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Improving services for upper GI (OG) cancer

Application template

Trust Barking Havering and Redbridge University Hospitals NHS Trust

Clinical lead Mr Dipankar Mukherjee

Managerial lead Eileen Moore

Date completed 12th

June 2012

Applying to provide:

Local OG Cancer unit √� Specialist OG Cancer surgical centre √�

This bid is to become one of the two proposed OG

specialist cancer centres for the Integrated Cancer

System covering North and North East London

Proposed sites

Local OG Cancer unit

Complete Part I

Queens Hospital (Barking ,Havering and Redbridge University

hospitals NHS Trust)

Specialist OG Cancer centre

Complete Part II

Queens Hospital (Barking ,Havering and Redbridge University

hospitals NHS Trust)

5

Vision for future upper GI (OG) cancer services

Introduction

Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) wholeheartedly welcomes the exciting

opportunity of radical cancer reform brought about by London Cancer and UCLPartners (UCLP). BHRUT is one of

the largest partners in UCLP and since joining the Trust has been working with UCLP in the areas of developing a

value based service, training provision, Academic Health Service Network (AHSN) for cancer. The Trust envisages

collaborative work to extend between two proposed oesophago-gastric (OG) cancer centres in the integrated

cancer system (ICS). We strongly believe this is crucial to deliver the vision of London cancer for the OG cancer

patients in the capital.

The OG cancer centre at Queens Hospital (QH) aspires to be a world leader in care provision, innovation,

education, training and research. In particular the OG cancer centre at BHRUT welcomes the opportunity to work

with the partners in London Cancer in delivering and developing care pathways. The vision for the future is to

work in collaboration with the other OG cancer centre (s) in London Cancer. This collaboration is envisaged to

extend to innovation, research, governance as well as having a joint multi-disciplinary team (MDT) meeting.

Collaborative working will extend into all disciplines working as a single team across the ICS.

The MDT recognises that innovations for early diagnosis are more likely to evolve from joined up working

between academics and clinicians. This is the reason that OG cancer centre at BHRUT is keen to work

collaboratively to deliver the best possible outcomes for our patients.

The OG cancer centre at BHRUT has worked with the Hutchison/Medical Research Council (MRC) Cancer Cell Unit

of Cambridge University in pioneering developments for screening of OG cancer and is keen to take this further

across London Cancer.

BHRUT

BHRUT serves a population of around 750,000 from a wide range of social and ethnic groups, making it one of the

largest acute hospital trusts in England. It delivers health care services for 4 main boroughs of Barking and

Dagenham, Havering, Redbridge and Waltham Forest. It also provides services for the population of South West

Essex.

Across the main boroughs, the population is growing faster than the London and national average, at a rate of 9%

over the last two years. The local boroughs of Barking and Dagenham, Havering and Redbridge anticipate a

further population increase of over 35,000 over the next 5 years. This is a significant demographic challenge and

this reality must be a major consideration in planning future services for the ageing population. With close

proximity to the M25 and extensive transport links, the physical location of BHRUT in the centre of these future

populations makes it ideal to be one of the OG Cancer centres under the auspices of London Cancer.

The Trust envisages that it will be providing services to an extensive catchment population. Patients from Harlow

and Waltham Forrest will naturally migrate to the specialist centre at QH where transport links are extensive and

travel times are short. Essex commissioners fully support patients exercising their right to choose to have their

surgical treatment at BHRUT.

Whilst acknowledging that the North London boroughs such as Barnet, Enfield and Haringey are not as well

connected, BHRUT is ideally situated and has the capacity and clinical expertise to also provide services to the

population of East London such as Tower Hamlets, Hackney and Newham as part of the configuration of two new

OG centres.

The long term vision for the BHRUT OG Specialist Cancer Centre and Specialist MDT is to provide a high quality,

patient centred specialist service for a population of 2 million. This service will be readily accessible and supports

the delivery of the care pathway, where appropriate, closer to the patient’s home. The Trust will ensure that

where patients can access these services it will facilitate the provision or transfer of care through a managed and

seamless process. Patient choice will be central to the care pathway.

Cancer in BHRUT

BHRUT has 14 cancer MDTs and treats 10% of all cancers in London and 50% of all cancers in the previous North

East London Cancer Network. BHRUT sees 1000 suspected cancer referrals a month. It has delivered all cancer

waiting time targets (CWT) for the last 4 years. BHRUT has participated in all local and national cancer projects,

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including National Awareness and Early Diagnosis Initiative (NAEDI). BHRUT has worked very closely with primary

care and patient groups and enhanced these links by implementing a clinically led management structure within

the Trust.

BHRUT has 1300 beds in two sites. Queens Hospital (QH) and King George Hospital (KGH). The Trust has

consolidated surgical and medical oncology and radiotherapy services at QH with the provision of modern

diagnostic, laparoscopic theatre and radiotherapy facilities. QH is a new modern building that opened in 2006

with 813 adult beds. As a Private Finance Initiative (PFI) hospital the equipment at QH is provided via a Managed

Equipment Service (MES) and as such the equipment is replaced and updated as part of a regular refresh cycle.

Annual funding for this is part of the PFI contract. This ensures premises and equipment are regularly renewed

and modernised. There are excellent purpose built oncology, theatre and academic facilities. There are more than

900 parking spaces for patients and visitors.

There is an Acute Oncology Service (AOS) that includes a newly refurbished cancer day centre and a dedicated

oncology ward with ring-fenced assessment beds for cancer patients. As a result of a successful bid the Trust was

awarded £750,000 from the Radiotherapy Innovation Fund and £750,000 was awarded. This money was used to

upgrade the department to deliver IMRT, VMAT and RapidArc. There are two JAG approved endoscopy suites

with full diagnostic and therapeutic capability including endoscopic ultrasound.

The thriving palliative care team has strong leadership and is extending its service to provide on-site care 7 days a

week.

The travel links, including train and bus routes, with outer North and North East London and Essex are well

established. Rural communities in these areas are particularly well served. For those who drive, QH is within easy

reach of the M25 and there is a dedicated car park for cancer patients and carers available free of charge. This is

an important part of the service for patients. There are 94 free spaces dedicated to oncology and a further 65

free for disabled parking.

BHRUT has consistently achieved excellent peer reviews in many tumour groups including for OG cancer. There

are regular cancer away days, both Trust wide and tumour group specific, to modernise and develop cancer

services. Excellent links with primary care and newly formed Clinical Commissioning Groups (CCGs) to provide

integrated care. The Trust has a track record of working with patient groups to shape services. The OG cancer

patient group has been meeting monthly for more than 10 years.

OG cancer centre

BHRUT has provided specialist OG cancer service for over 15 years and has a specialist MDT which evolves and

modernises itself in line with national and international developments. Prospective data collection has been

carried out from the date of inception of the first national database ASCOT (Assessment of Stomach and

Oesophageal Cancer Outcomes from Treatment) that was rolled out in 1999. Subsequently the Trust has entered

data into National Oesophago-gastric Cancer Audit (NOGCA). Comprehensive annual audits of process and

outcomes have been taking place for more than 10 years.

The specialist OG MDT at BHRUT is mature and highly successful with excellent clinical leadership and

engagement. The Trust’s MDT has a successful history of working with other specialist OG MDTs. These include

Barts Health, Imperial and Guys and St Thomas. The Trust’s vision is to continue to build on its capability to

collaborate and expects a single model of care to be developed across the specialist surgical centres.

To support this vision the MDT has an ultra modern video conferencing facility and the capability to video

conference with all hospitals in North and North East London and Essex. The Somerset database was introduced

two years ago and the MDT has participated in the national MDT-fit project. The OG specialist MDT has achieved

100% completeness of staging data in all four quarters of 2012-2013. BHRUT is the only Trust to achieve this in

OG cancer out of 38 Trusts in London, Sussex, Kent and Medway, Surrey and Hampshire.

7

The MDT believes care closer to the patient’s home is paramount and discussions with the stakeholder Trusts has

supported this. Travel to the centre is considered acceptable only when there is a valid clinical reason e.g. during

survivorship. Our vision is for the specialist clinicians to travel to the patient and to attend, develop and work

with local MDTs. This will ensure continuity, improve patient satisfaction to patients and crucially will support the

local/diagnostic MDT and Nurse Specialists.

BHRUT OG MDT has delivered this type of service to Basildon University Hospital for a number of years and the

model proved highly popular. The Trust has recently delivered surgical services to OG cancer patients from

Harlow. The additional benefit of this model is that for clinicians it helps to retain and update local expertise and

prevent erosion of clinical interest and skills for those participating in the diagnostic MDT.

Being strategically located, BHRUT has successfully treated patients from the Thames corridor and West Essex.

This is a direct result of the excellent reputation of the OG cancer centre and with patients exercising choice.

Commissioners have welcomed and sanctioned this.

Surgical service

The surgical caseload for OG resection was the highest among the three existing centres during the last recorded

year in the ICS. During 2012/2013 the Trust undertook the largest number of oesophagectomies (32) and the

largest number of palliative operations (9) in London cancer. 12 gastrectomies were also performed. Surgical

outcome data has demonstrated outstanding results. The 30 and 90 day mortality for resections has been zero

for the last four years. This has been a consequence of many years of close team working amongst all professions

delivering upper GI services at BHRUT and the clinical networks that they have developed with other referring

centres.

The OG cancer centre sub specialised 10 years ago. Three specialist surgeons, working as a cohesive team,

currently provide the OG surgical services. Patients have benefited from the skills and expertise of all three

surgeons where postoperative care is provided entirely by this team. Funds have recently been made available to

recruit a fourth surgeon to join this team. The surgeons also perform all complex benign OG surgery and provide

cover for specialist OG emergencies, such as strangulated hiatus hernia, oesophageal perforation for the local and

neighbouring hospitals.

OG resections are currently supported by specialist Upper GI anaesthetists who are all dually trained as

Intensivists. OG cancer patients receive goal directed fluid therapy, using the LIDCO devise. BHRUT has an

Enhanced Recovery Programme (ERP) supported by a nurse specialist. A dedicated team which includes an acute

pain service, three laparoscopic resectional surgeons, nutrition team and dedicated therapy support is well

established in providing enhanced recovery for OG cancer patients. This results in rapid recovery and patient

experience as well as reduced length of stay.

The Trust’s Executive Committee has approved funding for the reconfiguration of services in order to release

theatre capacity at QH. This will enable the service to meet the demands of the proposed increased surgical

capacity for OG cancer. This theatre capacity will be made available to both existing surgeons as well as OG

surgeons from other hospitals. Funding for a new surgeon will facilitate the employment of OG surgeons

currently practicing in the region, either as a full time or part time basis if required. They will be welcomed as a

key member of the team.

A planned reorganisation of critical care services in line with the Trust’s clinical strategy will increase the critical

care bed base from 32 at QH to 40 supporting those who need intensive care following surgery.

Clinical Governance

Joint working and learning between specialist centres and local providers in ICS is central to the Trust’s vision.

This is crucial to further develop the cancer services at BHRUT. It will ensure the patient pathway is constantly

reviewed against best practice. Adherence to guidelines and standards will ensure that the patient is kept central

to service provision. The Trust‘s vision is that there will be one joint audit, governance and research programme

8

across ICS.

The Trust has a yearly audit programme for all OG cancer patients (including operated patients) auditing and

examining both process and outcome. There are ongoing targeted audits in diverse areas of the patient pathway

e.g. anaesthetic care, ITU stay, pain control, palliative care, endoscopic palliation, patient experience, provision of

patient information, and quality of life.

The centre has participated in NOGCA from its inception. During the annual meetings of the MDT, operational

policies are revised to reflect changes in national guidelines, new evidence, service elements and change in

staffing. An annual work programme is developed to reflect this.

The team is developing a comprehensive governance framework which will be adopted in July 2013. The

expectation is that this will provide clinical and managerial governance to ensure ongoing clinical and financial

assurance for safety, quality and patient experience. The aim is to provide a listening service constantly updating

and learning from patient and staff feedback.

Joint policies will be developed and agreed between the two proposed centres, both for operational

management as well as governance and quality assurance. The Trust will also work with all referring organisations

to ensure there is a seamless transfer of data and patient information between organisations.

In summary

BHRUT’s vision is to provide a world class OG Specialist Surgical Cancer Centre at QH for the population of East

and North East London and West Essex and offer choice to those resident in South Essex. These services will be

delivered by a mature, well governed and forward thinking MDT, incorporating a specialist surgical team with a

proven track record of safety and quality. The service looks forward to the addition of new OG specialists, both

medical and allied health professionals, into this team.

OG cancer has the capacity and capability to extend its service to cover a much wider population. The Trust’s long

term clinical model of service reconfiguration will fully support the model of care required to deliver timely

services to a greater number of OG cancer patients. Additional capacity and funding has already been identified

to support the surgical cancer pathway.

The OG MDT, supported by a modern university hospital, the Acute Oncology Service, interventional radiology

services and on-site chemotherapy and a state-of-the art radiotherapy department, will ensure that patients will

access services closer to home wherever possible and that it will facilitate the provision of care through a

managed and seamless process. High quality care, timely access, patient choice and patient satisfaction will be

central to the care pathway.

Have you secured trust board-level approval for your application? (please give details)

Yes. Presentation of the bid was made to the Trust Board on the 5th

June 2013.

