NICaN Oesophageal & Gastric Cancer Meeting

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4 NICaN Oesophageal & Gastric Cancer Regional Group Meeting                 NICaN
13 December 2006

       4th NICaN Oesophageal & Gastric Cancer Regional Group Meeting
                       Wednesday 13th December 2006
                              9.30 - 12.00 noon
                 Park Plaza Hotel, Belfast International Airport

Record of Attendees:

           Ms Christine Allen             Ms Barbara Harvey
           Mr Declan Carey                Ms Liz Henderson
           Ms Karen Chambers              Ms Janice Palmer
           Ms Louise Collins              Dr Sheila Kelly
           Dr Graeme Crawford             Mr Andrew Kennedy
           Ms Joanne Cullen               Mr Eamon Mackle
           Dr Gerard Daly                 Ms Beth Malloy
           Dr Dermott Davison             Mr Lloyd McKie
           Ms Lesley Dent                 Mr Roy McMullan
           Dr Martin Eatock               Ms Lisa McWilliams
           Ms Julie Hanna                 Dr Michael Mitchell
           Mr Tim Harding                 Dr Colin Rodgers

Mr Manus Epanomeritakis, Ms Kathy Goumas, Professor Frank Kee, Mr Jim McGuigan
and Dr Tony Tham


Dr Gerard Daly welcomed everyone to the meeting before round table introductions. Dr
Daly stated that he was acting as the interim Chair for the Group and was hoping
someone from the Group would take this role on.
It was outlined that the purpose of the meeting was fourfold: to
 consider work progress to date;
 consider current practice across Northern Ireland including recent, current and future
    challenges and opportunities;
 seek agreement on the process required to develop evidence based timed care
    pathway for oesophageal and gastric cancer services in Northern Ireland; and
 building on work to date - agreeing deliverables and timescales.

Session 1: Scene Setting

The Oesophageal & Gastric Cancer Service today; Challenges and opportunities for
the future

Dr Daly outlined the background to the creation of this Regional Group stating that a
conference had been held in March 2005 and it was questioned whether the service had
changed since that time. The climate has certainly changed and Dr Daly outlined a
number of challenges and opportunities including the introduction of NICE, the review of
Public Administration, the Regional Cancer Control Plan (which was issued for
consultation in November 2006) and the Greater Belfast Surgical Network.

With regards to the Greater Belfast Surgical Network Dr Daly stated that Mr Terry Irwin,
(author of GI Surgeries Options Paper), was happy to share the question being asked
which is why would there be emergency surgery and large/major HDU/ICU provision
across 3 Trusts within Belfast. A number of options are being considered including
4 NICaN Oesophageal & Gastric Cancer Regional Group Meeting                    NICaN
13 December 2006

emergency surgery in one site and major surgery in another site, but that all options
require working differently. Mr Declan Carey who also sits on the Greater Belfast Surgical
Network confirmed that the summary reflected discussions of the Greater Surgical
Network meetings and that all on it want to be flexible and that the impetus was clinician
led as well as commissioner led.

Work to Date

The work to date via the group included the following and updates will be provided against
 2005 service provision and clinical practice – the NICR and NICaN Group Audit funded
   by RMAG);
 pathway development;
 patient perspective; 2 pieces of work carried out by Ms Louise Collins and Dr Aine
 referral guidance;
 MDM standards; led by Mr Andrew Kennedy;
 MDM database; Dr Lisa Ranaghan, Cancer Registry;
 Endoscopy capacity audit carried out by Professor Frank Kee and Ms Christine Allen;
 sample pathways of the last 5 patients; members were asked to provide details of
   these to the meeting.

