225 - Agenda Item 6.5 - The Establishment of Satellite Radiotherapy Facilities in North Merseyside

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225 - Agenda Item 6.5 - The Establishment of Satellite Radiotherapy Facilities in North Merseyside Powered By Docstoc
					                             Briefing Paper for PCT Boards
          The Establishment of Satellite Radiotherapy Facilities in North Merseyside




1. Summary

This paper seeks PCT Boards’ approval of the proposed expansion of radiotherapy
services in Merseyside and Cheshire through the development of satellite radiotherapy
services based at two locations north of the River Mersey.

The investment will significantly benefit cancer patients across Merseyside and Cheshire
by providing better access to radiotherapy services through increased capacity and
reduced travel times.

This development will enable the NHS in Merseyside and Cheshire to meet the key
recommendations for radiotherapy services described in the Cancer Reform Strategy1
and the ministerial report by the National Radiotherapy Advisory Group.2

Clatterbridge Centre for Oncology NHS Foundation Trust (CCO) has identified a location
on the Aintree Hospital site as the preferred position for the first new facility. The satellite
facility will be owned, funded and managed by CCO.

At a meeting of Merseyside and Cheshire PCT commissioners on 21st January, 2008,
this proposal was endorsed in principle subject to discussion with PCT Boards.

PCT commissioners also proposed in principle to support a second satellite centre north
of the River Mersey, subject to discussion with PCT Boards. These proposals was also
received and endorsed by the Cancer Network Taskforce on 23rd January, 2008.

The preferred location for the second facility is within the grounds of the Royal Liverpool
University Hospital, which would support proposals to develop a Cancer Research
Centre in association with the University of Liverpool and Cancer Research UK. It is
proposed that the establishment of this satellite will be funded by Liverpool and
Knowsley PCTs in acknowledgement of the high morbidity and mortality of their
populations and the ease of access to services at the Royal for those populations.

Increased access to radiotherapy for individual PCTs’ populations will be funded on a
usage basis by each PCT as outlined in the Cancer Reform Strategy and the North West
Cancer Plan




1
    Cancer Reform Strategy, Department of Health, December 2007
2
    ‘Radiotherapy: Delivering a World Class Service for England’, NRAG, February 2007

The Establishment of Satellite Radiotherapy Facilities in North Merseyside:
Board Meeting 11 March 2008                                                                1/10
Wirral PCT                                                                             Agenda Item: 6.5
                                                                                       Ref: W07-08/225

These proposals need to be discussed by PCT Boards, and with PPI Forums/Links and
Overview and Scrutiny Committees taking into account the views of the public. Public
representatives on the cancer taskforce are supportive of the proposals.




2. The Rationale for Developing Satellite Radiotherapy Services

Clatterbridge Centre for Oncology NHS Foundation Trust provides radiotherapy services
for cancer patients from its base on Wirral. It serves a population of 2.3m across
Merseyside and Cheshire and the Isle of Man.

The majority of radiotherapy treatments are delivered using Linear Accelerators (linacs),
of which there are currently nine at CCO.

The proposal to develop satellite radiotherapy services (i.e. new radiotherapy facilities
remote from the main site at Clatterbridge) is driven by a need to improve the experience
of patients by:

      a) improving access and reducing traveling times for patients

           National recommendations state that no patient should travel for more than 45
           minutes for radiotherapy3. Presently, two thirds of cancer patients treated at
           Clatterbridge live north of the River Mersey and a significant proportion of those
           from the North and North East end of the Cancer Network exceed the
           recommended maximum travel time. These patients are required to make daily
           trips for several weeks to receive the doses (or ‘fractions’) that make up their
           treatment. Currently 37% of the target patient group face a journey longer than
           45 minutes. This will fall to less than 4% following the satellite development.


      b) Providing the scope to increase treatment capacity

           The current waiting times at CCO (an average of 17 days) are understood to be
           amongst the shortest in the country. However, the demand for treatments will rise
           significantly as the number of patients with cancer is set to rise sharply over the
           next 15 years.4 Most of this increase is due to the ageing of the population,
           although the age-standardised rates for several cancers also continue to rise. A
           recently published study predicted a 33% increase for England5 which is similar
           to a local estimate of 37%. The Cancer Reform Strategy has also announced the
           introduction by December 2010 of new waiting times targets relating specifically
           to radiotherapy treatments.6 Specifically the standard for radiotherapy treatment
           will be within 31 days by 2012 where this is a second or subsequent treatment.