The Board fully support the bid and the requirement of investment.

Have you discussed your proposals with other trusts and/or local GPs? (If so please give details)

Yes. The local CCG chair persons have been involved and support the bid. Their letters of support are available on

request.

Formal meetings have taken place between cancer clinicians, managers and executives between BHRUT and Princess

Alexander Harlow (PAH). Patients from Harlow have now received treatment at BHRUT.

Agreement has been reached for cancer resections for PAH to take place at BHRUT if two centres are approved.

There have been several meetings between clinicians at University College London Hospitals (UCLH) and Barts Health

who all agree to work in a collaborative manner.

Have you discussed your proposals with any other relevant stakeholders? (If so please give details)

9

Yes:

Local Cancer Services Advisory Team (CAST).

Local patient support group linked to the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland

(AUGIS) that has a membership of 400 patients from local boroughs and Essex.

These local support groups will provide letters of support.

The Trust’s stakeholders including; Nursing Directorate, diagnostic services (radiology, pathology and endoscopy),

theatre, anaesthetic and critical care, Allied Health Professionals, the Acute Oncology Service and Palliative Care

services.

The Local Commissioning Support Units.

Part I: Outline of proposed Local OG cancer unit

N.B. The high-level summary in the column below provides an overview of the main features addressed by the service specification at each

pathway stage. Please consult the service specification document for a more detailed description of the provision we would expect services

operating at this level to offer.

Part of pathway High-level summary of

specification Proposal

Developments

necessary

Diagnosis of

cancer

• Fast-track referrals for

patients with suspected

upper GI (OG) cancer

• Clinical nurse specialist

present at all cancer

diagnoses

• Diagnostic facilities on-site

(CT and MRI)

• Robust coordination with

other centres in situations in

which facilities or resources

are not available in-house

(e.g. rapid access, PET-CT)

• Clinical workforce trained in

advanced communication

skills

Fast Track referrals

BHRUT has a proven track record for treating patients within the cancer waiting time standards.

The Trust has systems in place to accept Choose and Book (C&B), written or faxed referrals and those received via

e-mail through NHS.net. The Trust is currently working with the Clinical Commissioning Groups (CCGs) to increase

the use of C&B as the most efficient way to receive cancer two week wait (2ww ) referrals.

GPs use NICE 2-week GI referral criteria and London Cancer agreed forms and use the NICE dyspepsia guidance for

referrals.

BHRUT has extensive experience in the use of C&B and will employ its expertise to ensure that the system is

integrated within the patient administration system (PAS) to ensure maximum clinic utilisation. Patients who are

booked via the C&B system will have access to clinics at different locations to support their choice of being seen

locally. BHRUT, through regular service reviews, will work with GP’s to ensure the C&B services are meeting their

needs.

BHRUT has an established Inter Provider Transfer (IPT) team which tracks referrals to and from other providers to

affect efficient patient care and ensure that the Minimum Data Set (MDS) is correct. This enables smooth transition

of the patient data to manage a continuous pathway.

Referral from Primary Care is already supported by the provision of specialist advice from BHRUT to local GP

colleagues. To support early diagnosis GPs are given direct access to a pre-determined set of diagnostic services for

patients in accordance with agreed pathways GPs can also access pathology results on Cyberlab.

All patients referred with suspected cancer will be seen by a consultant within two weeks. The Trust’s performance

for the 2ww target in 2012-2013 was 97.23% and this performance is expected to increase going forward.

Treatment within 31 days for all cancers was 99.21%.

The Directory of Services for C&B directs GPs to the most appropriate clinician. The BHRUT website further

supports this with a section on Upper GI services. GPs can also call through directly to the 2ww office with any

queries. If the administration staff cannot assist, they will speak to the consultants to directly advise GPs

accordingly. Advice and guidance is available to GPs.

Three consultants review patients in clinic that have been referred through the 2ww cancer route. There is clinic

capacity to ensure cover for any leave or absence without causing delay to the patient. Patients referred into the

specialist clinics are seen within 10 working days. Patients’ notes and diagnostic tests are available at the time of

attendance.

11







Developments

necessary

There is a robust administrative infrastructure in place to ensure the waiting times are minimised between tests. All

patients suspected of cancer are fast tracked through the appointment systems. All referrals are entered onto the

cancer Somerset database so that the specialty team can track each patient through their diagnostic and treatment

pathway. Patient tracking meetings and escalation processes are in place twice a week to ensure there are no

delays in the pathway.

The pathology department makes the result available to the referring surgeon or imaging consultant. All pathology

specimens and diagnostic requests are highlighted as urgent with a 2ww sticker in order to fast track for diagnosis.

Patients are added to the MDT for discussion as soon as cancer is highly suspected or diagnosed.

For patients diagnosed in outpatient clinics, confirmation will be faxed by the CNS to the GP within 24 hours. The

hard copy of the fax/clinic letter is sent via the post within 3 to 5 working days. For patients diagnosed with Upper

GI cancer during a hospital admission, a discharge summary will be received by the GP within 1 to 3 working days

post discharge.

Benign clinical diagnosis is communicated to patients on the same day.

The OG specialist MDT uses the agreed North East London Cancer Network (NELCN) 2ww referral proforma and has

been involved with updating this proforma for use across London Cancer.

All patients are entered onto the Somerset cancer database which enables the specialty team to review all stages

of the cancer pathway up until the point of treatment or decision to discharge.

In order to improve early diagnosis of cancer BHRUT has a very large Barrett’s surveillance programme and has

worked collaboratively with GPs and with UCL for trials helping to recruit patients with Barrett’s and high grade

dysplasia

The OG department has collaborated with Dr Rebecca Fitzgerald, Cancer Research UK and Cambridge University

MRC cancer cell unit. This group is developing a cytosponge test for Barrett’s screening for early detection of

oesophageal cancer.

The Trust is also collaborating with the lead borough, Havering, with public awareness events and the Trust

currently participates in cervical screening, bowel cancer screening and breast screening programmes.

Clinical Nurse Specialist (CNS):

There are two full time CNS posts within the Trust for OG cancer. All new patients are allocated a CNS at the time of

diagnosis and at subsequent appointments or admissions. The CNS will ensure that they work with their colleagues

12







Developments

necessary

to support onward referral to other departments or providers and ensure that patients are aware of their diagnosis

at all times.

The CNS has received training in holistic assessment to the required standards.

CNSs undertake a significant part in the cancer pathway and are already present at the time of cancer diagnosis to

provide support to the patient and to the clinician when treatment options are being discussed with the patient.

Furthermore the CNS ensures that the appropriate written information is provided to the patient, including the use

of Information Prescriptions.

Patients are informed immediately by the clinician, accompanied by the on-site CNS, if they have suspected cancer.

Benign clinical diagnosis is communicated to patients on the same day at endoscopy.

There is an agreed communications protocol in place between the clinician and CNS to ensure timely follow-up. The

CNS functions as the patient’s key worker who also shares key information freely with specialist centre or other

providers delivering stages within the care pathway.

Diagnostic facilities

There is choice of diagnostic facilities and patients will have access to a full suite of diagnostic services provided by

BHRUT. This includes state of the art radiology facilities providing MRI and CT scanning and two modern JAG

accredited endoscopy suites each available at QH and KGH. The Trust recently completed the build of a new

endoscopy suite at KGH.

Following their 2ww consultation with a consultant, patients will leave their appointment with any additional

diagnostic tests booked, such as access to endoscopy, CT or other scanning facilities with dedicated appointment

slots to ensure timely access. There are drop in services for both ECG and blood tests at QH and KGH.

The Trust provides direct access to gastroscopy for all GPs that are graded according to urgency by a speciality

registrar or consultant. Access will be within 2-3 weeks. Results will be provided to the patients at this one stop

service.

The Trust provides direct referral to endoscopy within one week from any specialty for suspicion of OG cancer.

There is capacity for the patient to be seen sooner if there is clinical need. Patients will be discussed at the next

MDT.

With support from the CNS, the endoscopist informs the patient on the day if there is a suspicious cancer.

The patient is always offered a copy of the endoscopy report to take away with them, if appropriate.

Results of the endoscopy are faxed to the GP within 24 hours. The GP is informed of the diagnosis once the patient

13







Developments

necessary

has been informed.

The Trust has an excellent, long established, EUS service. This is a led by a highly skilled Gastroenterologist with 2

other consultants in support. The unit provides services to Basildon and Harlow Hospitals. The service runs 4 days

per week and can accommodate a patient within the next working day.24 hours of referral. Over 300 radial and

linear scopes are undertaken per annum with the capability of undertaking biopsies, FNAs and dopplers.

An urgent CT scan is requested as soon as cancer is suspected. Access to CT scans and dedicated slots for patients

when they leave their endoscopy appointment with a high suspicion of cancer can be provided by Radiology.

There is capacity for the CT scan to take place within one week following the endoscopy. However should there be

clinical need for the patient to be seen sooner this can be accommodated.

The key features of the Trust’s diagnostic services are:

• Patient centred, patient sensitive

• Responding to the patients needs and where these can be delivered

• Hot reporting on images with fast turnaround

• Reporting done by specialist radiologists

• Routine pathology tests within 4 hours

• Urgent pathology results with 60 minutes

• Order Comms in place for pathology and being implemented for radiology (October 2013)

• Compliance with Royal College of Radiologists and Royal College of Pathologists Guidelines

• MDT assessed competencies.

Endoscopy services are JAG accredited.

Radiology operate in accordance to IR(ME)R regulations

All required reporting is undertaken by qualified and experienced Consultants, Clinical Scientists or Radiographers

as appropriate who are registered with nationally recognised professional bodies.

The pathology department is compliant with Clinical Pathology Accreditation (CPA), Medicines and Healthcare

Products Regulatory Agency (MHRA), the Human Tissue Authority (HTA) and the Royal College of Pathology.

The competency of reporters and staff is assessed and reviewed:

Radiology:

Competencies are assessed and reviewed via a number of Peer meetings including:

• Clinical Governance

• Quality and Safety

14







Developments

necessary

• Morbidity and Mortality

• Clinical Leads

• Section Heads

• Radiation Supervisors

• Radiation Protection Committee

• Clinical Audit

• Clinical Discrepancies

Pathology:

All undertake formal Continuing Professional Development and participate in:

• National External Quality Assurance Schemes (NEQAS)

• Internal Quality Assurance

• Peer Reviews

• Clinical Audit

• Quality and Safety

• Clinical Governance

The Trust will ensure that patient choice is maximised throughout the patient pathway, with patients being able to

access sites and departments across a wide geographic area at a date and time of their choice.

There is a lead consultant radiologist in place who has overall responsibility for the imaging service provided to OG

cancer patients. There is protected time in job plans for preparation and attendance at MDT. Specialist

Interventional Radiologists are available for the upper GI service.

The Trust delivers timely imaging investigations and reports in order to meet the nationally set target for the

commencement of definitive treatment within 31 days of the decision to treat, or, if the patient is on the 2ww

pathway, within 62 -days of urgent referral.

All patients suspected of cancer or diagnosed have timely access to plain X-ray, US and FNA procedures, CT, MRI

and scintigraphy locally. Those requiring PET/CT scans currently access services at Bart’s Health.

Where it is not possible for the imaging department to provide a report within 5 working days the radiologist will

attend the next MDT meeting and provide a verbal report.

There are 13 histopathologists employed by the Trust. 4 support the Upper GI services and attend the MDT.

There are band 7 dietitians specialising in oncology currently supporting the treatment plans for the OG patients.

All patients are screened using the Malnutrition Universal Screening Tool (MUST) during their clinic appointment

and any patients with a MUST score of 2 will be referred to a specialist dietitian who is available during the one

15







Developments

necessary

stop clinic to offer advice on nutrition.

There is access to a senior specialist dietitian (level 3) as per the National Cancer Action Team (NCAT) definition or

patients during their inpatient treatment stage and as follow-up in the community. The dietetic service is provided

by North East London Community Services (NEL CS) at all stages so there is continuity across the pathway

regardless of setting.

All patients who present with an unintended weight loss weight loss over last 6 months are referred to the CNS and

dietitian for health needs assessment.

Coordination with other centres

In order to deliver an integrated care pathway the Trust will use its already established links with the following

organisations to coordinate and access services/support as required:

• Community health providers

• Social services

• Acute Trusts

• Acute Trust laboratories as required

• Local voluntary and third sector organisations

• Other local treatment centres

• Clinical Commissioning Groups

• NHS or independent Diagnostic Providers

The skills of collaboration and integration play an important role in patient care and the Trust will work with the

wider health economy to refine and improve current care pathways, encourage and develop innovative approaches

to pathway management and ensure that services are delivered at the convenience to the patient (not the

provider).

A strong interface between primary and secondary care services is vital to eliminate unnecessary delays and to

secure early diagnosis. The Trust collaborates with other providers as well as local GPs to share information and

work jointly to ensure the patient pathway is delivered without delay and the patient is supported throughout.

The Trust strives to deliver services that increase efficiency and reduce delays. Adherence to the cancer care

pathway is monitored by core members within the Trust.

In order to facilitate discussion with other health care trusts BHRUT has dedicated video conferencing facilities for

MDT discussions which can link to all London and Essex trusts. BHRUT is currently working with our partners to

ensure that all patients receive tests requested externally are done so in a timely manner.

