivery of both the DES and QOF.
2.1 Bowel Screening
The national programme for bowel cancer screening invites men and women, between the ages of 60 and 74 to take a test at home every two years. The age range is lowering to those over the age of 56 during the latter part of 2021. The target is 60% of patients to complete the test.
The latest published performance figures for bowel screening in Brighton and Hove are from 2019/20 these are included in table 2, showing bowel screening compliance for the period 2009/10 to 2019/20:
Table 2
 |
2.2 Breast Screening
The national programme for breast screening invites women for a mammogram from the age of 55 to 74 every 3 years. Women over 74 years are not routinely invited but can request a mammography screening.
The target is 70%. The latest published performance figures in Brighton and Hove are from 2019/20 and these are included in table 3 showing breast screening compliance for the period 2009/10 to 2019/20:
Table 3
2.3 Cervical Screening
The national programme has a target of 80% for cervical screening and unlike bowel and breast screening this activity is managed by General Practice and not by a separate provider. Some PCNs are undertaking group delivery and others are supported by the activity taking place within commissioned sexual health clinics.
Table 4 shows cervical screening compliance for the period 2009/10 to 2019/20:
Table 4
2.4 National Targeted Lung Health Checks Programme (THLC)
Brighton and Hove has been invited to take part in the third wave of National Targeted Lung Health Checks Programme. Currently in the planning stage, the aim is to start this from April 2022. This programme targets high risk people, 55 to 74 years old, who may not yet have symptoms and offers an assessment and where appropriate a computerised tomography (CT) scan. This should help to diagnose more patients with lung cancer at an early stage (1 or 2) to improve survival.
In Brighton and Hove, based on 2018 data, 44% of lung cancers were diagnosed at stage 1 and 12% at stage 2. 26% were diagnosed at stage 3 and 53% at stage 4.
In Brighton and Hove the one year lung cancer survival is 43.6% based on 2018 data compared to the England average of 44.5%
3.0 Health Inequalities, Improving Screening Coverage and Early Diagnosis
Partner organisations including Council services, voluntary and community sector services and support activities have also faced similar Covid related challenges adding to the reduction in workforces available to deliver cancer related health promotion and prevention programmes and to support those living with and beyond cancer.
Despite these challenges there are significant areas of work in place to improve the health and outcomes for the Brighton and Hove population.
The CCGs are in the process of mapping the screening activity and linking it to the learning from vaccine take up, to identify common areas and common themes where we can specifically engage and communicate with different groups and individuals.
There is both a national programme, including the “Help Us, Help You” campaign and local initiatives to raise awareness of the signs and symptoms of cancer.
The latest phase of the “Help Us, Help You” campaign was launched in August to raise awareness of the symptoms of abdominal, urological and lung cancer.
Responding to concerns about a lack of information about cancer services during Covid lockdown, Healthwatch delivered a series of webinars for the public attended by local experts who answered their questions.
Sussex patient engagement includes a focus on prostate cancer. A dedicated video has been produced, with the Integrated Care System (ICS) and the Surrey and Sussex Cancer Alliance, to tell the stories of two survivors.
3.1 Brighton and Hove City Council (BHCC) Public Health
BHCC Public Health team commission and provide a number of health promoting services that will support health behaviours that directly help to prevent cancers such as stopping smoking, promoting healthy diets and weight management, promoting physical activity and reduction of alcohol use. The Healthy Lifestyle Team (HLT) support people to make health behaviour changes on a one to one basis, in small groups and through communication campaigns.
Similarly, the HLT also provide support to people living with and beyond cancers. Awareness of signs and symptoms and promotion of cancer screening uptake is also highlighted as part of other commissioned services such as the GP NHS Health Checks. Stop smoking services are also commissioned in general practice and community pharmacies. Targeted work is delivered through maternity services, Stop (smoking) before the Op, to young people through schools and youth projects, and underpinned by a comprehensive multi-agency Tobacco Control Programme.
Public Health commissions both substance misuse and sexual health services which also include cancer awareness and prevention related to context such as support to stopping smoking related to drug use, reduction in alcohol consumption, hepatitis and liver cancer and awareness of sexual health related cancers.
The human papillomavirus (HPV) vaccination is actively promoted through young people services although vaccination uptake was greatly reduced due to Covid[1] and is also affected by this year’s timing of the Covid vaccination rollout to 12-15 year olds and the annual flu programme extending to all schools children reception to Year 11. Vaccination teams are restarting their HPV vaccinations to young women and young men within this context.