3
    ‘Radiotherapy: Delivering a World Class Service for England’, NRAG, February 2007, para 75
4
    Shack L et al., Cancer Incidence Projections in the North West, NWCIS, June 2007
5
    Moller et al., British Journal of Cancer (2007), 96 1484-1488
6
    Cancer Reform Strategy, Department of Health, December 2007, chapter 4 page 57

The Establishment of Satellite Radiotherapy Facilities in North Merseyside:
Board Meeting 11 March 2008                                                                       2/10
Wirral PCT                                                                    Agenda Item: 6.5
                                                                              Ref: W07-08/225

         Currently other than where radiotherapy is a first treatment after diagnosis, where
         the standard is 31 days, there are no standards other than for those patients
         referred urgently under the 62 day rule.




The development of satellite radiotherapy services would enable the NHS in Merseyside
and Cheshire to deliver both increased capacity and improved access.

It is proposed that each satellite would house three linacs. By providing a total of six
linacs sited north of the River Mersey, the current demand for radiotherapy treatments
for all North Mersey patients could be catered for. (A small number of patients will have
to travel to Clatterbridge for rare and/or complex treatments.) It is proposed that six
machines would remain at Clatterbridge, thereby increasing the total treatment capacity
available. The treatment of North Mersey patients in satellite centres will improve access
for Cheshire and Wirral patients to the facilities at Clatterbridge.


3. The process of selecting sites

A detailed analysis of all potential sites for the location of satellite radiotherapy was
undertaken. Details of all the sites considered and the pros and cons for each are
included in Appendix One.


4. Funding the satellites

Clatterbridge Centre for Oncology NHS Foundation Trust has outlined its plans to raise
the capital funding of approximately £15 million required to finance one satellite facility
and to meet the revenue costs from within its current revenue income levels.

Liverpool and Knowsley PCT Chief Executives, in discussing the proposals, indicated
that in the light of the high morbidity and mortality from cancer in their areas they were
minded to recommend to their Boards that they should identify revenue support to
finance an estimated £15 million investment for a second site.

The capital investment in the estate infrastructure would generate additional annual
capital charges of c £750k before running costs are included. This would be shared by
Liverpool and Knowsley PCTs as a premium on the current local tariff until such time that
national PbR tariffs are introduced which include capital costs. This approach would
effectively constitute a premium payment for improved access – travel times and waiting
times.

All PCTs’ patients will benefit form improved access and travel times. All PCTs will pay
the service costs of increased usage.

The cost of constructing, equipping and staffing the second satellite centre will be
subject to a detailed investment proposal to be prepared by CCO for consideration and
approval by Liverpool and Knowsley PCT commissioners.

The Establishment of Satellite Radiotherapy Facilities in North Merseyside:
Board Meeting 11 March 2008                                                              3/10
Wirral PCT                                                                    Agenda Item: 6.5
                                                                              Ref: W07-08/225




5. The Preferred Choice of Location for the First Satellite Facility

CCO evaluated in detail the relative risks and benefits of the options put forward for the
Royal Liverpool and Aintree Hospital sites in accordance with a set of benefit criteria and
weightings. Both sites clearly offered positive benefits compared with a “do nothing”
option. However in comparing the respective merits of the two sites evaluated, the
analysis concluded that a location at University Hospital Aintree would provide the
greatest patient benefit.

The key deciding factors in reaching this decision were focussed on improving the
patient experience, viz.

          A higher quality of external environment for the new centre
          Greater opportunity for dedicated ring-fenced car parking provision for
           patients and CCO staff
          Most significant improvement in travel times for patients undergoing
           treatment

In addition, the Trust also noted other additional benefits of the Aintree site, viz.

          Lower risk of delays associated with the acquisition and development of a
           suitable site and obtaining planning consent
          Potential for development of the stereotactic service at the Aintree site in
           conjunction with the Walton Centre for Neurology and Neurosurgery

Finally it should be noted that 19.9% of radiotherapy treatments currently delivered by
CCO follow on from a referral by Aintree/Walton Centre ( compared with 14.3% for the
Royal).

On the basis of detailed evaluation of the respective sites, there was no evidence that
the capital cost of equivalent investments would be materially different. Both sites offered
similar terms to CCO for the long-lease of land on which to build the satellite centre.

      6. The Proposed Location of the Second Satellite Facility

The proposed location for the second facility is in the grounds of the Royal Liverpool
University Hospital.