Should an inward referral from another centre or local provider be required facilities are in place to support rapid

referral via video conferencing, weekly MDT meetings and daily patient tracking supported by the Somerset cancer

database as well as the image exchange portal (IEP). This will facilitate both onward and inward referrals from

other trusts to ensure a seamless transfer for patients.

16







Developments

necessary

There is a robust cancer service administrative infrastructure in place to coordinate any onward/inward referrals.

All patients are entered onto the Somerset database to support the tracking of patient pathways. The Trust also

participates in the London Cancer Inter Trust Referral Service as a means of receiving referrals for patients from

other hospitals and will acknowledge receipt of these referrals.

Patients have access to key workers who are aware of their diagnosis at all times, the CNS ensure that they work

with their CNS colleagues in the patient’s local provider to coordinate tests and support onward referral. BHRUT

also proposes that a CNS network is established across North East London to ensure robust communication and

hand over of care.

The Trust also has in place a Palliative Care MDT where there is cross-working and provision of on-call Palliative

Care services with St Francis Hospital. In order to ensure further collaboration with other palliative care providers

the Trust would develop a network for palliative care teams that enables all providers to be linked into the Trust

and to facilitate communication between the specialty teams during each part of the care pathway.

Communication Skills

In order to ensure that staff are appropriately trained to communicate with patients on the cancer pathway, all

current key members of the clinical staff, including therapists, have obtained certificates of attendance on

Advanced Communication Skills training and the Trust will maintain access to the Advanced Communication Skills

training, supported by St Francis Hospice. In addition, facilities are in place to run in house training sessions to

wider members of the cancer team.

The Trust is also in the process of implementing level 4 supervision for those who have undergone level 2

psychology training.

MDT • Local MDT with conferencing

capability with specialist

MDT

• Access provided to a key

worker for all patients

(usually a clinical nurse

specialist)

• Carries out holistic

assessment, including

MDT and conferencing capability

As a Specialist MDT BHRUT is committed to providing the best systems to support patient focused healthcare. The

Trust’s IM&T systems are selected on the basis of:

• Resilience/Reliability

• Integration with existing clinical and administrative systems

• Integration with national systems ensuring security compliance

• Compliance now and in the future with NHS Information Standards Data Set notices.

BHRUT conduct a considerable number of IT system upgrades each year to ensure that its IT systems are compliant.

BHRUT has dedicated video conferencing facilities for MDT discussions which can link to all London and Essex

trusts. The current OG MDT is based in a video conferencing room and has connectivity to all local MDT’s. This has

17







Developments

necessary

palliative care and travel

needs

recently been upgraded to N3 and uses the BT network. This site is reliably connected to the Image Exchange Portal

(IEP), to facilitate the transfer of images. Through the use of IEP BHRUT are able to exchange Radiological images

securely with other NHS organisations.

The venue has sufficient capacity to accommodate all relevant members attending the meeting. It is equipped with

reliable video conferencing equipment to enable communication to take place. There is a microscope available,

which is compatible with the video conferencing equipment to enable projection of slides when needed. There is a

compatible diagnostic PACS workstation to enable clear projection of images.

There are well established referrals routes used for all MDTs from any specialty within the Trust which are

documented in the Cancer Access Policy.

A strong working relationship between the two surgical centres will enable the development of a single specialist

MDT to share knowledge, expertise and patient outcomes.

MDTs use proforma-based reporting, and include staging information. The MDT is supported by the Somerset

database on which there is capacity to record all patient tests, demographics and a full nutritional status. There is

live data collection into the Somerset Cancer Registry database during the MDT. This includes staging, treatment

options discussed and outcomes from the MDT. The Trust compliance to staging data for Upper GI in 2012-2013

was 100%.

Programmed Activities (PAs) are job planned to support these sessions that also include aspects of education.

Annual audits of performance takes place based on a clearly-defined and unified audit programme agreed across

the whole system.

The Trust’s MDT is held on a weekly basis video conferencing with KGH. Over 215 new cases per year are discussed.

The weekly MDT discusses 30 patients.

All tumour staging at the point of treatment planning are entered onto the Somerset database using the TNM7

staging system.

The Trust will participate in the completion of the London Cancer MDT proforma to inform MDT discussion.

The core membership of the local MDT is comprised of:

• Lead clinician

• Specialist OG surgeon

• Gastroenterologist

• Clinical Oncologist

• Radiologist

18







Developments

necessary

• Histopathologist

• Clinical Nurse Specialist

• MDT Coordinators

• Consultant Gastro Lead

• Specialist Palliative Care

Extended members include:

• Palliative care CNS

• Representative from anaesthetic/intensive care.

Band 7 dietitians specialising in oncology currently advise the OG patients.

A minimum data set is completed prior to discussion in the local and with specialist MDT.

The reason for non-curative therapy is recorded at the time of MDT and is entered onto the Somerset database.

This will include reasons for ‘watchful wait’ and palliative care.

The OG CNS is level 2 psychology trained. There is a programme in place to ensure that the CNS also receives

monthly clinical supervision by a level 3 or level 4 practitioners.

All patients are reviewed by a member of the MDT regarding fitness. The unit has been collecting data on ASA

grade, ECOG status, WHO performance status, possum scores and co-morbidities onto their local database for the

past 10 years. This data is also collected on the Somerset database.

The CNSs work as part of collective network. The CNS carries out holistic needs assessment, including an

assessment of palliative care and travel needs, and refers to cancer rehabilitation specialists as appropriate. All

cases for discussion are communicated to the coordinator before the agreed deadline.

The MDT meeting includes the following information:

• A brief clinical history which will include the patient’s presenting symptoms

• Any significant past medical history, including co morbidity assessment and performance status

• Any family history of cancer

• The diagnostic tests that have been performed

• The question to the MDT

• Demographics and information on the consultant in charge of care.

A provisional agenda is circulated to the MDT at least three days before the date of discussion and the final agenda

is circulated to the MDT prior to the meeting. All images relevant to the cases on the agenda are made available for

the radiologists to review pre MDT. The discussion notes are checked by a clinician or CNS before circulating. The

19







Developments

necessary

MDT coordinators for all relevant sites are able to communicate the outcomes and delegate accordingly to ensure

all outcomes are not over looked. The MDT also facilitates prompt referral to pre-treatment assessments.

In order to further support the joint MDT discussions the MDT coordinator is informed of the outcomes of target

cases upon their first appointment at the Trust.

All OG clinicians fill in a 2ww form when a patient on pathway is present in clinic. These forms are then passed onto

the MDT coordinator at the end of the clinic.

All cancer treated cases are logged centrally onto the data Somerset database. This provides accurate clinical

information to aid sufficient and accurate data for collection. This is mainly for national audits such as:

• National registries and datasets such Open Exeter and COSD

• AUGIS/HQUIP

Clinical trial recruitment is embedded into the MDT meeting process.

A procedure is in place for returning information on patients in the post-treatment follow-up phase.

Access provided to a key worker

The CNS, level 2 trained in psychology, works as the patient’s key worker.

All new patients are allocated a CNS at the time of diagnosis and at subsequent appointments or admission to the

dedicated ward. This is supported by a key worker policy. The CNS will be present at MDT meetings.

CNS undertakes a significant role in the cancer pathway and is present at the time of cancer diagnosis to provide

support to the patient and to the clinician when treatment options are being discussed with the patient and the

next steps.

The CNS will contact the patient to arrange a suitable time and will be present at the consultation. Furthermore the

CNS will ensure that the appropriate written information is provided to the patient, including tumour type and

treatment options and the use of Information Prescriptions.

BHRUT also proposes that a CNS network is established between the specialist centre and the local providers to

support onward and inward referral and to ensure that patients have access to Key Workers who are aware of their

diagnosis at all times.

Holistic Care

All patients will be individually assessed to ascertain their individual needs. As needs are identified, appropriate

referrals will be made in order to facilitate the patient’s care pathway where possible.

20







Developments

necessary

Non-English speaking patients, and those with other communication difficulties, will be provided with

interpretation and translation support at all points of their clinical care. This service is managed through the PALS

office via a central booking system. An external contract is in place for provision of interpreting services for

patients. This is available either through a telephone based service or via a face-to-face interpreter.

The British Sign Language interpreting is available for deaf patients through the contract with Newham Language

Shop. The Trust also has a communication system for patients who are deaf and blind.

The Trust has a Chaplaincy team, with access to a range of local faith leaders, so that patients and relatives are able

to access the support they require. Patients may be referred to Chaplaincy at any time. Chaplains work by making

an initial spiritual assessment of the patient’s needs. This assessment will be wide ranging focusing on what is

important to the patient. The Chaplain will endeavour to assist the patient or carer.

All Chaplains are able to offer informal counselling support and the team includes a qualified Counsellor. The

Chaplaincy team offers a 24-hour generic emergency on-call service. The team are supported by 40 trained

volunteers across both sites with links to local faith leaders as required. This service will be available to patients and

carers and staff are provided with the relevant contact numbers for both in hours and out of hours requests.

The Trust is currently part of the Macmillan electronic health needs assessment (EHNA) project. All patients will

have access to an EHNA questionnaire. The EHNA can be recorded on the Somerset database.

Based in the Trust’s Macmillan suite all cancer patients can access complimentary therapies such as aromatherapy,

reflexology and massage, all free of charge.

All patients will continue to undergo holistic assessment at diagnosis and throughout their pathway, supported by

the specialists in cancer rehabilitation such as specialist Physiotherapy (PT), Occupational Therapy (OT), Speech and

Language Therapy (SLT) and on-site Palliative Care team.

Band 7 dietitians specialising in oncology currently advise the OG patients. All patients are screened using the

Malnutrition Universal Screening Tool (MUST) during their clinic appointment and any patients with a MUST score

of 2 are referred to a specialist dietitian who is available during the one stop clinic to offer advice on nutrition.

There is access to a senior specialist dietitian (level 3) for patients during their inpatient treatment stage and as

follow-up in the community.

The dietetic service is provided by the North East London Community Services (NEL CS) at all stages so there is

continuity across the pathway regardless of setting. NELCS have sufficient resource to provide assessment and

treatment during follow up clinics and in the community.

The specialist clinical oncologist and palliative care MDT member s will also provide expertise in contributing to a

holistic approach to care.

Travel

21







Developments

necessary

QH in Romford and KGH in Goodmayes, Ilford have excellent transport links throughout London and Essex. Main

line and underground stations are close to both hospitals and several bus routes lead into both sites.

The Trust will meet patient requirements for provision of non-urgent patient transport through BHRUT’s contracted

Non-Emergency Patient Transport (NEPT) and Emergency Medical Technician (EMT) services. G4S, the leading

provider of patient transport services, is working in partnership with BHRUT to meet the needs of the patient and

GPs with a 24/7 operational service with a fleet of 29 vehicles operated by 83 professional, qualified, experienced

staff. The service is an integrated part of the patient’s clinical pathway. G4S and their staff take great pride in the

level of customer care they provide to our patients and they play a significant part in the patient experience.

The specialist team will inform patients of support available for travel to the departments serving the cancer

centre. The Trust will reimburse allowable patient transport costs on the day.

There is assistance available for patients on benefits needing applications for travel costs. There is a dedicated

person to support this. The Trust’s cancer patients are supported by a Citizens Advice Bureau worker with two

dedicated information centres that provide all of the necessary patient information, specific to their condition.

The Trust also provides free parking for patients undergoing Chemotherapy and Radiotherapy. Free parking will be

available for all cancer patients undergoing treatments regardless of their home address.

For patients who prefer to use public transport, both hospitals are well served by local transport links. There are

also are currently discussions taking place with Transport for London to further enhance bus routes and with the

local council to further increase car parking facilities particularly at the QH site.

The Trust will arrange overnight accommodation for patients requiring accommodation close to the hospital.

Treatment

decision

• Patients are offered all

appropriate treatment

options and all appropriate

types of reconstruction

whether or not these are

available at that particular

provider site

• Decision-making process

The Trust has the capacity to assess and treat patients with minimum delay within 62 days of urgent referral and 31

days of diagnosis.

Both surgical and oncology clinics are in place at which treatment decisions are discussed in the presence of a key

worker. The CNS is present when significant results are given. The CNS will be available at every one of the

subsequent meetings and this will continue and will be further supported by a written outcome of these

discussions being provided to the patient.

When being given results the patient has the option to bring someone with them. The CNS will call the patient and

arrange a time suitable for them to attend an appointment. The findings will be discussed with the patient in as

22







Developments

necessary

involves rehabilitation and

supportive care and

palliative care professionals

much detail as is felt appropriate at the time of consultation. They will be informed of their diagnosis, appropriate

treatment options and next steps.

Treatment options will include:

• Oesophagectomy or gastrectomy

• Reconstructive surgery such as gastric/colonic pull up. Options for reconstruction are undertaken at the

Trust

• Each surgeon undertakes minimally invasive techniques

• Palliative endoscopy - stenting or laser

• The patient is given the opportunity to participate in clinical trials if appropriate and once consent is

given samples are collected.

• EMR and HALO treatment is referred to UCLH. Expertise is available within the Trust for future

development.