There is an active multiagency Cancer Communications and Campaigns meeting to co-ordinate work across the city, for example using social media, community venues eg pharmacies and voluntary community sector services, to increase awareness of key cancer prevention related healthy behaviours, signs and symptoms, screening uptake and support during recovery.
3.2 Community Initiatives
3.2.1 Albion in the Community (AiTC)
Between September 2016 and March 2020, AiTC spoke
to over 43,000 people directly about cancer. Since then to
the end of February 2021, AiTC reached 826 people through a series
of webinars, and nearly 4,000 via Facebook Live events and
podcasts. Since the first lockdown, AiTC have motivated 7201
people to seek out further information about; checking their moles,
registering with a GP, finding out about screening and learning
about signs and symptoms of cancer.
AiTC have a team of thirty-eight volunteers with
lived experience of cancer, who have been trained to share their
experience in order to influence others to make positive behaviour
changes around early detection and cancer awareness. Seven of those
volunteers have been recruited and trained during the current Covid
restrictions. Many have joined the team having been through
the Brighter Outlook programme, which supports people living with a
cancer diagnosis to become more active. Volunteering provides
a vital opportunity to give something back, improve confidence,
enhance skills, and help support return to work after cancer.
As part of our summer sun safety and skin cancer campaign, AiTC worked with Public Health schools team and produced branded resources for schools and produced an animated video on sun safety messaging. AiTC also distributed sun safety goody bags including Gully’s top tips and sun cream samples to community groups and organisations across the city.
3.2.3 Speak Up Against Cancer
Commissioned by the CCG and Public Health, the Speak Up Against Cancer service raises awareness of cancer, giving people the confidence and tools, they need to attend screening appointments, recognise the signs and symptoms of cancer and to overcome barriers to getting help when it is needed. It targets engagement in deprived communities and tailors communications to specific audiences to address health inequalities. Examples of work include:
· ‘Let’s Talk About Men’s Health’ campaign launched by ex-professional footballers to encourage men to speak more opening about health issues and to encourage people to feel confident about seeking support from their GP.
· Twitter and Facebook awareness raising campaigns.
· Webinars such as Blind Veterans – Bowel and Prostate Staff education event, Brighton and Hove Community Radio Station - General Cancer Awareness and Legal and General – Skin Cancer.
3.2.4 Brighter Outlook
The Brighter Outlook programme supports anyone that has had a cancer diagnosis to prepare for, cope with, and recover from cancer treatments through offering tailored physical activity interventions, nutrition information, psychological support and relevant signposting.
It is designed to help people to feel better, physically and mentally, to take an active role in their cancer care, and live as well as possible with and beyond cancer.
Participants have reported benefits including:
· A decrease in fatigue score between baseline and 12 month follow up (70%)
· Increased or maintained self-efficacy scores between baseline and 12 month follow up (71%)
· Reduction in experience of anxiety and depression (11%).
4.0 Cancer Performance Targets
4.1 Urgent suspected cancer GP referral to first treatment for cancer target
The NHS constitutional (maximum) waiting times target for people with an urgent suspected cancer GP referral having their first definitive treatment for cancer is within 62 days of referral.
University Hospitals Sussex NHS Trust (UHSx), (formerly Brighton and Sussex University Hospitals NHS Trust (BSUH) and Western Sussex Hospitals NHS Trust (WSHT)), is the main provider of cancer services for the population of Brighton and Hove.
Trust performance on the 62 day cancer waiting times target is shown in table 5 below.
Table 5
|
Target 85% |
April |
May |
June |
July |
Aug |
Sept |
Oct |
Nov |
Dec |
Jan |
Feb |
March |
|
2019/20 |
62.7% |
63.5% |
64.4% |
58% |
62.9% |
74% |
73.1% |
72.9% |
85.7% |
76.5% |
69.1% |
79.5% |
|
2020/21 |
71.4% |
84.4% |
88.5% |
79.6% |
78.4% |
80.6% |
78.6% |
71.9% |
78% |
69.8% |
57.7% |
72% |
|
2021/22 |
69.5% |
65% |
70.1% |
68.4% |
|
|
|
|
|
|
|
|
Source: UHSxE cancer waiting times reports
Note: 2019/2021 data is BSUH only. From April 2021, BSUH merged with WSHT to form UHSx and the data from then, is for the whole Trust.
4.2 Comparative 62 day Performance
The annual 62 day performance by local Clinical Commissioning Groups and for England is given in table 6 below. The target is 85%.