Patient’s Pathway – RGHT

Ms Louise Collins stated that a random selection of patients, with surgical and palliative
referrals to the Royal, from October 2005 had been examined. It was highlighted that
there were gaps in data which were hard to source and there appeared to be delays in
getting patients to discussions at MDM. Ms Collins presented the data stating that some
of the definitions were now more up-to-date having received clarification from the Service
Delivery Unit and that Ms Lesley Dent had been carrying out more recent work in the
Royal. Dr Michael Mitchell indicated a weight of 12-14 weeks for routine OGD.

Dr Martin Eatock stated that Ms Collins data shows how far off the mark we currently are
with regards to meeting the 62 day targets. Ms Lesley Dent, MDT co-ordinator, was then
invited to present information captured automatically at the Royal’s MDM. It was
highlighted that for a significant number of cases it was not possible to identify date of
referrals received. Dr Anna Gavin thanked Ms Dent for her presentation stating that it was
an excellent demonstration of the type of data captured by current databases.

Patient’s Pathway - BCH

Mr Declan Carey then presented the BCH timelines for the last 5 patients which covered a
spectrum of management of patients and highlighted that 60% of management is in the
form of palliative care. It was highlighted that the BCH audit department had pulled out 25
patients in the absence of an MDM database. The range of journey time for the 5 selected
patients ranged from 33 to 101 days.

2005 Service Provision and Clinical Practice Audit

Dr Anna Gavin presented provisional findings from the audit which was carried out from
January to December 2005. It was stated that the completed 2005 data will be available in
approximately April 2007 and the following agreed to liaise with Dr Gavin to quality assure
the data: Mr Declan Carey (BCH), Dr Martin Eatock (BCH), Mr Andrew Kennedy (RGHT)
Dr Michael Mitchell (BCH), Mr Eamon Mackle (Craigavon) and Dr Colin Rodgers

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4 NICaN Oesophageal & Gastric Cancer Regional Group Meeting                     NICaN
13 December 2006

Following these inputs Dr Daly highlighted this Group has the licence to lead oesophageal
cancer services and that clinical guidance published by NICE/IOG for tumour specific
group should be adopted as the minimum standard for clinical practice in Northern Ireland.
Attention was drawn to a recommendation within the Cancer Control Programme which
states that the Cancer Network (and its regional groups) is critical to the implementation
and development of standards for the service.

Session 2: Regionally agreed evidence based and timed care pathway development

Care Pathway Development

The development of regionally agreed care pathways allows for clear and concise
accounts of key stages of patient’s journeys including diagnostics, treatment and follow-
up. It is anticipated that care pathways will provide the specification for cancer service
commissioning by the Regional Health and Social Services Authority and that care
pathways also provide a framework for audit and continuous quality of improvement. The
care pathway from the patients’ perspective and then from the clinicians’ perspective were
displayed, underpinned by quality and evidence based standards. The strength,
weakness, opportunities and threats of care pathways were then highlighted.

Dr Daly then highlighted the regional quality standards for timely access to cancer services
as the following:
 all patients diagnosed with cancer should begin treatment within a maximum of 31
    days from the diagnosis (decision on treatment);
 all patients with suspected cancer who have been referred urgently by their GP should
    begin the first definitive treatment within a maximum 62 days.

Key recording dates to be captured, and presented by Trusts periodically to the
Department of Health, include:
    data of referral received;
    date patient discussed with MDT;
    date decision to treat is discussed with patient;
    date of first definitive treatment commencing.

It was stated that the Network Team have agreed a timetable for development with
Service Delivery Unit ahead of the introduction of the mandatory access standards for
April 2007 and these were demonstrated. It was stated that in order to achieve the cancer
standards there needs to be 3 areas for early focus within the pathways:
 referral process
 diagnostic activities; and
 the effective functioning of multidisciplinary meetings.

A care pathway working group is to be convened and the following members were
identified for a meeting in January 2007: Mr Declan Carey, Ms Karen Chambers, Ms
Louise Collins, Ms Joanne Cullen, Ms Lesley Dent, Dr Sheila Kelly, Mr Andrew Kennedy,
Mr Eamon Mackle and Dr Colin Rodgers. Radiology representation is to be sought from
the PET Institute.