• All appropriate patients will be seen by a clinical oncologist and will be offered radiotherapy and or

chemotherapy. The Trust’s radiotherapy department has up-to-date, centre-specific information for OG

patients detailing the processes and side effects of treatment. The Trust recently won a bid from the

Radiotherapy Innovation Fund and £750,000 was awarded. This money was used to upgrade the

department to deliver IMRT and RapidArc. This will support an integrated patient pathway where a local

service can be provided for patients whose surgery is undertaken at the specialist centre. Volumetric Arc

Modulated radiotherapy will be available from October 2013. Working in collaboration with the

referring MDT, this service can be made available to all patients undergoing surgery at BHRUT if the

patient chose to do so.

• Palliative radiotherapy is provided at the Trust. 100% of patients receive this within 14 days of referral.

Complex benign work is being undertaken at the Trust for the local population and that of Harlow and Basildon.

This includes procedures for oesophageal perforations and oesophago-gastric conditions.

The consultant will write to the patients GP outlining their diagnosis and treatment options. They will also offer to

provide a copy of this letter to the patient. A full range of support services are on offer to the patient and family

such as the Oesophageal Patient’s Association.

Services supporting the decision making process

The MDT has core member from all specialities. The clinical oncologists all have dedicated sessions for attendance

at the MDT that enables them to participate in the decision making process.

Patients requiring EMR, ESD

and HALO treatment are

referred to UCLH. Skills are

available within the Trust,

however the specialty will

continue to collaborate

sending patients to another

specialist centre within the

ICS or support a visiting

clinician to provide an ‘in

reach’ service.

23







Developments

necessary

Dietitians and the nutrition team are involved in decisions regarding nutrition when required. This will include the

placing of feeding tubes. SLT will be involved in assessing the need for any short or long term interventions.

AHPs will assess the patient needs. Care plans will be agreed in advance with the patient whose surgery has been

decided and will plan for any pre and post rehabilitation needs. An assessment will be made as to whether this can

be delivered local to home or requires ongoing input from the specialist centre. This will include ongoing

psychological, physical and social care and will follow the NCAT rehabilitation guidelines for OG cancer patients.

A member of the Palliative Care team is also in attendance and plays a key role in deciding supportive therapy. The

Trust has end of life support in place with patients accessing the Liverpool Care Pathway where appropriate and

good symptom control is achieved with the support of the Acute Oncology team, Palliative Care team and the

Acute Pain team.

Therapeutic radiographers in radiotherapy provide patient support prior to and throughout there treatment

pathway. For those patients also undergoing chemotherapy additional support is provided by the oncology day unit

nursing staff and there is access to local support groups.

Clinical psychology services are also available to support the patient during their decision making process.

The Trust recognises that

with additional referrals

further investment in dietetic

and SLT at band 7 to support

attendance at all key points

in the patient pathway will be

required. This has been

presented to the Trust Board. This will also strengthen

adherence to the NCAT

rehabilitation pathway from

the start of a cancer

diagnosis being made.

There would be a recruitment

process in partnership with

North East London

Community Services (NELCS).

Surgery • Diagnostic and pre-operative

assessment (including access

to dental assessment)

procedures are available

When undergoing diagnostic assessment there will be choice and access to a full suite of diagnostic services

provided by BHRUT. This will include state of the art radiology facilities providing MRI and CT scanning and two

modern JAG accredited endoscopy suites each available at QH and KGH. All consultants undertaking endoscopy are

OG trained and JAG accredited.

These services will be made available to any clinician who refers into the specialist MDT.

The Trust has an excellent, long established, EUS service. This is a led by a highly skilled Gastroenterologist with 2

other consultants in support. The unit provides services to Basildon and Harlow Hospitals. The service runs 4 days

per week and can accommodate a patient within the next working day.24 hours of referral. Over 300 radial and

linear scopes are undertaken per annum with the capability of undertaking biopsies, FNAs and dopplers.

PET/CT is currently arranged externally at Bart’s Health and CPEX at Basildon.

Pre-assessment services are initiated throughout the care pathway. For patients requiring the back-up of specialist

services, e.g. anaesthetic or cardio-respiratory, the services at KGH and QH will be directly accessible. These

services will ensure patients are fit and ready for their procedure or advice when other treatments are required

before surgery can safely take place.

24







Developments

necessary

The Trust will also work in collaboration with local providers in order that patients could access pre-treatment

assessment closer to home where possible. The CNS network will be instrumental in ensuring that appropriate

information is gathered and available to the Trust in a timely fashion.

Patients are given practical and written information to plan how they will approach the challenges of treatment.

Relatives/carers are also involved in the preoperative process with particular emphasis on the provision of

nutrition. Written information and the contact number of the dietitian are provided.

At MDT the dietitian and clinicians will asses the need for tube feeding. Where tube feeding is required prior to the

start of treatment rapid access to endoscopy for insertion is in place.

In order to carry out a procedure a full pre-operative clinical and social assessment is undertaken. This will include:

• Pulse, BP, Oximetry

• Blood tests

• ECGs

• MRSA screen

• Any additional diagnostics

A risk assessment:

• VTE risk assessment

• Renal function

• Pathology

• Mobility, manual handling

• Tissue viability

• Falls and frailty assessment

A discharge assessment:

• Home situation

• Social service requirements

• Transport needs

• Rehabilitation requirements

• Home visit pre op as required

• Follow up care

• Medication requirements.

Prior to the start of treatment patients are assessed by a team that includes the surgeon, the CNS, dietitian and

physiotherapist with capacity for additional therapy input depending on functional status and co-morbidities.

Counselling prior to treatment will be provided by the CNS and the Psychology department.

Physiotherapy undertakes a rolling programme prior to surgery and this includes individual assessments and goal

setting. They also provide twice weekly prehabilitation classes including cardiovascular exercises and post operative

25







Developments

necessary

advice.

(Provision for dental assessment is available at QH if required. The dental service is managed by the Maxillofacial

surgical department).

Appropriate patients will also be reviewed by the nutrition team pre operatively and post operatively on a daily

basis whilst an inpatient.

The upper GI anaesthetists will fast track additional diagnostics. This may or may not include CPEX.

MDT coordinators and the CNS will also monitor the access to additional diagnostics during their patient tracking

meetings.

Patients will be cared for in a ring fenced, 30-bedded, single-sex compliant, surgical ward facility.

The surgical patients will be supported by:

• On-site critical care facilities

• Critical Care Out-reach team

• Anaesthetic emergency out of hours service

• Acute Oncology Service

• Palliative Care team

• Allied Health Professionals and CNS

For patients that require a higher intensity of care there are 32 critical care beds at QH and a further 8 beds at KGH.

Nursing staff ratios will be reconfigured to support Level 1 patients being cared for within the inpatient ward if

required.

The Trust also has a plan in place for 7 day working for all support services that will maintain the therapy input at

weekends for those whose surgery takes place later in the week. The Trust’s clinical strategy will also result in a

reconfiguration of critical care services that will increase the beds from 32 to 40 on the QH site.

Specialist Clinical

oncology (where

this service will be

provided locally)

• Radiotherapy offered to all

appropriate patients

• Oncologists with some

sessions devoted to OG

oncology

Patients will receive high quality radiotherapy including IMRT within the state-of-the-art unit at QH. Three linacs

are available, two with Rapid Arc, which operate five days a week. There is an on-call service provided over the

weekend supported by the Acute Oncology Service.

The Trust’s radiotherapy department has up-to-date, centre-specific information for OG patients detailing the

processes and side effects of treatment.

26







Developments

necessary

• Access to a Specialist

Dietitian with expertise in

dealing with Upper GI

• Takes full part in all relevant

clinical trials

The Trust recently won a bid from the Radiotherapy Innovation Fund and £750,000 was awarded. This money was

used to upgrade the department to deliver IMRT and RapidArc.

IMRT and VMAT modalities are fully available at BHRUT.

Palliative radiotherapy is provided at the Trust. 100% of patients receive this within 14 days of referral.

All appropriate patients will be seen by an OG clinical oncologist and will be offered radiotherapy. There are 2 OG

oncologists with dedicated sessions for OG cancer.

IMRT and VMAT are available at BHRUT. The Trust is attaining 29% of radical patients treated with inverse planned

IMRT against a target of 24%.

Treatment protocols are embedded within the department quality management systems. These are available in the

BSI Quality System for Radiotherapy. Pathways and partnership arrangements are in place to cross refer patients

between radiotherapy providers within London Cancer if there are capacity constraints to deliver optimum

radiotherapy techniques. However, the Trust is able to provide this treatment and proposes that all patients that

undergo surgery at BHRUT are offered treatment within this unit as part of patient choice.

There is access to a Specialist Dietitian (level 4) with expertise in dealing with Upper GI cancers.

The Trust takes part in all relevant clinical trials and has previously had good recruitment: Recruitment figure for

Upper GI studies (April 2011-March 2012):

• STO3- 6

• SCALOP- 2

• OE05- 3

• BOSS- 9

April 2012 to present: ST03- 3 (only study open this year).

If providing surgical services to a larger population, BHRUT will facilitate patient choice for radiotherapy wherever

practical. Choice closer to home will be fully supported.

Specialist

Oncology:

Chemotherapy

• Clear referral pathway with

chemotherapy units if not

delivered locally

• Neoadjuvant chemotherapy to

be offered to all OG cancer

patients who meet the criteria

Chemotherapy is delivered on the QH and KGH hospital sites. The QH cancer day unit has recently undergone

extensive refurbishment to expand its day care facilities.

Neoadjuvant chemotherapy and adjuvant chemotherapy and chemo-radiotherapy are offered on site for all

appropriate patients.

A senior, specialist dietitian is available to see all patients with a MUST score of 2 or more if considered to be

27







Developments

necessary

• Adjuvant chemotherapy or

chemoradiotherapy to be

offered if appropriate

• Senior Specialist Upper GI

Dietitian available to see all

nutritionally at risk patients.

nutritionally at risk.

BHRUT providing surgical services to a larger population will facilitate patient choice for chemotherapy wherever

practical. Choice closer to home will be fully supported.

Acute oncology • Full acute oncology service

that meets Peer Review

standards

There is an excellent Acute Oncology Service (AOS) within BHRUT, supported by the clinicians and 3 dedicated AOS

Nurses, all of which work an 8am – 8pm rota. This is set to become a 7 day a week service with the recruitment of

2 further nurses. The chemotherapy day unit provides acute assessment beds in order to support the AOS.

This service has been nominated for a national award run by the NURSING TIMES for developing an outstanding

oncology service.

There are 8 consultants of which 2 are dedicated AOS leads. All consultants have dedicated time in their job plans.

Administrative support for this service is in place. This service was assessed in November 2012 as fully compliant

with peer review standards.

All patients attending A&E are flagged by the A&E staff to the AOS service. The Trust is currently looking at

extending the use of the A&E Symphony system to introduce an electronic flag.

Clear guidelines are in place in A&E on the management of neutropenic sepsis and metastatic spinal cord

compression. A patient Passport System has been in situ for some time within the Trust for those who are

undergoing or have undergone treatments within the last 6 weeks.

During working hours patients are seen in the assessment beds within the chemotherapy day unit to avoid any

unnecessary waits in A&E. There are also ring fenced beds within the specialist oncology ward for out of hours

admissions. There are excellent links with the OG and Palliative Care service. Contact details of all OG cancer unit

staff are available in the emergency department. The Upper GI clinicians can directly refer to the AOS and palliative

care service.

The AOS is also in the process of developing inpatient beds into a 24/7 assessment unit so that acute oncology

patients do not have to attend A&E and can be fasted tracked straight to the Oncology ward for assessment.

An AOS operational policy which includes policies for managing oncological emergencies is available on the Trust

intranet. Printed copies are available in A&E. These describe protocols on the management of patients presenting

as emergencies. An annual audit of neutropenic sepsis is carried out.

Pathways and protocols also exist for the management of patients presenting as emergencies as a consequence of

non-surgical treatment i.e. neutropenic sepsis, treatment related pain, dysphagia and dehydration. The protocol

requires the notification of the AOS when a cancer patient presents and is admitted as an oncological emergency.

28







Developments

necessary

In hours, the CNS is the first point of contact and the on call member of the AOS is contacted out of hours. The CNS

ensures that a holistic needs assessment is completed and referral made to the appropriate specialist.

With the recruitment of additional oncology nurses a dedicated training programme will be established for A&E

and medical staff on the management of these emergencies.

Post treatment • Clear procedures governing

the receipt of patients who

have been discharged from

care of the specialist

treatment centres

• Follow-up clinics for post-

treatment patients (involving

surgeon, oncologist, CNS,

rehabilitation services)

• Process in place to enable a

patient’s rapid readmission,

if necessary

Discharge

Same day electronic discharge summaries for patients and their GPs are already implemented within the Trust. For

patients diagnosed with cancer during a hospital admission, a discharge summary will be received by the GP within

1-3 working days post discharge. This is communicated via secure email.

When discharged from clinic a hard copy of the clinic letter is sent via the post within 3-5 working days.

All treatment decisions and post treatment summaries are entered onto Somerset and sent to GPs.

All dietetic services are provided by NEL CS. On discharge there is ease of handover between dietitians that work in

the same team, or the patient may keep the same dietitian throughout the pathway. Where handover is required

to other teams this is already provided. Each patient has a 6-12 month plan for follow up. Good communication

links currently exist between SLT and Dietetic colleagues across organisations. Discharge from the Trust’s specialist

centre is direct to community based services. For patients requiring social care this is coordinated by the CNS.

