Agenda Item 8b

Achievement of Revised Cancer Waiting Times Standards

1.Introduction

This paper provides an update on performance against the Cancer Waiting Times Standardsand the plan to improve and ensure compliance with the revised waiting times standards in accordance with the Cancer Reform Strategy as part of “Going further on Cancer Waits”. In particular the paper details the challenges identified with the implementation of the new standards that came into force from 1stJanuary 2009, together with the new rules on the measurement of cancer waiting times which change the way patient choice and deferrals for medical reasons are reflected in the time waited by a patient. Whilst the definitive thresholds for the new cancer standards and associated changes to waiting times have not been published, the National Cancer Action Team have provided some benchmarking information, which are detailed in this paper and are being used as a working standard in the interim.

2.Background

The NHS Cancer Plan in September 2000 introduced specific cancer waiting times standards. The first of these standards was the maximum wait of two weeks for patients to be seen by a specialist following referral by their GP with a suspected cancer (2-week wait). Secondly, where a cancer is diagnosed, following the urgent referral by a GP, patients should wait no longer than two months (from the date of the initial decision to refer) for the treatment to commence (62-day target).As not all cancers are diagnosed via urgent referral for a suspected cancer,the third standard that was introduced in the Cancer Plan was that all patients should wait no longer than one month following agreement to treat the cancer, through to the commencement of treatment, irrespective of the initial route into the service, e.g. as an emergency admission or via a routine outpatient appointment.

2.1.Changes to the standards from 1st January 2009

In the Cancer Reform Strategy published in 2007, it was recognised that the 2-week wait, 62-day and 31-day target only applied to a limited number of patients in that the standards only applied to first cancers and for the 2-week wait and 62-day target only included urgent referrals made be GPs. As part of the Cancer Reform Strategy two significant changes to the cancer waiting times standards came into effect in January 2009.

1)The first change was to increase the categories of patients included within the 31 and 62-day standards. From 1st January 2009, any patients who are found to have a suspected or confirmed cancer identified via any of the three national cancer screening programs (Breast, Bowel and Cervical) should now receive their first treatment within 62 days of a referral being generated from their initial investigation within the screening program. In addition consultants working within the organisation can choose to ‘upgrade’ patients they suspect may have a cancer, so that they are managed along with GP and screening referralsunder the 62-day standard. The scope of the 31-day standard has also been expanded to include all phases of treatment, for example, where chemotherapy is given ahead of surgery and also for non primary cancers, i.e. recurrent or metastatic disease. All treatment types will be included in this 31-day standard. However there is a national recognition that radiotherapy services will take longer to increase capacity and as such the target does not become operational until December 2010 for those patients receiving radiotherapy other than for first treatment.

2) The second change to the waiting times standards relates to the way in which we measure the length of time a patient has waited.This change was made to bring cancer waiting times measurement in line with the national rules for 18-week Referral to Treatment time measurement. From the 1st January 2009 it is no longer possible to adjust for a patient’s decision to wait longer for an outpatient appointment, diagnostic test or any treatment carried-out in an outpatient setting. Similarly, time cannot be taken out of a patients total waiting time to reflect periods when they were not medically fit for treatment (e.g. if a patient has heart problems and cannot undertake surgery without further management of their condition). The only permissible adjustments to the waiting times that can now be applied are to reflect:

  • The period when a patient was not able to be seen following their failure to attend their first appointment following a suspected cancer referral (two week wait)
  • The patient choosing to delay their treatment if being delivered in the inpatient setting (e.g. choosing to delay the date for their admission for surgery)

3.How will performance against these new standards be managed by the Healthcare Commission and Monitor?

As mentioned in the opening part of this paper, the Department of Health has not yet confirmed the operational thresholds for the 31, 62-day or the 2-week wait waiting times standards. However, indications have been given that nationally, performance for the three targets is expected to be in the region of the following:

  • 93% for 2-week wait (formerly 98%)
  • 86% for 62-day target (formerly 95%)
  • 98% for 31-day target (no change from previous threshold)

The Healthcare Commission will assess performance against the 31 and 62-day standards by way of two indicators: a) performance under the ‘Existing’ standards for quarters 1-3; b) performance against the new standards with the application of the new rules for waiting times measurement for quarter 4. Performance against these two indicators will be combined to create a single score which will determine whether each of the 31 and 62-day targets was ‘achieved’, ‘under-achieved’ or ‘failed’. Performance figures for each of the ‘Existing’ standards during quarters 1-3 have already been submitted to the Department of Health. For this part of the combined target the Trust is expected to have ‘underachieved’ the required standard for the 31 and 62-day targets, although for the 31-day target this is still subject to confirmation due to lack of clarity over whether the 97.6% performance will be rounded-up to the required 98%.

Within Monitor’s Compliance Framework there are two sets of targets for both the 31 and 62-day targets, with the new standards replacing the ‘Existing’ from the 1st January 2009.

4.Operational Challenges

During the first three quarters of 2008/2009 the Trust encountered difficulties in achieving the former (‘Existing’) 31 and 62-day standards. However, the change to the standards and the way waiting times are measured has brought new challenges which need to be identified and managed afresh. Analysis has therefore been undertaken of the first month of data (i.e. January 2009. From this some common themes are emerging, some of which where previously present for the Existing standards and for which actions have already been taken, some of which are new. It appears at this stage though that the main challenges are limited to a small number of specialties and are not spread across the whole range of tumour sites for which the trusts provides cancer services.