Table 6
|
Year |
B&H CCG |
East Sussex CCG |
West Sussex CCG |
England |
|
|
2019-20 |
69.6% |
77.2% |
76.5% |
77.7% |
|
|
2020-21 |
75.1% |
74.3% |
76.7% |
70.8% |
|
|
2021-22 (April to July) |
74.4% |
73.4% |
74.9% |
70.4% |
|
|
Source: National Statistics, Cancer Waiting Times, 62-DAY (URGENT GP REFERRAL TO TREATMENT) WAIT FOR FIRST TREATMENT: ALL CANCERS |
|||||
4.3 28 days from suspected cancer two week wait referral to diagnosis
The NHS constitutional (maximum) waiting times target for people with an urgent suspected cancer GP referral to diagnosis (whether they have a cancer or it is ruled out) is 28 days from referral.
Table 7 below shows the data completeness (target 80%) and table 8 shows the data compliance (target 75%) at UHSxE for 28 day standard. UHSxE has achieved compliance since May this year.
Table 7 Table 8
|
|
|
There are various plans in place to support improvement in compliance and some of these are detailed in section 5.
5.0 Challenges, Programmes and Service Improvements
During the pandemic, referrals dropped significantly (by about 50-80% at times) and have been gradually picking up to a point now where they are now consistently anywhere between 10-25% in excess of the 2019 baseline.
Despite the challenges caused by the pandemic and the impact on some health services, during the pandemic, significant efforts were made to ensure cancer and clinically urgent services continued wherever clinically safe to do so. In addition, Queen Victoria Hospitals NHS Trust was set up as a “cancer hub” and maintained a Covid free site to ensure treatments could continue.
Restoration and recovery is a key priority and plans are in place to address this.
5.1 UHSxE Service Improvements
5.1.1 New Lower Gastrointestinal (LGI) pathway
In August 2021, UHSxE implemented a new LGI pathway incorporating faecal immunochemical test (FIT) as a diagnostic for patients with symptoms in line with NICE guidance on suspected colorectal cancer. This consultant led, nurse delivered service uses the FIT score to stratify patients referred with suspected colorectal cancer to enable faster diagnosis. Patients are assessed using the FIT score alongside symptoms, past medical history and performance status, to ensure that they receive the right test at the right time.
The aim of the service is to be able to inform patients within 28 days of their referral whether cancer has been diagnosed or, in the majority of cases, ruled out. Achieving this standard reduces patient anxiety and clinical risk, whilst improving pathway efficiencies for all symptomatic patients.
5.1.2 Suspected Cancer Lung Pathway
In 2015 Brighton and Sussex University Hospitals NHS Trust (now UHSxE) launched an ACE (Accelerate, Coordinate, Evaluate) pilot to implement a radiology led diagnostic pathway to support faster diagnosis for patients with respiratory symptoms that could indicate lung cancer. The pathway enables a patient with an abnormal chest x-ray, to be referred straight to the next test (computerised tomography (CT)) rather than back to their GP for a referral to the respiratory team at the hospital to organise a CT.
When the National Optimal Lung Cancer Pathway (NOLCP) by the NHS England Clinical Expert Group for Lung Cancer was published in 2017, the Brighton Lung pathway was already in a strong position to improve performance. Amongst other elements in line with the NOLCP, the Trust introduced a consultant upgrade route which enabled patients to be seen for a CT within 3 days of a referral and a diagnosis by day 7.
5.1.3 Review of Urology service
UHSxE is planning a specific piece of tailored work to review and plan required medium term diagnostic capacity in urology, broken down by modality to consider ring fencing weekly capacity for both diagnostics and interventions. This will result in the implementation of a dedicated Urology Investigation Unit (UIU) at Princess Royal Hospital which will act as a hub for all urology diagnostics. This will allow the service to become more efficient and move towards one stop models of care.
5.1.4 Personalised Care
The personalised care main priorities are personalised supported self-management pathways (PSFU) across Breast, Prostate and Colorectal and identifying two more pathways to implement from April 2022. UHSxE has breast in place and is working on colorectal and prostate and will continue to develop additional pathways over the period ahead.
Holistic Needs Assessments (HNAs) and care planning are co-ordinated by the clinical nurse specialist (CNS) teams. UHSxE is also looking at the prehabilitation/rehabilitation programme working with the Surrey and Sussex Cancer Alliance (SSCA) who have in year funding available to try to standardise the approach across the geography.
With funding from the SSCA, UHSxE have just started a twelve month project with a psychological therapies team to improve patient access and reduce waiting times for this service.