The Trust will make arrangements that the referring hospital will be provided with details of discharge.

Carer information from CNS and AHPs is currently provided on discharge.

Follow up clinics

Follow-up of patients adheres to published guidelines.

Post operative follow up clinics are held within one week of discharge where x-ray and blood tests are arranged.

The CNS will also agree with the patient the frequency of further follow ups once full histology is known.

Arrangements will be made to provide an OG Consultant out-reach follow up service from this specialist centre.

Patients are followed up by their oncologist as per Network guidelines. Each patient will receive an end of

treatment summary following their treatment and the necessary information on living with and beyond cancer.

The CNS will support the patient at these appointments and will liaise with community services to ensure that the

patient has the correct level of rehabilitation support.

The specialty will develop an

electronic end of treatment

summary to be provided to

any referring provider and

the patient’s GP.

The Trust recognises that

with additional referrals

further investment in dietetic

and SLT at band 7 will be

required to support

attendance at all key points

in the patients’ pathway. This

has been presented to the

Trust Board. This will also

strengthen adherence to the

NCAT rehabilitation pathway

from the start of a cancer

diagnosis being made.

There would be a recruitment

process in partnership with

NELCS.

29







Developments

necessary

All patients will continue to undergo holistic assessment at diagnosis and throughout their pathway, supported by

the specialists in cancer rehabilitation such as specialist Physiotherapy (PT), Occupational Therapy (OT), Speech and

Language Therapy (SLT) and the on-site Palliative Care team.

The CNS will also arrange for follow up support at local providers where necessary.

Band 7 dietitians, specialising in oncology, provide follow up advice for the upper GI patients. The dietetic service

provided by North East London Community Services provides continuity across the pathway regardless of setting.

The services have sufficient resource to provide assessment and treatment during follow up clinics and in the

community. For patients who have undergone radiotherapy reviews are provided weekly. Patient’s weight will be

monitored for those undergoing chemotherapy and followed up accordingly.

Different patients will have differing needs therefore the follow up support from AHPs will be tailored accordingly.

An assessment will be made as to whether this can be delivered local to home or requires ongoing input from the

Trust’s specialist centre. This will include ongoing psychological, physical and social care and will follow the NCAT

rehabilitation guidelines for OG cancer patients.

The Trust provides GPs with details of the primary care follow-up required for the OG cancer patients and clear

instructions for how to re-access secondary care, if this becomes necessary.

Co-ordinated by the CNS, the Trust will make arrangements for patient follow-ups to take place at their local

provider where possible.

Physiotherapy will offer a 7 Day follow-up service whilst a surgical inpatient. Patients will be seen 2-3 times daily

(as clinically indicated) by specialised UGI Physiotherapist until discharge. A personalised home exercise

programme will be provided upon discharge to every patient with the ability to contact specialised physiotherapist

for additional support. Post discharge review/follow-up as an outpatient will be available to reviewing exercise

ability and advice on limitations, with or without cardiovascular assessment. Post-operative rehabilitation classes

will be available for identified patients. All patients referred into the surgical specialist centre will be able to access

this service.

The CNS will also coordinate follow up care from a wide range of providers should there be a need:


• Social services

• Acute Trusts




30







Developments

necessary

There is a ‘Buddy’ system in place for patients prior to surgical treatment and information leaflets are provided.

There is also an active monthly support group run at the Trust. This is chaired by the CNS and has consultant

support.

Rapid readmission and A&E avoidance

There is a process in place for rapid access to advice or re-admission if necessary. This process avoids attendance to

A&E. The Trust has recently implemented a Surgical Assessment Unit that enables GPs to make a referral for

immediate assessment. The surgical ‘hot-clinic’ runs alongside the assessment unit. This can also be used for

assessment for those who may require an emergency attendance. This facility has been shown to be of great

success in the surgical pathways and patient satisfaction levels have been extremely high. There are ring-fenced

beds within this facility. GPs can directly contact the on call team for advice when required. The nursing team has

just received a Trust award for delivering this high quality service and the Clinical Director was invited to share the

learning at the annual dinner of the Local Medical Committee (LMC) of primary care physicians.

Local GPs regularly access these services in order fast track assessments and interventions. There are also patient

initiated contacts. These services are widely advertised for an expanded patient group in order to provide the

specialist input at critical periods.

The Trust has recently invested in additional surgical consultant posts that will now provide further support to the

Upper GI on call rota. 7 day working is in place for surgical consultants on the QH site.

A triage telephone service is available at the hospice for advice from the oncology community team. Patients have

direct access to this service and can also access the CNS in-hours or the oncology ward at the Trust out of hours.

A patient Passport System has been in place for some time within the Trust for those who are undergoing or have

undergone treatments within the last 6 weeks. This will enable a fast-track assessment or admission. During

working hours patients are seen in the assessment beds within the chemotherapy day unit to avoid any

unnecessary waits in A&E. There are also ring fenced beds within the specialist oncology ward for out of hour

admissions.

Palliative care • Clear referral pathways for

patients with palliative and

specialist palliative care

needs

The Trust has end of life support in place with patients accessing the Liverpool Care Pathway where appropriate

and symptom control is achieved with the support of the Acute Oncology team, Palliative Care team and the Acute

Pain team. District Nurses within the primary care setting also support the discharge of patients.

Referral forms are available to all staff and GPs have direct access to palliative care telephone numbers. Protocols

31







Developments

necessary

are available on the Trust Internet for the management of end of life care and complex symptom control.

There are two full- time and one part -time consultant, supported by 7 CNS posts, dedicated to palliative care.

There is a 24/7 palliative care consultant service available. This service provides and advises on complex symptom

control and will shortly deliver a programme to extend cover at weekends.

There is clear referral guidance available in the Trust for management of end of life and all internal referrals are

seen urgently within 24 hours.

The Specialist Palliative Care team is linked with the community services; St Francis or St Joseph’s Hospice for care

in community. A triage telephone service is available at the hospice for advice from the oncology community team.

Patients have direct access to this service and can also access the CNS in hours or the oncology ward out of hours.

The Palliative Care MDT is fully established. There are domiciliary visits and there is cross-working and provision of

on-call palliative care services with St Francis Hospice.

Research and

innovation

• Access to multidisciplinary

oncology service including

clinical trial research and

research nursing

BHRUT has a well-staffed Research and Development unit that is supported by clinical research assistants and

specialist research nurses. The team supports trials led by the specialists as well as Oncologists. There is also a

research dosimetrist for the radiotherapy trials.

BHRUT was selected as a Green Shoot research site by the NCRN in December 2011.

The Trust has established policies providing staff guidance that cover clinical activity and the governance

framework.

The diagram below demonstrates the governance structure for research and development and audit.

32







Developments

necessary

t of pathway Summary of specification Proposal necessary The patients are screened at the MDT meeting and in the oncology clinics as to whether they are eligible for a trial.

Patients have access to a number of NCRN and commercially sponsored trials.

The Trust has a robust, computerised in-house data collection system to record patients screened. Details are

entered into registered randomised trials. BHRUT has participated in Network wide research audits and is currently

participating in the prospective A&E audit with London Cancer.

Representatives attend the NCRN quarterly Research Steering Committee where recruitment figures are compared

with the other centres in NE Thames and latterly North Central.

The Trust will continue to access tissue banking through the NCRN.

The Trust participates in London Cancer audit programmes and national audits.

In addition the Trust currently participates in cervical screening, bowel cancer screening and breast screening

programmes.

33







Developments

necessary

BHRUT Cancer Trials has now been appointed as a prime site for cancer trials with Quintiles Ltd. This means that for

all cancer trials, including OG trials, that they will receive funding from commercial pharmaceutical companies, BHR

will be among the first sites to be approached to take part. This is expected to increase the level of commercial

trials activity at BHRUT and offer our patients more choice on trial therapies.

One of the major visions of London cancer, UCLP and AHSN is to make the opportunity to be included in national

trials to be available to all patients. As the largest provider in London, BHRUT welcomes the opportunity. This is one

area where not only the other centre in the ICS, but other cancer services and local providers can collaborate.

Nationally OG cancer clinicians have a rich tradition for doing this. The OG clinicians at the Trust have GCP training

and actively recruit into in many NCRI (National Cancer Research Institute) trials. In particular BHRUT has recruited

into trials such as MAGIC, OEO2, OEO5, OEO3, and STO3. OG cancer centre is part of OCCAMS group.

The OG department has collaborated with Dr Rebecca Fitzgerald, Cancer Research UK and Cambridge University

MRC cancer cell unit. This group is developing a cytosponge test for Barrett’s screening for early detection of

oesophageal cancer.

BHRUT has embedded identification of individual potential trial candidates in regular MDM discussion.

BHRUT has a very large Barrett’s surveillance programme and has worked collaboratively with GPs and UCL for

trials helping to recruit patients with Barrett’s and high grade dysplasia.

Education training Innovation & research

Education and training has been an integral part of daily work of the centre.

Specialist higher surgical training positions have been hugely popular and competitive over a long period among

the higher trainees in London Deanery. This is due to the quality of training and available surgical workload of

complex patients. The lead for OG cancer has received the prestigious Silver Scalpel award for excellent training

provision. The OG cancer centre attracts senior trainees, usually in the final years of their training who are the

surgeons of the future. Over recent years a large number of them have been appointed across London and broader

afield after acquiring their expertise in this busy OG centre.

Surgeons and other clinicians regularly teach in specialist national courses and participate and present in national

and international meetings, both as delegate as well as faculty. They all maintain membership of specialist

associations including AUGIS and ALS.

In order to ensure that staff are appropriately trained to communicate with patients on the cancer pathway, all

current key members of the Trust’s clinical staff, including therapists, have been trained in Advanced

Communication Skills and the Trust will maintain access to the Advanced Communication Skills training, supported

34







Developments

necessary

by St Francis Hospice. In addition, facilities are in place to run in house training sessions to wider members of the

cancer team.

All staff access to funding for courses through the Education department. This will include Upper GI specific

courses. Training needs and personal development is identified during clinical supervision and at time of appraisal.

Training for dietitians to become level 4 specialist s is available.

Patient travel • Informs patients of support

available for travel to

specialist centre and

radiotherapy units

The Trust will meet patient requirements for provision of non-urgent transport through BHRUT’s contracted Non-

Emergency Patient Transport (NEPT) and Emergency Medical Technician (EMT) Services. G4S, the leading provider

of patient transport services, is working in partnership with BHRUT to meet the needs of the patient and GPs with a

24/7 operational service available 365 days of the year. There is a fleet of 29 vehicles operated by 83 professional,

qualified, experienced staff. The service is an integrated part of the patient’s clinical pathway. G4S and their staff

take great pride in the level of customer care they provide to our patients and they play a significant part in the

patient experience.

The Trust will reimburse allowable patient transport costs on the day where relevant.

The specialist team will Inform patients of support available for travel to the departments serving the cancer

centre.

There is dedicated finance assistance available for patient s to help complete their benefits application for travel

costs. The Trust’s Cancer patients are also supported by a Citizens Advice Bureau worker with two dedicated

information centres that provide all of the necessary patient information, specific to their condition.

For those patients eligible and requiring transport, the Trust also provides free parking for patients undergoing

Chemotherapy and Radiotherapy. Free parking will be available for all cancer patients undergoing treatments

regardless of their home address. There are 94 spaces for oncology patients, 65 free parking spaces for disabled

patients and a further 600 spaces for patients or visitors.

For patients who prefer to use public transport QH is well served by local transport links. There are also are

currently discussions taking place with Transport for London to further enhance bus routes and with the local

council to further increase car parking facilities particularly at the QH site.

The Trust will arrange overnight accommodation for patients that require accommodation close to the hospital.

35

Part 2: Outline of proposed Specialist OG cancer centre




Part of

pathway

Summary of


Developments

necessary

MDT • Hosts a

specialist

MDT

(specialist

surgical

centres

only)

• Or video-

conferences

with

specialist

MDT

(specialist

chemo-

radiotherap

y providers)

MDT and conferencing capability

As a Specialist MDT BHRUT is committed to providing the best systems to support patient focused healthcare. The Trust’s IM&T systems are selected

on the basis of:

• Resilience/Reliability

• Integration with existing clinical and administrative systems

• Integration with national systems ensuring security compliance

• Compliance now and in the future with NHS Information Standards Data Set notices.

BHRUT conduct a considerable number of IT system upgrades each year to ensure that its IT systems are compliant.

BHRUT has dedicated video conferencing facilities for MDT discussions which can link to all London and Essex trusts. The current OG MDT is based in a

video conferencing room and has connectivity to all local MDT’s. This has recently been upgraded to N3 and uses the BT network. This site is reliably

connected to the Image Exchange Portal (IEP), to facilitate the transfer of images. Through the use of IEP BHRUT are able to exchange Radiological

images securely with other NHS organisations.

The venue has sufficient capacity to accommodate all relevant members attending the meeting. It is equipped with reliable video conferencing

equipment to enable communication to take place. There is available a microscope, which is compatible with the video conferencing equipment to

enable projection of slides when needed. There is a compatible diagnostic PACS workstation to enable clear projection of images.

There are well established referrals routes used into all MDTs from any specialty within the Trust which are documented in the Cancer Access Policy.

