bps sigopac bristol october 2016 - liz price : commissioning cancer as a long-term condition
TRANSCRIPT
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Liz Price, Senior Strategy Lead (Living with and beyond cancer)Transforming Cancer Services Team for London
Making progress on Demonstrating Quality and outcomes in psycho-oncology
Bristol, 18 October 2016
Commissioning cancer as a long term condition
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TCST’s LWBC team objectives
We develop guidance and provide strategic support to commissioners on the local planning and delivery of:
• The cancer recovery package and stratified follow up pathways
• The management of consequences of treatment (physical, psychological, social)
• Cancer as a long term condition and integrated care
We work with our partners in London to achieve these objectives: including London’s CCGs and STP cancer boards, UCLH
Collaborative (London Cancer), Royal Marsden Partners, South East London ACN, Macmillan and other charities. We always involve
service users and clinicians in developing our guidance.
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London 32 CCGs, 5 STP footprints, 8.6m people plus ~3m commuters daily
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A message from Dr Pawan RandevTCST GP Advisor, Primary Care Cancer Lead, CCG governing body member
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Transforming London’s health and care together6
Policy and evidence
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Recap on cancer prevalence
• Cancer remains the leading cause of mortality (NHSE).
• 1 in 2 people will get cancer sometime in their life (CRUK).
• In 2010, over 2m people living with and beyond cancer in the UK; rising to 4m by 2030 (Macmillan).
• In 2013, 223,500 people in London LWBC. Expect around 387,000 people by 2030.
• 70% of people who have cancer, have at least one other long term condition (Macmillan).
• Around 1600 GP practices in London. Average of 149 people with cancer per practice and around 8 new diagnoses per GP per year.
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National policy drivers
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Regional policy and guidanceImportant in improving access to psychological support for people affected by cancer
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Evidence for cancer as a long term conditionThere are specific issues for patients with cancer that would benefit from a holistic, long term conditions approach:
• 94% of people with cancer experience physical health problems in their first year after treatment
• 70% of people who live with and beyond cancer have at least one other long term condition
• 64% of people living with cancer have practical or personal support needs, and 78% have emotional support needs; the majority (75%) of which say that these needs are caused by their cancer or cancer treatment.
• 58% of people feel their emotional needs are not looked after as much as their physical needs.
• At diagnosis, half of all patients experience anxiety and depression sufficient to impair their quality of life. One quarter will have ongoing symptoms for the next six months. Psychological morbidity impacts upon not just quality of life, but survival.
• Of those who receive social care support, more people receive this 18 months after their cancer diagnosis. Social care use for those with cancer is less than for those with other chronic diseases.
• Late effects of radiotherapy and chemotherapy can lead to a raised risk of new primary cancers, heart disease, diabetes, osteoporosis, cognitive dysfunction/dementia, hypothyroidism.
• There is increasing evidence of the importance of diet and physical activity to: reduce likelihood of new primary cancers, reduce rates of cancer recurring, manage the physical and psychological effects of treatment.
• Evidence from the United States shows that exercise following a cancer diagnosis can prevent recurrence of cancer by 40% - this is more cost effective than chemotherapy and much greater reduction in patients developing consequences of cancer treatment.
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Transforming London’s health and care together11
Model of care for LWBC
Layers of patient perspectives
Prevention, screening, diagnosis, treatment, LWB, end of life care12
One patient with all their
holistic needs
identified
All prostate cancer patients
All patients with
psycho-oncology
needs, any tumour type
All cancersAll long
term conditions
All NHS care
All health and social
care
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1. Recovery package
Routine use of the ‘recovery package’
A combination of different interventions, which when delivered together, greatly improves the outcomes and coordination of care for people living with and beyond cancer. Interventions support people to self manage to the best of their ability.
Primary care should receive copies of the Holistic Needs Assessments with an up to date care plan (subject to patient consent) and the Treatment Summary so that they can conduct holistic cancer care reviews and support patients to self manage.
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2. Stratified follow up pathways
Implement stratified pathways of care
The clinical team and the person living with cancer make a joint decision about the best form of aftercare based on:
• their knowledge of the disease (what type of cancer and what is likely to happen next)
• the treatment (what the effects or consequences may be both in the short term and long term)
• the person (whether they have other illnesses or conditions, and how much support that they feel they need).
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3. Consequences of Treatment
Consequences of treatment (short term and late effects)
Lymphoedema, Pelvic radiation disease, Sexual dysfunction (men and women), Fertility, Psychological support, Hormone symptoms, Cancer related fatigue, pain management etc.
Pre/rehabilitation from point of diagnosis
Physical activity, Vocational rehabilitation.