4.1Analysis of performance against the new standards under the new rules

1) Two-week wait - No patient should wait longer than two weeks to be seen for their first appointment following referral from their GP

Old Threshold for ‘Existing’ standards / Expected Threshold / Quarter 1 – 3 performance under ‘Existing’ standards / January 2009 performance
98% / 93% / 99.7% / 89.9%

Figure 1 – Reasons for patients waiting longer than the 2-week to be first seen by a specialist during January 2009

During January, 396 suspected cancer referrals were received from GPs, of which 34 patients choose an appointment outside of the 14 days to which an adjustment to the waiting times can no longer be applied. This adversely affected performance reducing performance to 89.9%. During the same month there were 2 breaches resulting from internal delays, i.e. lack of capacity for an appointment to be offered within 14 days. Under the ‘old’ rules performance would have exceeded 99%.

2) 31-day standard –No patient should wait longer than 31 days for treatment following the decision to treat

Old Threshold for ‘Existing’ standards / Expected Threshold / Quarter 1 – 3 performance under ‘Existing’ standards / January 2009 performance
98% / 98% / 97.6% / 97.2%

Figure 2 – Reasons for patients waiting longer than the 31 days for treatment, following the decision to treat, during January 2009

During January, 213 patients received treatment (165 for first definitive; 48 for subsequent treatment) against the new 31-day standard. Of these, 6 patients received their treatment outside of the 31-day standard, 1 of which for medical reasons, which could not be adjusted for, and 4 due to lack of theatre capacity. One further reason for breach is under review. Performance is currently close to the expected required standard of 98%.

3) 62-day standard - No patient should wait longer than 62 day following an urgent GP referral,consultant upgrade or referral via a national screening program

Old Threshold for ‘Existing’ standards / Expected Threshold / Quarter 1 – 3 performance under ‘Existing’ standards / January 2009 performance
95% / 86% / 93.4% / 82.3%

During January 70.5[1] patients received treatment against the 62 day standard, of these 12.5 (15 cases) received their treatment outside of the standard.Delays caused by the Trust included the inability to offer an outpatients appointment in a timely manner, to enable onward planning of treatment, and the inability to schedule surgery within the target time. In addition to theseinternal delays, 5 patientscould have been treated within target but chose to wait for later dates for outpatient appointments and diagnostic tests.As it currently stands the threshold for this standard is such that avoidable delays have to almost be eliminated in order to consistently achieve the 86% target, due to the volume of patients that choose to wait longer or are not fit to proceed to treatment, which previously we could have made adjustments to the waiting times to account for.

  1. Key actions to achieve improvement and sustainability:

It is clear that whilst the changes to the waiting times measurement and the inclusion of more patients under the 31 and 62-day standards has had a significant negative impact on the reported performance, there are still underlying themes which were present during the first three quarters if the year. Throughout the year, work has been undertaken to improve performance against the ‘Existing’ cancer standards, including changes to the management of beds to improve the throughput of thoracic (lung) capacity, and improvements to the management of pathways for patients with skin cancer. These changes have begun to have an effect and will continue to reduce the breaches of standard over coming months. However, the Trust has also developed a comprehensive action plan to support specifically the delivery of these new cancer standards, recognising that challenges remain and have been added to by the changes in the waiting times measurement rules. The table below identifies deliverables and time scales for the high impact actions within the action plan.

Action / Impact / Delivery date
1. / Aim to offer all patients referred via the suspected cancer route the opportunity of an appointment within 7 days / Decrease the effect of patient choiceby enabling patients to cancel and re-book appointments still within the required 2 weeks / June 2009
2. / Work collaboratively with NHS Bristol to fully implement Choose and Book for suspected cancer referrals across the health community / Improve the quality and timeliness of suspected cancer referrals / Pilot to start July 2009
3 / Work collaboratively with NHS Bristol to agree a local policy for the management of patients who do not wish to receive their first appointment within 14 days / Ensure patients are referred knowing they will receive an appointment within 14 days and improve the performance against the 2-week wait standard / June 2009
4 / Review the outpatient capacity for all specialities identified from breach analysis as being at risk of insufficient capacity (colorectal, Urology, lung) / Reduce the length of the pathway before a patient reaches a decision to treat to increase the number of patients being treated within 62-days / April 2009
5 / Ensure all specialities have the required theatre capacity to offer a treatment time within target / Reduce the length of the pathway from decision to treat to treatment, increasing the number of patients that will be treated within both 31 and 62-day targets / April 2009
6 / Redesign pathways to ensure all patients to reach a decision to treat by day 41 / Remove all unnecessary delays from the patient pathway, ensuring appropriate time available to plan care
Reduce the length of the pathway before a patient reaches a decision to treat to increase the number of patients being treated within 62-days / June 2009
7 / Re-affirm and reinforce via regular feedback, the tertiary referral process and timeliness by which referrals should be received from other trust / Improve the length of time in which we have to plan and deliver treatment
Reduce the length of the pathway before a patient reaches a decision to treat to increase the number of patients being treated within 62-days / June 2009

Prepared by: Teresa Levy (Cancer Service Manager)

Xanthe Whittaker (Head of Performance Improvement)

Presented by:Irene Scott (Chief Operating Officer)

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[1]Under national ‘accountability’ rules patient referred from other trusts for treatment are count as 0.5 patients in the total treated and total breaches, reflecting the role the referring trusts should play in the management of the pathway to the national standards.