A strong working relationship between the two surgical centres will enable the development of a single specialist MDT to share knowledge, expertise

and patient outcomes.

MDTs use proforma-based reporting, and include staging information. The MDT is supported by the Somerset database on which there is capacity to

record all patient tests, contacts and a full nutritional status. There is live data collection into the Somerset Cancer Registry database during the MDT.

This includes staging, treatment options discussed and outcomes from the MDT. The Trust compliance to staging data for Upper GI in 2012-2013 was

100%.

Programmed Activities (PAs) are job planned to support these sessions that also include aspects of education. Annual audits of performance takes

place based on a clearly-defined and unified audit programme agreed across the whole system.

The Trust’s MDT is held on a weekly basis video conferencing with KGH. Over 215 new cases per year are discussed. The weekly MDT discusses 30

patients.

All tumour staging at the point of treatment planning are entered onto the Somerset database using the TNM7 staging system.

The Trust will participate in the completion of the London Cancer MDT proforma to inform MDT discussion.

36





Part of

pathway

Summary of


Developments

necessary

The core membership of the Local MDT is comprised of:

• Lead clinician

• Specialist OG surgeon

• Gastroenterologist

• Clinical Oncologist

• Radiologist

• Histopathologist

• Clinical Nurse Specialist

• MDT Coordinators

• Consultant Gastro Lead

• Specialist Palliative Care

Band 7 dietitians specialising in oncology currently advise the OG patients.

Extended members include:

• Palliative care CNS

• Representative from anaesthetic/intensive care.

A minimum data set is completed prior to discussion in the local and with specialist MDT.

The reason for non-curative therapy is recorded at the time of MDT and is entered onto the Somerset database. This will include reasons for ‘watchful

wait’ and palliative care.

The OG CNS is level 2 psychology trained. There is a programme in place to ensure that the CNS also receives a minimum 1 hour per month clinical

supervision by a level 3 or level 4 practitioners.

All patients are reviewed by a member of the MDT regarding fitness. The unit has been collecting data on ASA grade, ECOG status, WHO performance

status, possum scores and co-morbidities onto their local database for the past 10 years. This data is also collected on the Trust’s database, Somerset.

The CNSs work as part of collective network. The CNS carries out holistic needs assessment, including an assessment of palliative care and travel

needs, and refers to cancer rehabilitation specialists as appropriate. All cases for discussion are communicated to the coordinator before the agreed

deadline.

The MDT meeting includes the following information:

• A brief clinical history which will include the patient’s presenting symptoms

• Any significant past medical history, including co morbidity assessment and performance status

• Any family history of cancer

• The diagnostic tests that have been performed

Recruitment to

specialist dietitian

required.

37





Part of

pathway

Summary of


Developments

necessary

• The question to the MDT

• Demographics and information on the consultant in charge of care.

A provisional agenda is circulated to the MDT at least three days before the date of discussion and the final agenda is circulated to the MDT prior to

the meeting. All images relevant to the cases on the agenda are made available for the radiologists to review pre MDT. The discussion notes are

checked by a clinician or CNS before circulating. The MDT coordinators for all relevant sites are able to communicate the outcomes and delegate

accordingly to ensure all outcomes are not over looked. The MDT also facilitates prompt referral to pre-treatment assessments.

In order to further support the joint MDT discussions the MDT coordinator is informed of the outcomes of target cases upon their first appointment at

the Trust.

All OG clinicians fill in a 2ww form when a patient on pathway is present in clinic. These forms are then passed onto the MDT coordinator at the end

of the clinic.

All cancer treated cases are logged centrally onto the data Somerset database. This provides accurate clinical information to aid sufficient and

accurate data for collection. This is mainly for national audits such as:

• National registries and datasets such Open Exeter and COSD

• AUGIS/HQUIP

Trial recruitment is embedded into the MDT meeting process.

A procedure is in place for returning to the MDT information on patients in the post-treatment follow-up phase.

Access provided to a key worker

There are two CNS posts for OG cancer. The CNS works as the patient’s key worker and details are shared with the patient during the first clinic

appointment. The two posts provide adequate cover for periods of leave.

All new patients are allocated a CNS at the time of diagnosis and at subsequent appointments or admission to the dedicated ward. This is supported

by a key worker policy. The CNS will be present at MDT meetings.

CNS undertakes a significant role in the cancer pathway and is present at the time of cancer diagnosis to provide support to the patient and to the

clinician when treatment options are being discussed with the patient and the next steps.

The CNS will contact the patient to arrange a suitable time and will be present at the consultation. Furthermore the CNS will ensure that the

appropriate written information is provided to the patient, including tumour type and treatment options and the use of Information Prescriptions.

BHRUT also proposes that a CNS network is established between the specialist centre and the local providers to support onward and inward referral

and to ensure that patients have access to Key Workers who are aware of their diagnosis at all times.

38





Part of

pathway

Summary of


Developments

necessary

Holistic Care

All patients will be individually assessed to ascertain their individual needs. As needs are identified appropriate referrals will be made in order to

facilitate the patient’s care pathway where possible.

Non-English speaking patients, and those with other communication difficulties, will be provided with interpretation and translation support at all

points of their clinical care. This service is managed through the PALS office via a central booking system. An external contract is in place for provision

of interpreting services for patients. This is available either through a telephone based service, or via a face-to-face interpreter.

The British Sign Language interpreting is available for deaf patients through the contract with Newham Language Shop. The Trust also has a

communication system for patients who are deaf and blind.

The Trust has a Chaplaincy team, with access to a range of local faith leaders, so that patients and relatives are able to access the support they

require. Patients may be referred to Chaplaincy at any time. Chaplains work by making an initial spiritual assessment of the patient’s needs. This

assessment will be wide ranging focusing on what is important to the patient. The Chaplain will endeavour to assist the patient or carer.

All Chaplains are able to offer informal counselling support and the team includes a qualified Counsellor. The Chaplaincy team offers a 24-hour

generic emergency on-call service. The team are supported by 40 trained volunteers across both sites with links to local faith leaders as required. This

service will be available to patients and carers and staff are provided with the relevant contact numbers for both in hours and out of hours requests.

The Trust is currently part of the Macmillan EHNA project. All patients will have access to an electronic health needs assessment questionnaire. The

EHNA can be recorded on the Somerset database.

Based in the Trust’s Macmillan suite all cancer patients can access complimentary therapies offering aromatherapy, reflexology and massage, all free

of charge.

All patients will continue to undergo holistic assessment at diagnosis and throughout their pathway, supported by the specialists in cancer

rehabilitation such as specialist Physiotherapy (PT), Occupational Therapy (OT), Speech and Language Therapy (SLT) and on-site Palliative Care team.

Band 7 dietitians specialising in oncology currently advise the OG patients. All patients are screened using the Malnutrition Universal Scoring Tool

(MUST) during their clinic appointment and any patients with a MUST score of 2 are referred to a specialist dietitian who is available during the one

stop clinic to offer advice on nutrition. There is access to a senior specialist dietitian (level 3) for patients during their inpatient treatment stage and as

follow-up in the community.

The dietetic service is provided by the North East London Community Services (NEL CS) at all stages so there is continuity across the pathway

regardless of setting. NELCS have sufficient resource to provide assessment and treatment during follow up clinics and in the community.

The specialist clinical oncologist and palliative care MDT member s will also provide expertise in contributing to a holistic approach to care.

Travel

QH in Romford and KGH in Goodmayes, Ilford have excellent transport links throughout London and Essex. Main line and underground stations are

39





Part of

pathway

Summary of


Developments

necessary

close to both hospitals and several bus routes lead into both sites.

The Trust will meet patient requirements for provision of non-urgent PTS through BHRUT’s contracted Non-Emergency Patient Transport (NEPT) and

Emergency Medical Technician (EMT) Services. G4S, the leading provider of patient transport services, is working in partnership with BHRUT to meet

the needs of the patient and GPs with a 24/7 operational service available 365 days of the year. This service has a fleet of 29 vehicles operated by 83

professional, qualified, experienced staff. The service is an integrated part of the patient’s clinical pathway. G4S and their staff take great pride in the


The specialist team will inform patients of support available for travel to the departments serving the cancer centre. The Trust will reimburse

allowable patient transport costs on the day.

There is assistance available for patients on benefits applications for travel costs. There is a dedicated resource to support this. The Trust’s cancer

patients are supported by a Citizens Advice Bureau worker with two dedicated information centres that provide all of the necessary patient

information, specific to their condition.

The Trust also provides free parking for patients undergoing Chemotherapy and Radiotherapy. Free parking will be available for all cancer patients

undergoing treatments regardless of their home address.

For patients who prefer to use public transport, both hospitals are well served by local transport links. There are also are currently discussions taking

place with Transport for London to further enhance bus routes and with the local council to further increase car parking facilities particularly at the

QH site.

The Trust will arrange overnight accommodation for patients requiring accommodation close to the hospital.

Treatment

decision

• Patients are

offered all

appropriate

treatment

options and

all

appropriate

types of

reconstructi

The Trust has the capacity to assess and treat patients with minimum delay within 62 days of urgent referral and 31 days of diagnosis.

Both surgical and oncology clinics are in place at which treatment decisions are discussed in the presence of a key worker. The CNS is present when

significant results are given. The CNS will be available at every one of the subsequent meetings and this will continue and will be further supported by

a written outcome of these discussions being provided to the patient.

When being given results the patient has the option to bring someone with them. The CNS will call the patient and arrange a time suitable for them to

attend an appointment. The findings will be discussed with the patient in as much detail as is felt appropriate at the time of consultation. They will be

informed of their diagnosis, appropriate treatment options and next steps.

Treatment options will include:

40





Part of

pathway

Summary of


Developments

necessary

on whether

or not these

are available

at that

particular

provider site

• Decision-

making

process

involves

rehabilitatio

n and

supportive

care

professional

s and

palliative

care

professional

s


• Reconstructive surgery such as gastric/colonic pull up. Options for reconstruction are undertaken at the Trust

• Each surgeon undertakes minimally invasive techniques

• Palliative endoscopy - stenting or laser

• The patient is given the opportunity to participate in clinical trials if appropriate and once consent is given samples are collected.

• EMR and HALO treatment is referred to UCLH. Expertise is available within the Trust for future development.

• All appropriate patients will be seen by a clinical oncologist and will be offered radiotherapy and or chemotherapy. The Trust’s

radiotherapy department has up-to-date, centre-specific information for OG patients detailing the processes and side effects of treatment.

The Trust recently won a bid from the Radiotherapy Innovation Fund and £750,000 was awarded. This money was used to upgrade the

department to deliver IMRT and RapidArc. This will support an integrated patient pathway where a local service can be provided for

patients whose surgery is undertaken at the specialist centre. Volumetric Arc Modulated radiotherapy will be available from October 2013.

Working in collaboration with the referring MDT this service can be made available to all patients undergoing surgery at BHRUT if the

patient chose to do so.

• Palliative radiotherapy is provided at the Trust. 100% of patients receive this within 14 days of referral.

Complex benign work is being undertaken at the Trust for the local population and that of Harlow and Basildon. This includes procedures for

oesophageal perforations and oesophago-gastric conditions. Shared contracts with the other surgical centre will enable the two centres to provide a

full service for benign surgical activity.

The consultant will write to the patients GP outlining their diagnosis and treatment options. They will also offer to provide a copy of this letter to the

patient. A full range of support services are on offer to the patient and family such as the Oesophageal Patient’s Association.

Services supporting the decision making process

The MDT has core member from all specialities. The clinical oncologists all have dedicated sessions for attendance at the MDT that enables them to

participate in the decision making process.

The Trust recognises the value of cross

Dietitians and the nutrition team are involved in decisions regarding nutrition when required. This will include the placing of feeding tubes. SLT will be

involved in assessing the need for any short or long term interventions.

AHPs will assess the patient needs. Care plans will be agreed in advance with the patient for those where surgery has been decided and will plan for

any pre and rehabilitation needs. An assessment will be made as to whether this can be delivered local to home or requires ongoing input from the

specialist centre. This will include ongoing psychological, physical and social care and will follow the NCAT rehabilitation guidelines for OG cancer

Patients requiring EMR,

ESD and HALO

treatment are referred

to UCLH. Skills are

available within the

Trust however the

specialty will continue

to collaborate sending

patients to another

specialist centre within

the ICS or support a

visiting clinician to

provide an ‘in reach’

service.

The Trust recognises

that with additional

referrals further

investment in dietetic

and SLT at band 7 to

support attendance at

all key points in the

patient pathway will be

required. This has been

presented to the Trust

Board. This will also

strengthen adherence

to the NCAT

rehabilitation pathway

from the start of a

cancer diagnosis being

made.

There would be a

recruitment process in

partnership with North

East London

Community Services.

41





Part of

pathway

Summary of


Developments

necessary

patients.

A member of the Palliative Care team is also in attendance and plays a key role in deciding supportive therapy. The Trust has end of life support in

place with patients accessing the Liverpool Care Pathway where appropriate and good symptom control is achieved with the support of the Acute

Oncology team, Palliative Care team and the Acute Pain team.

Therapeutic radiographers in radiotherapy provide patient support prior to and throughout there treatment pathway. For those patients also

undergoing chemotherapy additional support is provided by the oncology day unit nursing staff and there is access to local support groups.