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4. Long term conditions management
“The House of Care takes a whole system approach to LTC management. It makes the person central to care. It is about aligning levers, drivers, evidence and assets to enhance the quality of life for people with long term conditions no matter what or how many conditions they have.”
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Transforming London’s health and care together17
How does commissioning work?
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Commissioning cycleThere is a commissioning process (not time bound), and a planning round (set out in NHSE planning guidance).
1. Analysis and prioritisation
- Population segmentation
- Initial assessment- Prioritisation
2. Pathway strategy & planning
- Market profiling- Intervention strategy- Stakeholder testing- Implementation and procurement planning
3.Implementation- Procurement (rules apply)
- Analysis of incumbent provider performance
- Signalling of intentions, common baseline & data
- Negotiate contract and agree development plans
4. Manage contractual relationship- Ongoing performance evaluation and management
Time Tasks
Q2 Commence planning, identifying needs, prioritisation, develop headline commissioning intentions for engagement.
Q3 Developing detailed commissioning intentions and understanding financial situation.30 September – date when commissioners and providers must give 6 months notice in writing re any intentions for the following year (to commission/decommission). This is specified in NHS Standard Contract.
Q4 Contract negotiations – agreeing Heads of Terms including total financial envelope. By 31st March, full contracts to be signed off which includes Heads of Terms, detailed Finance & Activity, KPIs, Information Requirements, CQUINs etc.
Q1 Negotiations of specific schedules in the contract can overspill to a “long stop” date (often this is 30 June).
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Population health needs assessmentHow do we know what services we need?
A Joint Strategic Needs Assessment (JSNA) looks at the current and future health and care needs of local populations to inform and guide the planning and commissioning (buying) of health, well-being and social care services within a local authority area. The JSNA:
Is concerned with wider social factors that have an impact on people’s health and wellbeing, such as housing, poverty and employment.
Looks at the health of the population, with a focus on behaviours which affect health such as smoking, diet and exercise.
Provides a common view of health and care needs for the local community
Identifies health inequalities
Provides evidence of effectiveness for different health and care interventions
Documents current service provision
Identifies gaps in health and care services, documenting unmet needs
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System architectureHow are stakeholders involved in transformation, service redesign, performance management?
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NHS Standard contractWhat is the point of contracts? How are they used?
3 Parts – particulars, service conditions and general conditions
Particulars (the schedules):
1. Service commencement and contract term
2. Services - specifications, specialist service derogations, activity, safeguarding etc
3. Payment – local prices, variations etc
4. Quality requirements – operational standards, national and local quality standards, CQUINs, local incentive schemes etc
5. Governance – subcontractors, commissioner roles & responsibilities
6. Contract management & reporting – information requirements, data quality improvement plans, incident reporting, service development plans, surveys.
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Transforming London’s health and care together22
What data do we track in London?
20 Year Prevalence in England (Crude Rate) 1991-2013London prevalence is well below the England average
Sources: Public Health England (NCIN), Population estimates (ONS)23
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Prevalence of common cancersPrevalence: Crude rate of registered cancer patients alive at 31/12/2013 (breast, colorectal, prostate).
Source: Public Health England (NCIN)
STP Breast Colorectal Prostate
North Central London 9928 3190 5322
North East London 10621 2702 7427
North West London 14814 2640 6772
South East London 12320 2662 6449
South West London 11868 2532 6952
London 59,551 13,726 32,922
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The Cancer Patient Experience Survey (2015)The CPES tells us that there is a marked difference between patient satisfaction of their stay in hospital compared to that of the support provided by primary and community care. Patient satisfaction with support following discharge is even worse.