This is based on the following information:

    a) Referrals from the Royal Liverpool and Broadgreen University Hospitals NHS
       Trust account for 14.3% of current treatments following referral to Clatterbridge
       for radiotherapy. This is the third highest volume of referrals after Aintree/Walton.

    b) By positioning the first facility at Aintree and the second facility at the Royal
       Liverpool University Hospital, the majority of patients across the whole of
       Merseyside and Cheshire will travel less than 45 minutes to their nearest
       radiotherapy service. As has already been stated a small number of patients may
       have to travel to Clatterbridge for rare and/or very complex treatments.

The Establishment of Satellite Radiotherapy Facilities in North Merseyside:
Board Meeting 11 March 2008                                                              4/10
Wirral PCT                                                                    Agenda Item: 6.5
                                                                              Ref: W07-08/225

         Improvements in travel times to each of the sites and the benefits to the main
         commissioning PCTs are included at Appendix 1.

    c) The Royal Liverpool and Broadgreen University Hospital NHS Trust hosts a
       significant number of network-wide specialist cancer services, including
       pancreas, neuroendocrine, sarcoma, haematology (level 4) and urology.

    d) The Royal, in close association with the University of Liverpool, is central to
       cancer research within Merseyside and Cheshire. Following discussions with the
       Chief Executive of Cancer Research UK, the University of Liverpool and NHS
       organisations in Merseyside and Cheshire have indicated their commitment to
       collaborate to establish a Cancer Research UK Cancer Research Centre in
       Liverpool. The intention is to submit an application to Cancer Research UK in
       April 2008 to secure funding to support the development of a research centre
       which will carry the name and brand of Cancer Research UK. The aim is to
       develop a research centre in Merseyside which will undertake leading edge
       cancer research which in turn will enhance outcomes in the United Kingdom and
       beyond. It is envisaged that the Cancer Research Centre will bring together all
       those scientists who are currently working on cancer research in Merseyside,
       including those currently working in The School of Cancer Studies (headed by
       Professor JP Neoptolemos) and other groups based on the main University
       Campus site, co-located with the Royal Liverpool University Hospital. The
       University strongly supports the location of the Liverpool Cancer Treatment
       Centre including radiotherapy as well as chemotherapy as part of the CR-UK
       Liverpool Cancer Research Centre on the Royal site.

    e) This option will particularly benefit the population of Liverpool who experience the
       worst cancer morbidity and mortality in Merseyside and Cheshire with over 350
       deaths each year in excess of what would be expected compared with England
       and Wales; and of Knowsley where there are almost 100 excess deaths from
       cancer per annum.

7. Action Required by PCT Boards

PCT Boards are asked to:

    a) support the proposed expansion of radiotherapy services through the
       establishment of two satellite services situated north of the River Mersey as a
       joint commissioning decision across the Merseyside and Cheshire Cancer
       Network. Subject to PCT Boards’ views planning for two satellite sites can
       proceed concurrently. The aim would be to have both sites operational as soon
       as possible over the next 2-4 years.

    b) note CCO’s preferred location for the development of the first satellite facility,
       namely co-located with University Hospital Aintree and Walton Centre for
       Neurology and Neurosciences.

    c) support the proposal to site the second satellite facility on the Royal Liverpool
       University Hospital site, noting the funding offer from Liverpool and Knowsley.



The Establishment of Satellite Radiotherapy Facilities in North Merseyside:
Board Meeting 11 March 2008                                                              5/10
Wirral PCT                                                                    Agenda Item: 6.5
                                                                              Ref: W07-08/225

    d) discuss the proposal with their PPI Forums/Links and Overview and Scrutiny
       Committee(s) and feed back conclusions by the end of April 2008 to allow project
       planning to be established on a firm basis.




Paper prepared by Merseyside and Cheshire Cancer Network

February 2008




The Establishment of Satellite Radiotherapy Facilities in North Merseyside:
Board Meeting 11 March 2008                                                              6/10
Wirral PCT                                                                    Agenda Item: 6.5
                                                                              Ref: W07-08/225


Appendix 1

1.    A summary of the 100 page report by Matrix commissioned by CCO considered
      the following in getting to the shortlisted sites.