Clinical psychology services are also available to support the patient during their decision making process.

Surgery • Close

working

relationship

between

both

specialist

surgical

centres

(prior to

consolidatio

n into a

single

surgical

centre), with

unified

treatment

protocols

and sharing

of skills,

Surgical Volumes

During 2012/2013 the Trust undertook the largest number of oesophagectomies (32) and the largest number of palliative operations (9) in London

cancer. 12 gastrectomies were also performed.

Consolidating into two specialist centres will enable each centre to carry out a minimum of 60 oesophago-gastric resections per year. The Trust

envisages that patients from Harlow and Waltham Forrest will naturally migrate to the specialist centre at QH where transport links are extensive and

travel times are short. This will ensure high quality and consistent care to be offered in centres of excellence. This will enable stabilisation of the

cancer services and analysis of results. BHRUT considers this is much safer step by step approach for the consolidation. This will also ensure that the

current high clinical excellence offered by the 3 centre is not compromised and there will be minimal disruption to patient care.

Commissioners fully support patient choice for those in Essex requiring surgery to be treated at BHRUT.

Whilst acknowledging that the travel links to North Central London are restrictive, BHRUT is ideally situated to also provide services to the population

of East London such as Tower Hamlets, Hackney and Newham as part of the configuration of two new OG centres.

The catchment population for BHRUT will be extensive and will meet the requirement to deliver services to a population of 2 million.

A full suite of surgical options are available at BHRUT. These include:

• Reconstructive surgery such as gastric/colonic pull up. Reconstructions are undertaken at the Trust.


• Palliative endoscopy - stenting or Laser

• Each surgeon undertakes minimally invasive techniques.

Patients will receive pre surgery counselling from the CNS and supported by the Psychology department.

Anaesthetics

42





Part of

pathway

Summary of


Developments

necessary

data, etc.

• Rigorous

approach to

surgical

clinical trial

participation

• Systematic

data

collection,

including

capture of

outcomes

• Integration

with local

services and

oncology

services to

provide a

seamless

experience

for patients

The surgeons are supported by 3 dedicated Upper GI anaesthetists trained in thoracic anaesthesia. All are Critical Care Physicians as their background

specialty. This provides useful insight and active involvement in the whole perioperative pathway rather than limiting to Intra operative events.

There is clear benefit and advantage of having a dedicated Consultant Anaesthetic/ Intensivist team with a major interest for this specialty which

certainly contributes to excellent outcomes, improves patient experience and patient satisfaction.

All patients are seen by consultant anaesthetist prior to surgery and careful evaluation is made with regards to optimisation and fitness for surgery.

As a result there are no cancellations for lack of fitness or optimisation on day of surgery which is the result of excellent teamwork and

communication between the team.

The Anaesthetic Consultants make themselves available on a flexible basis and are so committed to the service that they will work during their annual

leave to prevent delay of the surgery. To meet the Goal Directed Fluid Therapy standards perioperative advanced monitoring, including advanced

cardiac output monitoring (LIDCO) is used to carefully titrate intravenous fluids in this group of patients.

Post operative period

Patients will be cared for in a ring fenced, 30-bedded, single-sex compliant, surgical ward facility.

The surgical patients will be supported by:

• On-site critical care facilities

• Critical Care Out-reach team

• Anaesthetic emergency out of hours service

• Acute Oncology Service

• Palliative Care team

• Allied Health Professionals and CNS such as Upper GI physiotherapist and nutritionist

• Enhanced Recovery CNS

Appropriate patients will also be reviewed by the nutrition team pre operatively and post operatively on a daily basis whilst an inpatient.

The Trust also has a plan in place for 7 day working for all support services that will maintain the therapy input at weekends for those whose surgery

takes place later in the week.

For patients that require a higher intensity of care there are 32 critical care beds at QH and a further 8 beds at KGH. Nursing staff ratios will be

reconfigured to support Level 1 patients being cared for within the inpatient ward if required.

Working relationship

Both surgical centres will work as a unified team using the same protocols and guidelines with each surgeon aiming to undertake at least 15 - 20

resections per year.

The Trust proposes a joint consultant appointment to provide an in-reach service undertaking cancer resections and to participate with the three

43





Part of

pathway

Summary of


Developments

necessary

Trust consultants in providing a 24/7 on call cover for Upper GI cancer patients. Surgeons will work in pairs and will also be job planned to provide

outreach sessions and attend diagnostic MDTs at local providers.

The specialist OG cancer MDT at BHRUT has considerable experience of providing seamless care. The learning for this has come from providing

specialist OG cancer services for Basildon. The challenges in teamwork, communication, transfer of information, co-ordination of whole pathway

across various sites were anticipated and encountered. Any barriers were overcome by working together as equal partners. This has emphasised how

close the working relationship must be with local MDTs as further reconfiguration takes place.

Examples of such joint working include; adoption of agreed operational policies and pathways, adoption of common language, continuous learning,

joint MDT, clinicians from the centre attending local MDTs, development of referral proforma, cross site joint working of all CNS , joint audit meeting,

regular study days, operational policy meetings as well as social events.

The recent discussions with stakeholder Trusts has emphasised this further. BHRUT believes local care for local people, closer to home whilst

achieving cutting -edge, “fit for the future” care. Travel to the centre is considered acceptable only when there is a good clinical reason for this. Our

vision is for clinicians to travel closer to patients, to attend and work with local MDTs. This is likely to ensure continuity, excellent satisfaction to

patients and crucially support the local/diagnostic MDT, especially the CNS. This retains and updates local expertise and prevents erosion of clinical

interest and skills in the diagnostic MDT. Any other model is likely to de-skill and take away expertise from large areas and will make provision of

complex benign OG emergencies difficult.

Moreover during survivorship, care closer to home becomes a priority for a postoperative OG cancer patient. These patients are usually frail and

elderly and often have an elderly carer. Frequent attendance may be needed for close support and A&E avoidance.

It is important for the local MDT to have a clear view of the whole care pathway otherwise there is a risk of silo working and gradual attrition of skill

will invariably deteriorate care. Just being kept in the loop is not sufficient, local MDTs must be full partners and will need to be empowered to

challenge OG cancer centre and hold the centre to account.

Clinical trial participation

One of the major visions of London cancer, UCLP and AHSN is to make the opportunity to be included in national trials to be available to all patients.

As the largest provider in London, BHRUT welcomes the opportunity. This is one area where not only the other centre in the ICS, but other cancer

services and local providers can collaborate. Nationally OG cancer clinicians have a rich tradition for doing this. The clinicians at OG cancer centre at

BHRUT have GCP training and currently actively recruiting in many NCRI (National Cancer Research Institute) trials. In particular BHRUT has recruited

into trials such as MAGIC, OEO2, OEO5, OEO3, and STO3. The Trust is part of OCCAMS group.

The Trust’s OG cancer centre has collaborated with Dr Rebecca Fitzgerald, Cancer Research UK and Cambridge University MRC cancer cell unit. This

group is developing a cytosponge test for Barrett’s screening for early detection of oesophageal cancer.

44





Part of

pathway

Summary of


Developments

necessary

BHRUT has embedded identification of individual potential trial candidate patient in regular MDM discussion.

BHRUT has a very large Barrett’s surveillance programme and has worked collaboratively with UCL for trials helping to recruit patients with Barrett’s

and high grade dysplasia.

Data collection

There has been a yearly audit programme for all OG cancer patients (including operated patients) auditing both process and outcome. There are

ongoing targeted audits in diverse areas such as; anaesthetic care, ITU, pain control, palliative care, endoscopic palliation, patient experience,

provision of patient information and quality of life. The centre has participated in NOGCA (National Oesophago-gastric Cancer Audit) from its

inception.

The team is developing a comprehensive governance framework which will be adopted in July. This will provide clinical and managerial governance to

ensure ongoing clinical and financial assurance for safety, quality and patient experience. The aim is to provide a listening service constantly updating

and learning from patient and staff feedback. This will include reporting of near misses and adverse events such as; unplanned return to theatre or

nosocomial infection anastomotic leak .A root-cause analysis to investigate a cancer breach is already in place and this will be extended to include

missed or delayed cancer. This will generate action plans to aid continuous improvement.

Sharing and learning from the other centre in ICS is crucial. Joint audit, governance and research programmes should be developed across ICS. To

achieve this, the Trust currently holds a monthly audit meeting to look at outcomes. In addition the Trust proposes a bi-monthly meeting with the

second specialist centre and local providers to audit and present each others surgical outcomes.

MDTs use pro forma-based reporting, that includes staging information. The MDT is supported by the Somerset database. Somerset has

comprehensive data fields which can support a wide variety of patient data. Examples of these include demographics, investigation results, cancer

stage, fitness, nutritional status, MDT discussion, decision to offer curative treatment, palliative treatment and key workers. Reason for non-curative

therapy is also recorded at the MDT on the Somerset system.

Data is collected live during the MDT.

All tumour staging at the point of treatment planning are entered onto the Somerset database using the TNM 7 staging system

The Trust compliance to staging data for Upper GI in 2012-2013 was 100%. This is the only MDT to achieve this among 38 trusts in the South East.

Locally integrated services providing care for the surgical patient.

In order to deliver an integrated care pathway the Trust will use its already established links with the following organisations to coordinate and access

services/support as required:


• Social services

• Acute Trusts

• Acute Trust laboratories as required


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Part of

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Summary of


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necessary



• NHS or independent Diagnostic Providers

The skills of collaboration and integration play an important role in patient care and the Trust will work with the wider health economy to refine and

improve current care pathways, encourage and develop innovative approaches to pathway management, ensure that services are delivered at the

convenience to the patient and not the provider.

The Trust strives to deliver services that increase efficiency and reduce delays. Adherence to the cancer care pathway is monitored by core members

within the Trust.

A strong interface between primary and secondary care services is vital to eliminate unnecessary delays. The Trust collaborates with other providers

as well as local GPs to share information and work jointly to ensure the patient pathway is delivered without delay and the patient is supported

throughout.

For those requiring diagnostics there will be choice of diagnostic facilities and patients will have access to a full suite of diagnostic services provided by

BHRUT. This will include state of the art radiology facilities providing MRI and CT scanning and 2 modern JAG accredited endoscopy suites each

available at QH and KGH. These services will be made available to any clinician who refers into the specialist MDT. MDT coordinators and CNS will

also monitor the access to additional diagnostics during their patients tracking meetings.

For those undergoing surgery pre-assessment services are initiated throughout the care pathway. For patients requiring the back-up of specialist

services such as anaesthetic or cardio-respiratory. The services at KGH and QH will be directly accessible. These services will ensure patients are fit

and ready for their procedure or advice when other treatments are required before surgery can safely take place. The Trust will also work in

collaboration with local providers in order that patients could access pre-treatment assessment closer to home where possible. The CNS network will

be instrumental in ensuring that appropriate information is gathered and available to the specialist centre in a timely fashion.

Patients are given practical and written information to plan how they will approach the challenges of treatment. Relatives/carers are also involved in

the preoperative process with particular emphasis on the provision of nutrition. Written information and the contact number of the die titian are

provided.

At MDT the dietician and clinicians will asses the need for tube feeding. Where tube feeding is required prior to the start of treatment rapid access to

endoscopy for insertion is in place.

Post

treatment

• Provision for

timely

discharge

and liaison

Discharge

Same day electronic discharge summaries for patients and their GPs are already implemented within the Trust. For patients diagnosed with cancer

during a hospital admission, a discharge summary will be received by the GP within 1-3 working days post discharge. This is communicated via secure

email.

The specialty will

develop an electronic

end of treatment

summary to be

provided to any

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Part of

pathway

Summary of


Developments

necessary

with local

units,

primary care

and local

rehabilitatio

n services

• Prompt

provision of

comprehens

ive

discharge

information

following

completion

of treatment

in line with

national

standards

• Process in

place to

enable a

patient’s

rapid

readmission,

if necessary

When discharged from clinic a hard copy of the clinic letter is sent via the post within 3-5 working days.

All treatment decisions and post treatment summaries are entered onto Somerset and sent to GPs.

All dietetic services are provided by NEL CS. On discharge there is ease of handover between clinicians that work in the same team, or the patient may

keep the same dietitian throughout the pathway. Where handover is required to other teams this is already provided. Each patient has a 6-12 month

plan for follow up. Good communication links currently exist between SLT and Dietetic colleagues across organisations. Discharge from the Trust’s

specialist centre is direct to community based services. For patients requiring social care this is coordinated by the CNS.

The Trust will make arrangements that the referring hospital will be provided with details of discharge.

Carer information from CNS and AHPs is currently provided on discharge.

Follow up clinics

Follow-up of patients adheres to published guidelines.

Post operative follow up clinics are held within one week of discharge where x-ray and blood tests are arranged. The CNS will also agree with the

patient the frequency of further follow ups once full histology is known.

Arrangements will be made to provide an OG Consultant out-reach follow up service from this specialist centre.

Patients are followed up by their oncologist as per Network guidelines. Each patient will receive an End of Treatment summary following their

treatment and the necessary information on living with and beyond cancer.

The CNS will support the patient at these appointments and will liaise with community services to ensure that the patient has the correct level of

rehabilitation support.