5.2 Community Diagnostic Hubs (CDH)
Professor Sir Mike Richards was commissioned to undertake a review of NHS diagnostics capacity. The independent report , Diagnostics: Recovery and Renewal, October 2020, recommends the need for a new diagnostics model, where more facilities (CDHs) are created in free standing locations away from main hospital sites, providing quicker and easier access to a range of tests on the same day, supporting reduction in health inequalities, earlier diagnosis, greater convenience to patients.
The Sussex CDHs will deliver additional digitally connected tests
providing patients with a more co-ordinated service, in as few
visits as possible, enabling accurate and fast diagnosis.
It will be a local service, separated from acute hospitals and situated close to areas of health inequalities and high cancer incidence, offering a real opportunity to improve population health outcomes, delivering personalised care, through co-ordinated and shared decision-making.
The Amex Stadium at Falmer was identified for the population of Brighton and Hove. This service is an addition to existing diagnostic services in Brighton and Hove, and patients will still have the choice to go to their nearest diagnostic provider which may be community or acute hospital site and in some diagnostics (such as blood tests) the GP.
6.0 Risks
6.1 Patients and members of the public coming forward for screening to enable early diagnosis and improved outcomes
To mitigate the risk that partners are working with in the Voluntary Community Sector to target communities and areas with low uptake using public insight and expert by experience including some of the projects described under the Community Initiatives section.
6.2 Delivery against the 62 day waiting time standard
There is a risk that patients wait longer than the 62 days with implications for patient experience and outcomes. To mitigate this all patients referred on a two week wait pathway are clinically triaged. For those patients waiting more than 104 days for treatment, there is a “Clinical no Harm” review for assurance. Provider focus on actions to address patients waiting and deliver the 28 day Faster Diagnostic Standard – ensures that all patients are diagnosed within 28 days of referral.
6.3 Capacity Constraints
UHSxE is under significant operational pressures and the continued increase in referrals above plan are impacting capacity.
To mitigate UHSxE is working closely with UHSxW as well as
providing additional enhanced activity and working with other
providers, including the independent sector to insource and
outsource activity to support capacity constraints. For
example, in endoscopy where current capacity is outstripped by
demand.
7.0 Patient Experience
The National Cancer Patient Experience Annual Survey (NCPES) is commissioned by NHS England, and overseen by a national Cancer Patient Experience Advisory Group. It is designed to monitor national progress on patient experience of cancer care and provides a valuable insight into patient experience across the cancer pathway in order to inform service improvements.
The NCPES is designed to monitor national progress on cancer care to:
• provide information to drive local quality improvements;
• assist commissioners and providers of cancer care; and
• inform the work of the various charities and stakeholder groups supporting cancer patients.
The last full survey was in 2019. As a result of the Covid-10 pandemic, the 2020 survey was voluntary and in Sussex, Brighton and Sussex University Hospitals NHS Trust (now University Hospitals Sussex NHS Trust) was the only Trust to take part. Due to challenges as a result of the Covid-19 pandemic, the survey was delayed until July 2021. Outcomes are expected in the autumn of 2021.
The 2021 survey is expecting to run to a similar timetable as previous surveys, with sampling guidance now issued to the Trusts, fieldwork in the autumn 2021/winter 2022 and publication of outcomes in Spring 2022.
The 2019 survey involved 143 NHS Trusts. Out of 111,366 people, 67,858 people responded to the survey, yielding a response rate of 61%. Outcomes of the survey were shared with providers and plans produced to address any need for service improvements.
For UHSxE, the majority of responses were within the expected range. However, there were three above the national score and eight below.
As a result of the survey, UHSxE reviewed the content and produced a plan and are addressing those areas where improvement was needed. For example, when asked if they were given the name of a clinical nurse specialist (CNS) who would support them through their pathway, 88% of UHSxE patients said yes compared to the England score of 92%.
UHSxE operate a team system to ensure that there is always a CNS available to support patients. Patients are informed verbally that their keyworker CNS is in fact in a team. The actions as a result of this are to ensure consistent message in all CNS conversations and in CNS teams leaflets to explain that the keyworker is part of a team.
7.0 Summary
There is much positive action in hand to continue to improve the experience and outcomes of people diagnosed with cancer and we will to continue to implement action and monitor cancer performance to ensure improvements across all of the targets including the four indicators in the NHS Oversight Framework.
Lisa
Elliott
Senior Planned Care and Cancer Manager
Sussex CCGs
October 2021