SPG CCG Overall how would you rate
your care(Q59)
Do you think the GPs and nurses at your GPs did everything
they could to support during your cancer
treatment? (Q53
Were you given enough care and support from
health or social services (Q51)
Best in England Adjusted scores 8.9 65% 64%
England average All England CCGs 8.7 63% 45%
London average 8.5 57% 38%
North Central London
Barnet 8.4 55% 28%
Enfield 8.4 54% 27%
Haringey 8.4 56% 29%
Camden 8.7 59% 50%
Islington 8.7 57% 36%
East London City & Hackney 8.1 54% 48%
Tower Hamlets 8.2 62% 41%
Newham 8.2 46% 21%
Waltham Forest 8.3 49% 31%
Redbridge 8.4 54% 40%
Barking & Dagenham 8.4 61% 30%
Havering 8.6 63% 46%
Source: National Cancer Patient Experience Survey (2015)
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SPG CCG Overall how would you rate your care
(Q59)
Do you think the GPs and nurses at your GPs did everything
they could to support during your cancer treatment? (Q53)
Were you given enough care and support from
health or social services (Q51)
South East London Lambeth 8.6 62% 43%
Southwark 8.3 53% 39%
Lewisham 8.4 49% 27%
Greenwich 8.6 57% 39%
Bexley 8.8 57% 44%
Bromley 8.6 51% 46%
South West London
Wandsworth 8.6 65% 35%
Richmond 8.5 56% 45%
Kingston 8.6 56% 27%
Merton 8.6 59% 36%
Sutton 8.9 57% 41%
Croydon 8.6 57% 35%
North West London
Central London 8.6 61% 46%
West London 8.8 72% 53%
H’smith & Fulham 8.4 47% 38%
Brent 8.4 58% 39%
Ealing 8.5 58% 39%
Hounslow 8.5 51% 32%
Harrow 8.4 62% 33%
Hillingdon 8.7 58% 41%
Source: National Cancer Patient Experience Survey (2014)
GP – QOF CAN002: Patient Review within 6 months of diagnosisThere are no national quality standards on what a good CCR should cover
Sources: HSCIC QOF Data (http://www.hscic.gov.uk/catalogue/PUB18887)
NOTE: This metric uses a 15 month reporting cycle – therefore it represents patients diagnosed from Jan 14 – Mar 15
CCG Name
Percentage of patients receiving
intervention
NHS WEST LONDON CCG 72.52 NHS CENTRAL LONDON (WESTMINSTER) CCG 74.69 NHS REDBRIDGE CCG 77.57 NHS HAMMERSMITH AND FULHAM CCG 77.87 NHS EALING CCG 78.19 NHS ISLINGTON CCG 78.69 NHS WEST ESSEX CCG 78.97 NHS WALTHAM FOREST CCG 79.53 NHS LEWISHAM CCG 79.60 NHS CITY AND HACKNEY CCG 79.88 NHS SOUTHWARK CCG 80.06 NHS BROMLEY CCG 80.20 NHS BEXLEY CCG 80.87 NHS CAMDEN CCG 81.41 NHS CROYDON CCG 82.14 NHS NEWHAM CCG 82.33 NHS MERTON CCG 82.34 NHS HILLINGDON CCG 82.64 NHS HOUNSLOW CCG 82.64 NHS TOWER HAMLETS CCG 82.76 NHS HARINGEY CCG 82.82 NHS LAMBETH CCG 83.01 NHS BRENT CCG 83.10 NHS SUTTON CCG 83.25 NHS HARROW CCG 83.78 NHS KINGSTON CCG 84.05 NHS BARNET CCG 84.36 NHS BARKING AND DAGENHAM CCG 84.62 NHS HAVERING CCG 85.21 NHS GREENWICH CCG 85.50 NHS WANDSWORTH CCG 85.76 NHS ENFIELD CCG 86.05 NHS RICHMOND CCG 89.10
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GP – QOF CAN001: Cancer Register Compliance
Sources: HSCIC QOF Data (http://www.hscic.gov.uk/catalogue/PUB18887)
CCG NameAchievement
rate(per cent)
NHS CENTRAL LONDON (WESTMINSTER) CCG 97.06 NHS BARKING AND DAGENHAM CCG 100.00 NHS BARNET CCG 100.00 NHS CAMDEN CCG 100.00 NHS CITY AND HACKNEY CCG 100.00 NHS ENFIELD CCG 100.00 NHS HARINGEY CCG 100.00 NHS HAVERING CCG 100.00 NHS ISLINGTON CCG 100.00 NHS NEWHAM CCG 100.00 NHS REDBRIDGE CCG 100.00 NHS TOWER HAMLETS CCG 100.00 NHS WALTHAM FOREST CCG 100.00 NHS BRENT CCG 100.00 NHS EALING CCG 100.00 NHS HOUNSLOW CCG 100.00 NHS HAMMERSMITH AND FULHAM CCG 100.00 NHS HARROW CCG 100.00 NHS HILLINGDON CCG 100.00 NHS WEST LONDON CCG 100.00 NHS BEXLEY CCG 100.00 NHS BROMLEY CCG 100.00 NHS CROYDON CCG 100.00 NHS GREENWICH CCG 100.00 NHS KINGSTON CCG 100.00 NHS LAMBETH CCG 100.00 NHS LEWISHAM CCG 100.00 NHS RICHMOND CCG 100.00 NHS SOUTHWARK CCG 100.00 NHS MERTON CCG 100.00 NHS SUTTON CCG 100.00 NHS WANDSWORTH CCG 100.00 NHS WEST ESSEX CCG 100.00
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29
CI 12: Recovery Package – Holistic Needs Assessment (70% of new patients in 15/16)
% of patients receiving element of the recovery package is an estimate derived by comparing the number of patients reported by the trust against the number of first treated patients reported.