All patients will continue to undergo holistic assessment at diagnosis and throughout their pathway, supported by the specialists in cancer

rehabilitation such as specialist Physiotherapy (PT), Occupational Therapy (OT), Speech and Language Therapy (SLT) and the on-site Palliative Care

team.

The CNS will also arrange for follow up support at local providers where necessary.

Band 7 dietitians specialising in oncology provide follow up advice for the upper GI patients. The dietetic service provided by North East London

Community Services provides continuity across the pathway regardless of setting. The services have sufficient resource to provide assessment and

treatment during follow up clinics and in the community. For patients who have undergone radiotherapy reviews are provided weekly. Patient’s

weight will be monitored for those undergoing chemotherapy and followed up accordingly.

Different patients will have differing needs therefore the follow up support from AHPs will be tailored accordingly. An assessment will be made as to

referring provider and

the patient’s GP.

The Trust recognises

that with additional

referrals further

investment in dietetic

and SLT at band 7 will

be required to support

attendance at all key

points in the patients’

pathway. This has been

presented to the Trust

Board. This will also

strengthen adherence

to the NCAT

rehabilitation pathway

from the start of a

cancer diagnosis being

made.

There would be a

recruitment process in

partnership with North

East London

Community Services.

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whether this can be delivered local to home or requires ongoing input from the Trust’s specialist centre. This will include ongoing psychological,

physical and social care and will follow the NCAT rehabilitation guidelines for OG cancer patients.

The Trust provides GPs with details of the primary care follow-up required for the OG cancer patients and clear instructions for how to re-access

secondary care, if this becomes necessary.

Co-ordinated by the CNS, the Trust will make arrangements for patient follow-ups to take place at their local provider where possible.

Physiotherapy will offer a 7 Day follow-up service whilst a surgical inpatient. Patients will be seen 2-3 times daily (as clinically indicated) by specialised

UGI Physiotherapist until discharge. A personalised home exercise programme will be provided upon discharge to every patient with the ability to

contact specialised physiotherapist for additional support. Post discharge review/follow-up as an outpatient will be available to reviewing exercise

ability and advice on limitations, with or without cardiovascular assessment. Post-operative rehabilitation classes will be available for identified

patients. All patients referred into the surgical specialist centre will be able to access this service.

The CNS will also coordinate follow up care from a wide range of providers should there be a need:


• Social services

• Acute Trusts




There is a ‘Buddy’ system in place for patients prior to treatment surgery and information leaflets are provided. There is also an active monthly

support group run at the Trust. This is chaired by the CNS and has consultant support.

Rapid readmission and A&E avoidance

There is a process in place for rapid access to advice or re-admission if necessary. This process avoids attendance to A&E. The Trust has recently

implemented a Surgical Assessment Unit that enables GPs to make a referral for immediate assessment. The surgical ‘hot-clinic’ runs alongside the

assessment unit. This can also be used for assessment for those who may require an emergency attendance. This facility has been shown to be of

great success in the surgical pathways and patient satisfaction levels have been extremely high. There are ring-fenced beds within this facility. GPs can

directly contact the on call team for advice when required. The nursing team has just received a Trust award for delivering this high quality service and

the Clinical Director was invited to share the learning at the annual dinner of the Local Medical Committee (LMC) of primary care physicians.

Local GPs regularly access these services in order fast track assessments and interventions. There are also patient initiated contacts. These services

are widely advertised for an expanded patient group in order to provide the specialist input at critical periods.

The Trust has recently invested in additional surgical consultant posts that will now provide further support to the Upper GI on call rota. 7 day working

is in place for surgical consultants on the QH site.

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Part of

pathway

Summary of


Developments

necessary

A triage telephone service is available at the hospice for advice from the oncology community team. Patients have direct access to this service and can

also access the CNS in-hours or the oncology ward at the Trust out of hours.

A patient Passport System has been in situ for some time within the Trust for those who are undergoing or have undergone treatments within the last

6 weeks. This will enable a fast-track assessment or admission. During working hours patients are seen in the assessment beds within the

chemotherapy day unit to avoid any unnecessary waits in A&E. There are also ring fenced beds within the specialist oncology ward for out of hour

admissions.

Acute

oncology

• Full acute

oncology

service that

meets Peer

Review

standards

There is an excellent Acute Oncology Service (AOS) within BHRUT, supported by the clinicians and 3 dedicated AOS Nurses, all of which work an 8am –

8pm rota. This is set to become a 7 day a week service with the recruitment of 2 further nurses. The chemotherapy day unit provides acute

assessment beds in order to support the AOS.

There are 8 consultants of which 2 are dedicated AOS leads. All consultants have dedicated time in their job plans. Administrative support for this

service is in place. This service was assessed in November 2012 as fully compliant with peer review standards.

This service has been nominated for a national award run by the NURSING TIMES for developing an outstanding oncology service.

All patients attending A&E are flagged by the A&E staff to the AOS service. The Trust is currently looking at extending the use of the A&E Symphony

system to introduce an electronic flag.

Clear guidelines are in place in A&E on the management of neutropenic sepsis and metastatic spinal cord compression. A patient Passport System has

been in situ for some time within the Trust for those who are undergoing or have undergone treatments within the last 6 weeks.

During working hours patients are seen in the assessment beds within the chemotherapy day unit to avoid any unnecessary waits in A&E. There are

also ring fenced beds within the specialist oncology ward for out of hours admissions. There are excellent links with the OG and Palliative Care service.

Contact details of all OG cancer unit staff are available in the emergency department. The Upper GI clinicians can directly refer to the AOS and

palliative care service.

The AOS is also in the process of developing inpatient beds into a 24/7 assessment unit so that acute oncology patients do not have to attend A&E

and can be fasted tracked straight to the Oncology ward for assessment.

An AOS operational policy which includes policies for managing oncological emergencies is available on the Trust intranet. Printed copies are

available in A&E. These describe protocols on the management of patients presenting as emergencies. An annual audit of neutropenic sepsis is carried

out.

Pathways and protocols also exist for the management of patients presenting as emergencies as a consequence of non-surgical treatment i.e.

neutropenic sepsis, treatment related pain, dysphagia and dehydration. The protocol requires the notification of the AOS when a cancer patient

presents and is admitted as an oncological emergency. In hours, the CNS is the first point of contact and the on call member of the AOS is contacted

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Part of

pathway

Summary of


Developments

necessary

out of hours. The CNS ensures that a holistic needs assessment is completed and referral made to the appropriate specialist.

With the recruitment of additional oncology nurses a dedicated training programme will be established for A&E and medical staff on the management

of these emergencies.

Palliative

care

• Clear

referral

pathways

for patients

with

palliative

and

specialist

palliative

care needs

The Trust has end of life support in place with patients accessing the Liverpool Care Pathway where appropriate and symptom control is achieved with

the support of the Acute Oncology team, Palliative Care team and the Acute Pain team. District Nurses within the primary care setting also support

the discharge of patients.

Referral forms are available to all staff and GPs have direct access to palliative care telephone numbers. Protocols are available on the Trust Internet

for the management of end of life care and complex symptom control.

There are two full- time and one part -time consultant, supported by 7 CNS posts, dedicated to palliative care. There is a 24/7 palliative care

consultant service available. This service provides and advises on complex symptom control and will shortly deliver a programme to extend cover at

weekends.

There is clear referral guidance available in the Trust for management of end of life and all internal referrals are seen urgently within 24 hours.

The Specialist Palliative Care team is linked with the community services; St Francis or St Joseph’s Hospice for care in community. A triage telephone

service is available at the hospice for advice from the oncology community team.

Patients have direct access to this service and can also access the CNS in hours or the oncology ward out of hours.

The Palliative Care MDT is fully established. There are domiciliary visits and there is cross-working and provision of on-call palliative care services with

St Francis Hospice.

Research

and

innovation

• Access to

multidiscipli

nary

oncology

service

including:

tissue

BHRUT has a well-staffed Research and Development unit that is supported by clinical research assistants and specialist research nurses. The team

supports trials led by the specialists as well as Oncologists. There is also a research dosimetrist for the radiotherapy trials.

BHRUT was selected as a Green Shoot research site by the NCRN in December 2011.

The Trust has established policies providing staff guidance that cover clinical activity and the governance framework.

The diagram below demonstrates the governance structure for Research and Development and Audit.

50





Part of

pathway

Summary of


Developments

necessary

banking,

clinical trial

research,

and research

nursing

Part of pathway Summary of specification Proposal Developments necessary The patients are screened at the MDT and in the oncology clinics as to whether they are eligible for a trial. Patients have access to a number of NCRN

and commercially sponsored trials.

The Trust has a robust, computerised in-house data collection system to record patients screened. Details are entered into registered randomised

trials. BHRUT has participated in Research Network wide research audits and is currently participating in the prospective A&E audit with London

Cancer.

Representatives attend the NCRN quarterly Research Steering Committee where recruitment figures are compared with the other centres in NE

Thames and lately North Central.

The Trust will continue to access tissue banking through the NCRN.

The Trust participates in London Cancer audit programmes and National Audits.

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Part of

pathway

Summary of


Developments

necessary

In addition the Trust currently participates in cervical screening, bowel cancer screening and breast screening programmes.

BHR Cancer Trials has now been appointed as a Prime Site for cancer trials with Quintiles Ltd. This means that for all cancer trials, including OG trials,

that they will receive funding from commercial pharmaceutical companies, BHR will be among the first sites to be approached to take part. This is

expected to increase the level of commercial trials activity at BHR and offer our patients more choice on trial therapies.

One of the major visions of London cancer, UCLP and AHSN is to make the opportunity to be included in national trials to be available to all patients.

As the largest provider in London, BHRUT welcomes the opportunity .This is one area where not only the other centre in the ICS, but other cancer

services and local providers can collaborate.

Nationally OG cancer clinicians have a rich tradition for doing this. The OG clinicians at the Trust have GCP training and actively recruit into in many

NCRI (National Cancer Research Institute) trials. In particular BHRUT has recruited into trials such as MAGIC, OEO2, OEO5, OEO3, and STO3. OG

cancer centre is part of OCCAMS group.

The OG department has collaborated with Dr Rebecca Fitzgerald, Cancer Research UK and Cambridge University MRC cancer cell unit. This group is

developing cytosponge test for Barrett’s screening for early detection of oesophageal cancer.

BHRUT has embedded identification of individual potential trial candidates in regular MDM discussion.

BHRUT has a very large Barrett’s surveillance programme and has worked collaboratively with GPs and UCL for trials helping to recruit patients with

Barrett’s and high grade dysplasia.

Education and Training

Education and training has been an integral part of daily work of the centre.

Specialist higher surgical training positions have been hugely popular and competitive over a long period among the higher trainees in London

Deanery. This is due to the quality of training and available surgical workload of complex patients. The lead for OG cancer has received the prestigious

Silver Scalpel award for excellent training provision. The OG cancer centre attracts senior trainees, usually in the final years of their training. These are

the surgeons of the future. Over recent years a large number of them have been appointed across London and broader afield after acquiring their

expertise in this busy OG centre.

Surgeons and other clinicians regularly teach in specialist national courses and participate and presents in national and international meetings, both

as delegate as well as faculty. They all maintain membership of specialist associations including AUGIS and ALS.

In order to ensure that staff are appropriately trained to communicate with patients on the cancer pathway, all current key members of the Trust’s

clinical staff, including therapists, have obtained certificates of attendance on Advanced Communication Skills training and the Trust will maintain

access to the Advanced Communication Skills training, supported by St Francis Hospice. In addition, facilities are in place to run in house training

sessions to wider members of the cancer team.

All staff access to funding for courses through the Education department. This will include Upper GI specific courses. Training needs and personal

52





Part of

pathway

Summary of


Developments

necessary

development is identified during clinical supervision and at time of appraisal. Training for dietitians to become level 4 specialist s is available.

Patient

travel

• Informs

patients of

support

available for

travel to

specialist

centre and

radiotherapy

units

The Trust will meet patient requirements for provision of non-urgent transport through BHRUT’s contracted Non-Emergency Patient Transport (NEPT)

and Emergency Medical Technician (EMT) Services. G4S, the leading provider of patient transport services, is working in partnership with BHRUT to

meet the needs of the patient and GPs with a 24/7 operational service available 365 days of the year. There is a fleet of 29 vehicles operated by 83

professional, qualified, experienced staff. The service is an integrated part of the patient’s clinical pathway. G4S and their staff take great pride in the


The Trust will reimburse allowable patient transport costs on the day where relevant.

The specialist team will Inform patients of support available for travel to the departments serving the cancer centre.

There is dedicated finance assistance available for patient s to help complete their benefits application for travel costs. The Trust’s Cancer patients are

also supported by a Citizens Advice Bureau worker with two dedicated information centres that provide all of the necessary patient information,

specific to their condition.

For those patients eligible and requiring transport, the Trust also provides free parking for patients undergoing Chemotherapy and Radiotherapy. Free

parking will be available for all cancer patients undergoing treatments regardless of their home address.

For patients who prefer to use public transport, both hospitals are well served by local transport links. There are also are currently discussions taking

place with Transport for London to further enhance bus routes and with the local council to further increase car parking facilities particularly at the

QH site.

The Trust will arrange overnight accommodation for patients that require accommodation close to the hospital.

improving services for upper gi og cancer application ...€¦ · 7 the mdt believes care closer to...

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