8.4.1 Quality and safety
The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report raised concerns about the quality and safety of systemic anti-cancer therapy (SACT). The model of acute oncology has been proposed in response to these concerns. The 2009 National Chemotherapy Advisory Group (NCAG) report identified a need to extend the availability of emergency assessment and treatment for cancer patients suffering side effects from systemic treatments.88
Policies and protocols should be in place for the oncological assessment of cancer patients who present at accident and emergency (A&E) with the symptoms of their disease or the side effects of SACT. These protocols should be readily accessible and cover managing complications seen in the emergency department (for example neutropenic sepsis), training senior and junior doctors from medical specialties in acute oncology, and processes for ensuring rapid referral and assessment (including treat-and-transfer, where appropriate) by an oncologist and other members of the acute oncology team. Each acute oncology team should have named permanent members of the rehabilitation professions and good links with palliative care.
The NCAG report concluded that all hospitals with emergency departments should establish an acute oncology
service to bring together the necessary expertise from emergency medicine, general medicine and oncology.
Medicines to control the adverse symptoms of chemotherapy are now much
improved. The use of symptom control, combined with better patient education about symptoms and 24-hour access to advice, should make emergency admissions due to side effects of treatment a rare event. The establishment of proactive telephone support to identify possible problems before they become serious should be considered. Patients with known cancer should have access to advice 24 hours a day. If problems arise, the aim should be for the acute oncology team to manage patients in an ambulatory care setting without the need for admission.
Acute oncology services in hospitals with an A&E service would be ideal settings to provide 24-hour acute oncology telephone advice lines and ambulatory care settings where adverse side effects of SACT can be treated. As acute oncology services would have 24-hour cover by the in-house oncology team and access to inpatient cancer beds when necessary; this model would provide high quality, safe care. The Department of Health’s Manual for Cancer Services states that the
chemotherapy group in each current network should agree a list of acceptable chemotherapy regimens for the network, which should be updated annually.89
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National Chemotherapy Advisory Group, Chemotherapy Services in England: Ensuring quality and
safety, 2009
This is to prevent individual practitioners having non-standard practice that does not
correspond to that used across the network. London’s provider networks should comply with this requirement and agree lists of regimens that have been
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commissioned for use in the tumour site and disease stage, and for which funding has been agreed.
8.4.2 Service delivery
The 2009 NCAG report also recommended that inpatient delivery of SACT should be minimised and that services should be provided closer to a patient’s home, where clinically appropriate.90
Advances in drug therapies mean that many cancer patients no longer have to stay in hospital as inpatients. With the exception of complex haematological treatments, almost all chemotherapy treatments could be delivered in an ambulatory care setting and some patients can even take oral medication at home.
Care close to home reduces travel times for patients at a time when they often feel unwell, leading to improved patient experience. It could also make them more prepared to accept the treatments recommended.
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Delivering treatment closer to home must be a clinical decision based on a risk assessment. The risk should be assessed as a combination of the complexity of delivery and the status of the patient. It is likely that a simple regimen may
sometimes need to be administered at a specialist centre if the patient requires other medical support or complex supportive care.
To provide high quality care close to home, satellite services should be set up and linked to a central unit in the provider network. The provider network as a whole should ensure governance of quality and safety. The provider network should ensure that protocols and pathways are in place to enable standardised care and smooth transfers across settings. This will include protocols for the transfer of patients to a networked acute oncology service in the event of an acute situation arising. Provider networks will also allow flexible working of clinical staff across community and central settings as well as the establishment of appropriate communication systems (in real time) to support this model.
Satellite services could include outreach teams to enable treatment at home. NHS Bristol is currently piloting a scheme providing nurse-administered chemotherapy at patients’ homes as part of their drive to give people more choice about where they receive their treatment. Strong consideration should be given to whether providing treatment at home is an efficient use of resources. In this instance, the community setting would allow provider networks to provide high quality care closer to home while using resources efficiently.
The availability of clinical information is critical to localising SACT delivery. It will be essential that all points in the pathway have the relevant information available in real time, 24 hours a day. This information should include multidisciplinary team
outcomes, e-prescribing (at sites where chemotherapy is not given a view only
access would still be needed), records of administration (including presence or not of central line access), the patient’s clinical management plan, and the availability of
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National Chemotherapy Advisory Group, Chemotherapy Services in England: Ensuring quality and
safety, 2009 91
diagnostic imaging through PACS (picture archiving and communication system) wherever the patient is treated.
It is also important that data relating to chemotherapy are collected systematically. A minimum dataset for chemotherapy is being developed (likely to be implemented in 2012) so that all areas where SACT is prescribed, dispensed or administered would need to have systems in place to collect and submit the data.
8.4.3 New drugs
Londoners should have equal access to clinically appropriate and cost-effective treatments that cancer clinicians are able to prescribe. To achieve this, the role of the London Cancer New Drugs Group should be strengthened to ensure that its recommendations are adopted by commissioners.
The London Cancer New Drugs Group would be supported by the work of the newly formed pan-London new medicines and treatment project in Commissioning Support for London, the organisation set up to provide clinical and business support to NHS commissioners across London. The project will identify and evaluate options for a London-wide approach to horizon-scanning and prioritisation, supporting PCTs to manage Individual Funding Requests (IFRs). The project will also identify
processes to support medicines and treatments disinvestment and decommissioning and promoting prescribing cost-effective medicines and treatments in primary care and acute trusts.
The expected benefits of the work of the project include: • Less variation to minimise costs and complaints
• High quality and timely decisions to reduce IFR pressures • Centralised monitoring, learning and horizon scanning
• The potential for decommissioning with more funding available for genuine innovation.
Key recommendations:
All hospitals with emergency departments should establish an acute oncology service to ensure the appropriate early assessment of cancer patients presenting as an emergency.
Inpatient delivery of SACT should be minimised. Satellite services should be set up and linked to a central unit in the provider network to provide treatment closer to home where clinically appropriate.
The community setting should be considered by provider networks to provide high quality care closer to home.
The role of the London Cancer New Drugs Group should be strengthened to ensure that its recommendations are adopted by commissioners.