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Threshold
30
London eHNA + concerns checklistIn the last 12 months, 38% of care plans identify worry, fear or anxiety as a concern for the patient at any point on the cancer pathway. About 15 Trusts in currently London are using eHNA.
31
CI 12: Recovery Package – Treatment Summary (70% of new patients in 15/16)
% of patients receiving element of the recovery package is an estimate derived by comparing the number of patients reported by the trust against the number of first treated patients reported.
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Threshold
32
CI 12: Recovery Package – Health & wellbeing events/clinics (70% of new patients in 15/16)
% of patients receiving element of the recovery package is an estimate derived by comparing the number of patients reported by the trust against the number of first treated patients reported.
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Threshold
33
CI 12: Recovery Package – Stratified Pathways (Breast – 70%, Colorectal - 40% Prostate – 40%)
% of patients receiving element of the recovery package is an estimate derived by comparing the number of patients reported by the trust against the number of first treated patients reported.
05
Transforming London’s health and care together34
So what?
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Data is kingCommissioners (and planners) use data to justify new or change in expenditure to benefit the whole population for their whole lifetime
Sustainability and transformation plans (STPs) are increasingly taking on responsibility for asking (and answering) these kinds of questions:
• What are the outcomes in our area?
• Where are our gaps/inadequacies in service delivery?
• What differences in outcomes exist amongst our population?
• How well are our services integrated? Acute & community/primary care, physical & mental health, health & social care?
• What benefits will our population get from this investment?
• What happens if we don’t invest at all/ enough?
• How do we prioritise?
• How efficient can we be/ are we?
• How long can we sustain this kind of investment?
• How do we invest? What service models/contracting models should we use?
• How do we compare to other similar areas?
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Discussion – how do we compare?
1. How confident are you in answering each of these lines of enquiry, using robust evidence? On a scale 1-10 (10 very confident)
2. Which LOEs are most difficult to answer and why? Your top 3
3. What do we need to do to improve our answers? Plenary discussion
• What are the outcomes in our area?
• Where are our gaps/inadequacies in service delivery?
• What differences in outcomes exist amongst our population?
• How well are our services integrated? Acute & community/primary care, physical & mental health, health & social care?
• What benefits will our population get from this investment?
• What happens if we don’t invest at all/ enough?
• How do we prioritise?
• How efficient can we be/ are we?
• How long can we sustain this kind of investment?
• How do we invest? What service models/contracting models should we use?
In small groups/with your neighbours…
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Key messages• For commissioners, data is king. And benchmarked data is even better!
• The numbers of people surviving cancer are increasing, and people are also living longer following a cancer diagnosis.
• Cancer is a long term condition. 70% of people with cancer have at least one other long term condition.
• Significant need arising from consequences of treatment can be prevented or better managed. Requires good commissioning and provision
• 15 months after diagnosis, people with cancer are more likely to use urgent and emergency care services compared to others in the same age and gender groups.
• 58% of people feel their emotional needs are not looked after as much as their physical needs.
• The Recovery Package and stratified follow up needs to be integrated into cancer pathways and extend across secondary and primary care to provide co-ordinated and holistic care to support for people in the long term.
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Recovery package LWBC Commissioning Guidance: Recovery Package (2015) Treatment Summaries: a briefing for cancer GPs (2016)
Cancer Care Reviews & integrated care
Cancer as a long term condition report (2015) Primary Care Cancer Checklist (2016)
Primary care education LWBC Training Needs Analysis surveys for the primary care workforce (2016)o GPs https://www.surveymonkey.co.uk/r/LWBC_GP o GP Trainees https://www.surveymonkey.co.uk/r/LWBC_trainee_GPso Primary Care nurses https://www.surveymonkey.co.uk/r/LWBC_Primary_care_nurseso Community pharmacists and dentists (in development)o Community allied health professionals (in development)
Prospectus (in development)
Prostate cancer (Primary care led follow up)
Croydon Primary Care led Prostate Cancer follow Up project evaluation (2016) ICF’s Economic Analysis (2016) Desktop review of the Prostate Cancer UK projects in London (2016) CCG/STP sample business case (2016)
Stratified follow up pathways (hospital led)
Financial modelling tools (in development)o London Cancer colorectal cancer pathwayo London Cancer prostate cancer pathwayo London Cancer breast cancer pathway
Cancer Rehabilitation Psychological support for people affected by cancer: commissioning guidance (2015)
Pathway and service specification for psychological support for people affected by cancer (in development)
Lymphoedema commissioning guidance (2016) Cancer Rehabilitation commissioning guidance (in development)
Accessing TCST resources