             –    Assess Trust’s direction of travel
             –    Explore possible models of care
             –    Identify a long list of possible sites
             –    Reduce to a short list using ‘hurdle’ criteria
             –    Undertake non-financial appraisal of sites
             –    Undertake financial appraisal of sites
             –    Identify preferred options

2.       The Long list considered the following core and non core sites

         •   Freestanding (near M62)*
         •   Alder Hey
         •   Liverpool Women’s
         •   Southport & Ormskirk
         •   Aintree (main site)
         •   Aintree / Walton Neuro
         •   Whiston Hospital
         •   St Helens Hospital
         •   Royal Liverpool Hosp
         •   Broadgreen (Royal/CTC)

         *several other non core sites were considered

3.       The following ‘hurdle’ criteria were agreed

         •   Could the satellite be opened on site by 2010/11?
         •   Does the site have space for 3 linacs unit?
         •   Does the site have planning permission?
         •   Does the site have good public access?
         •   Does the site improve travel times for pts?
         •   Can CCO Trust work with host site?

4.       This resulted in the exclusion of some sites as follows

         •   Freestanding non core sites (near M62) – failed on timescale
         •   Alder Hey – failed on space
         •   Liverpool Women’s – short listed *
         •   Southport & Ormskirk – failed on travel times
         •   Aintree (main site) - short listed
         •   Aintree / Walton Neuro - short listed
         •   Whiston Hospital – failed on timescale
         •   St Helens Hospital - short listed
         •   Royal Liverpool Hosp - short listed
         •   Broadgreen (Royal/CTC) - short listed


The Establishment of Satellite Radiotherapy Facilities in North Merseyside:
Board Meeting 11 March 2008                                                              7/10
Wirral PCT                                                                       Agenda Item: 6.5
                                                                                 Ref: W07-08/225

*(removed later following the decision to relocate breast services on the RLH site)

5.       The non Financial criteria were as follows:-

             –    Patient access
             –    Clinical infrastructure
             –    Recruitment & retention
             –    Reputation of host trust / patient perception
             –    Environment
             –    Research and academic links
             –    Potential for market growth
             –    Future site development (potential for growth)
             –    Willingness of host site to work with CCO
             –    Clinical infrastructure to relocate chemo and radiotherapy
             –    Reduced travel times

6.       The financial criteria were as follows:-

             –    Departmental cost allowance
             –    On costs
             –    Median index of public sector tender prices
             –    Provisional location adjustment
             –    Fees
             –    Non-work costs
             –    Equipment costs
             –    Planning and contingency
             –    Optimism bias

7.       The non-financial appraisal revealed:-

             •    Aintree (main site)
             •    Aintree (Walton Neuro)
             •    Royal Liverpool
             •    St Helens
             •    (Not Broadgreen / CTC – no chemo)

8.       The financial appraisal revealed:-

             •    Aintree (main site)
             •    Aintree (Walton Neuro)
             •    Royal Liverpool
             •    Broadgreen / CTC
             •    (not St Helens – lowest income & expenditure margin)

9.       When taken together this led to a final shortlist of

             •    Aintree (main site)
             •    Aintree (Walton Neuro)
             •    Royal Liverpool



The Establishment of Satellite Radiotherapy Facilities in North Merseyside:
Board Meeting 11 March 2008                                                                 8/10
Wirral PCT                                                                    Agenda Item: 6.5
                                                                              Ref: W07-08/225


10.      The process of getting from one to two sites

             •    Commissioners meeting with CCO 21st Jan 2008
             •    Aintree site proposed by CCO for 3 linacs
             •    3 linacs would satisfy 50% demand from North Mersey
             •    Commissioners were keen to supplement with additional 3 linacs on
                  second site.

11.      Where should the second satellite be?

             •    Referrals to CCO: highest = Aintree, third = Royal
             •    Clinical adjacencies: pancreas, haematology (level 4), specialist urology,
                  sarcoma, lung and OG (with CTC)
             •    Research – University of Liverpool and the links with the Cancer
                  Research UK designation
             •    The biggest PCT population in the network
             •    Excess cancer deaths in Liverpool – 350 per annum – the highest in the
                  network and Knowsley – c 100 per annum




The Establishment of Satellite Radiotherapy Facilities in North Merseyside:
Board Meeting 11 March 2008                                                              9/10
                                                    Wirral PCT                                                                                                                                                                                                              Agenda Item: 6.5
                                                                                                                                                                                                                                                                            Ref: W07-08/225

                                      Derived from the Matrix report the travel times of the best two sites are shown below as is the Impact on
                                      travel times for individual PCTs for the two preferred sites


                                                                                                                                                                                                                          ROYAL LIVERPOOL: Distribution of Travel Times - Patients "Eligible" for Satellite
                                                AINTREE: Distribution of Travel Times - Patients "Eligible" for Satellite
                                                                                                                                                                                                                                       (where "eligible" = Breast, Lung & Prostate only [Radical & Palliative])
                                                     (where "eligible" = Breast, Lung & Prostate only [Radical & Palliative])
                                                                                                                                                                                          300
                     300