Referral Guidance and Criteria – Dr Graeme Crawford

Dr Graeme Crawford stated that a number of examples of referral guidelines for
oesophageal and gastric cancer had been provided for each of the participants including
NICE and draft guidance developed by subgroup of the Primary and Upper GI Regional
Group. There followed some discussion including the requirement for a whole diagnostic

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4 NICaN Oesophageal & Gastric Cancer Regional Group Meeting                    NICaN
13 December 2006

pathway so that GPs can differentiate between routine and urgent referrals with a
confidence that patients will be seen in a timely manner. Ms Beth Malloy stated that a 13
week maximum timescale for diagnostics is to be announced by the Health Minister in
2007. There followed some discussion with regard to the quality of the nationally agreed
guidance and it was proposed that Dr Colin Rogers and Dr Michael Mitchell work closely
with the subgroup to make final amendments. Dr Dermott Davison then highlighted
discussions from the Primary Care Regional Group by stating that an additional regional
access standard would be all GPs making a referral of suspected cancer within 24 hours,
to the appropriate referral points.

At the recent regional Breast Cancer Group members had undertaken to look at the
referral receipt processes of their Trusts and it was suggested that it might be worthwhile
for members to look at entry points for referrals into their Trusts.

Endoscopy Capacity Audit – Ms Christine Allen

Since the last meeting Ms Christine Allen stated that the data was being verified and that
currently showed 63% of capacity being scheduled with a further 20% available but not
funded. An early conclusion of this work would indicate that capacity is available but
needs greater examination. Ms Allen then highlighted elective waiting times for the
various procedures and members stated that they appeared to be too short. It was
highlighted that the information had been verified by information forwarded from Dr Martin
Connor at the Department of Health. Dr Colin Rogers stated the data was not currently
accurate but that having spoken to Dr Connor there was an agreement for the Service
Delivery Unit to purchase an Endoscopy data system (Endosoft) if 85% of units could
agree to using it.

With regards to the concern raised about the quality of the data it was agreed that Ms
Allen and Professor Kee seek information from the SDU Diagnostic workstream led by Ms
Rosemary Huelett. The offer from Dr Martin Connor is to be further considered in order to
manage and accurately record endoscopy waiting list and activities.

Standards for Multidisciplinary Teams / Meetings

It was outlined that the English Manual of Cancer Services contains national standards for
MDTs and their meetings. It was agreed that a working group consider these standards
for adopting or adaptation for the Northern Ireland Service. Working group members were
identified as Ms Lesley Dent and Mr Andrew Kennedy and representatives of the units are
to be forwarded before the Christmas break.

Session 3: Agreement of deliverables and timetable

A record of agreed actions is to be forwarded within a week. Dr Daly again highlighted that
members need to give consideration for a new chair of this group with interested parties to
email Gerard Daly at before the Christmas break.

Hepato-Pancreatico Biliary Cancer
A meeting is to be scheduled to discuss a forum / include in existing forum for Hepato-
Pancreatico-Biliary Cancer. Attendees for the meeting were identified as Dr Daly, Dr
Eatock, Mr Kennedy and Mr Lloyd McKie. A Gastroenterologist is to be identified and this
matter was to be raised at the upcoming Colorectal Regional Group.

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4 NICaN Oesophageal & Gastric Cancer Regional Group Meeting                NICaN
13 December 2006

Response to Cancer Control Plan
As previously highlighted the Cancer Control Programme was issued for consultation in
November 2007. Members were encouraged to make individual responses during the
consultation process.

Response to Regional Pathology Review
It was highlighted to members that the regional pathology review had been issued for
consultation and members were encouraged to make individual responses during the
consultation process.

Date of Next Meeting

The next meeting will take place on Thursday 8th February 2007 from 2.00pm to 5.00pm in
the Park Plaza Hotel at Belfast International Airport.

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