                                                                                                                                                                                                                                                                                          NRAG: Best Practice maximum
                                                                                                     NRAG: Best Practice maximum                                                          250
                     250                                                                                                                                                                                                                                                                  travel time of 45 mins
                                                                                                     travel time of 45 mins



                                                                                                                                                                                          200
                     200




                                                                                                                                                                     Number of Patients
Number of Patients




                                                                                                                                                                                                                                                                                                                                         Current
                                                                                                                                               Current
                                                                                                                                                                                          150
                     150                                                                                                                                                                                                                                                                                                                 Satellite
                                                                                                                                               Satellite

                                                                                                                                                                                          100
                     100



                                                                                                                                                                                          50
                     50



                                                                                                                                                                                           0
                      0                                                                                                                                                                         5       10    15    20       25         30        35        40        45        50          55        60        65        70        75        80          85        90
                           5    10   15   20   25     30        35        40       45        50        55        60        65      70     75        80     85   90
                                                                                                                                                                                                                                                                      Times (mins)
                                                                                  Times (mins)
                                                                                                                                                                                                              AINTREE v ROYAL LIVERPOOL: Distribution of Travel Times - Patients "Eligible" for Satellite
                                                                                                                                                                                                                              (where "eligible" = Breast, Lung & Prostate only [Radical & Palliative])

                               PCT                                   No. of % Time % Time Likely                                                                                          300

                                                                     Pat    Saved: Saved: Preferred                                                                                                                                                     NRAG: Best Practice
                                                                                                                                                                                                                                                    maximum travel time of 45
                                                                                                                                                                                                                                                                                                            Aintree:
                                                                                                                                                                                                                                                                                                            Number pat: 1,685
                                                                            Aintree Royal Site?                                                                                           250
                                                                                                                                                                                                                                                                        mins                                Total mins saved: 34,274
                                                                                                                                                                                                                                                                                                            Percentage mins saved: 47%
                               Liverpool                             518    43%     63%   Royal                                                                                                                                                                                                             Patients > 45 mins: 62 (or 3.7%)
                                                                                                                                                                                                                                                                                                            Max benefit (reduced time): 30mins
                               Sefton                326                                 58%                    33%                     Aintree                                           200
                                                                                                                                                                                                                                                                                                            Median benefit (reduced time): 25mins
                                                                                                                                                                                                                                                                                                            Average benefit (reduced time): 22mins
                                                                                                                                                                     Number of Patients




                               Knowsley              163                                 61%                    48%                     Aintree                                                                                                                                                             RLUH:
                                                                                                                                                                                                                                                                                                            Number pat: 1,685
                               Halton & St Helens 240                                    49%                    36%                     Aintree                                           150
                                                                                                                                                                                                                                                                                                            Total mins saved: 27,680
                                                                                                                                                                                                                                                                                                            Percentage mins saved: 38%
                               Sub Total: Main 4 1,248                                   51%                    45%                     Aintree                                                                                                                                                             Patients > 45 mins: 120 (or 7.1%)
                               PCTs                                                                                                                                                       100
                                                                                                                                                                                                                                                                                                            Max benefit (reduced time): 20mins
                                                                                                                                                                                                                                                                                                            Median benefit (reduced time): 15mins
                               Others          (incl 437                                 38%                    23%                     Aintree                                                                                                                                                             Average benefit (reduced time): 16mins

                               Warrington)                                                                                                                                                 50                                                                                                                                                              Royal

                               Total                 1,685                               47%                    38%                     Aintree                                                                                                                                                                                                            Aintree

                               Total           excl 1,533                                50%                    40%                     Aintree                                                 0

                               Warrington                                                                                                                                                           5    10    15    20           25         30        35        40        45
                                                                                                                                                                                                                                                                        Times (mins)
                                                                                                                                                                                                                                                                                     50          55        60        65        70        75          80        85        90




                                                    Non Financial criteria weightings

                                                                                                                                                                                                        22%                                             20%




                                                                                                                                                                                                    20%

                                                                                                                                                                                                                                                            38%




                                                                                                   Site Issues
                                                    The Establishment of Satellite Radiotherapy Facilities in North Merseyside: Patient Experience Issues
                                                    Board Meeting 11 March 2008                    Clinical Issues              Future Strategy Issues    10/10

				
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