Background
The initiative – combining academic research and local knowledge
Methods
Site 1 | Site 2 |
---|---|
Lung | |
• Remove minimum time threshold for referral • Introduction of RATs as reference tool • For persistent high risk symptoms OR suspicious CXR patient referred simultaneously to 2-week wait pathway 2WW clinic AND CT scan 2WW | • Formal use of RATs alongside existing national NICE guidelines including a recommended risk assessment threshold of 2% • Option to do 2WW and simultaneous CXR for highly suspicious symptoms • Radiology given initiative to initiate 2WW referral and CT scan following suspicious CXR |
Pancreas | |
• RAT introduced as reference tool • Built on previous pilot by secondary care trust • Splits jaundice into a separate pathway (recognition of high risk) • Fast track for jaundice and suspicion of cancer • Simultaneous referral for CT and 2WW on non-jaundice pathway for high risk symptoms • Fast track route in for GP generated ultrasound referrals w/suspicion of malignancy | • Formal use of RAT and threshold score for 2WW • High risk symptoms go direct to CT scan followed by consultant review • Below national NICE guidance and RAT threshold consider abdominal US scan, if suspicious into 2WW |
Colorectal | |
• No change to national NICE guidelines | • Formal introduction of RAT with lower threshold than national NICE guidelines • For high risk symptoms and patients that meet the safety criteria GPs given a direct access to colonoscopy option |
Primary care | Secondary care | Non-clinical | Total | |
---|---|---|---|---|
Interviewed (invited) | Interviewed (invited) | Interviewed (invited) | Interviewed (invited) | |
Site 1 | 2 (3) | 5 (7) | 1 (1) | 8 (11) |
Site 2 | 3 (3) | 1 (4) | 2 (2) | 6 (9) |
Results
Pathway development – overview of outcomes
Site 1 | Site 2 | |
---|---|---|
Meeting 1 | ||
Date of meeting | 29/07/2013 | 01/09/2013 |
Meeting structure | 3 sub-groups established for each cancer pathway Chaired by Discovery research lead, 1 PPI member | 3 sub-groups established for each cancer pathway Chaired by local stakeholder 1 observer from National Cancer Action Team, 2 PPI members and 2 members of Discovery research team |
Post-meeting actions/activity | Discovery research team collate minutes and design pathways | Local reference group members action the pathway design |
Meeting 2 | ||
Date of meeting | 11/11/2013 | 13/11/2013 |
Meeting structure | No sub-groups – pathway changes reviewed by full reference group Chaired by Discovery research team lead Significant change in membership/attendance | No sub groups – pathway changes reviewed by full reference group Chaired by local stakeholder 2 Discovery researchers present |
Meeting outcome | Pathways presented by Discovery research team not accepted by reference group and required further work | New pathways considered and accepted with minor amendments agreed prior to implementation |
Post-meeting actions/activity | Discovery team liaise with clinical leads from reference group to redraw pathways | Local reference group members amend pathways |
Meeting 3 | ||
Date of meeting | 21/01/2014 | N/A – pathway design completed |
Meeting structure | No sub-groups – pathway changes reviewed by full reference group Chaired by Discovery research team lead Significant change in membership | |
Meeting outcome | Pathways submitted by Discovery team were not fully accepted by reference group; further work required | |
Post-meeting actions/activity | Discovery team liaise with clinical leads from reference group to redraw pathways 2 meetings with colorectal sub-group failing to reach agreement | |
Meeting 4 | ||
Date of meeting | 11/03/2014 | N/A – pathway design completed |
Meeting structure | Pathway changes reviewed by full reference group Chaired by Discovery researcher | |
Meeting outcome | Lung and pancreas pathways subject to further amendment and tentatively agreed No agreement on colorectal pathway | |
Launch and promotion of modified cancer pathways | ||
Launch meeting date | 01/05/2014 | 14/02/2014 |
Meeting details | 8 GPs in attendance No protected GP time, i.e. GPs attending in their own time Discovery team lead with support from clinical reference group members | ~230 GPs attended Protected time for GPs as part of ‘time in time out’ training day Pathways presented by reference group team Short intro from Discovery researcher |
The CMO of pathway development
CMO 1. A stable group made up of the ‘right’ people who have previously worked together successfully (context) facilitates a shared purpose (mechanism), which leads to effective and timely pathway development (outcome)
Site 1 | Site 2 | |||||||
---|---|---|---|---|---|---|---|---|
Profession/role | Meeting 1 | Meeting 2 | Meeting 3 | Meeting 4 | Change (%) | Meeting 1 | Meeting 2 | Change (%) |
Secondary care clinician | 4 (31%) | 6 (46%) | 11 (61%) | 6 (50%) | +19% | 5 (28%) | 3 (20%) | –8% |
Secondary care manager | 0 (0%) | 2 (15%) | 3 (17%) | 1 (8%) | +8% | 1 (6%) | 1 (7%) | +1% |
Primary care clinician | 4 (31%) | 2 (15%) | 0 (0%) | 1 (8%) | –22% | 5 (28%) | 5 (33%) | +6% |
Research team | 4 (31%) | 3 (23%) | 4 (22%) | 3 (25%) | –6% | 2 (11%) | 2 (13%) | +2% |
Clinical network | 0 (0%) | 0 (0%) | 0 (0%) | 0 (0%) | 0% | 3 (17%) | 2 (13%) | –3% |
Patient/public | 1 (8%) | 0 (0%) | 0 (0%) | 1 (8%) | +1% | 2 (11%) | 2 (13%) | +2% |
Total | 13 | 13 | 18 | 12 | 18 | 15 |
“I think the benefit of it obviously was getting people in the same room at the same time so obviously having a mix of different people from primary care, from secondary care, from trust management, that obviously needs to happen if you’re going to try and make changes like the ones that have been made … I don’t think it would have worked so well if you had – if you didn’t have the right people in the room.” (Site 2, 004)
“I think the personal relationships between the participants were quite important, that these were people who’ve worked together for some time and who have interacted through the cancer network previously and I think that helped.” (Site 2, 003)
“I’ve always been struck by the collaborative way in which clinicians come together on cancer services. … they genuinely behave as if it’s a service that’s important not their organisation. We do talk about people taking their team’s shirt off as they come in the door and they do, you know, in these workshops that we’ve organised over the years people are very keen to talk about the service and patients not the organisational politics but it inevitably on some occasions does come into play.” (Site 2, 003)
CMO 2. Respected, independent and well-connected local leaders who model partnership working across organisational boundaries (context) foster engagement from reference group members (mechanism) who are proactive in pathway design and development
“I guess the lead GP, if we could describe as such, would be XX … he’s very committed, he’s a very committed GP to cancer and I think he is now, I think at that point he was becoming an executive – he was becoming part of the executive of the [policy-making organisation] and he was leading on cancer so that was extremely helpful.” (Site 2, 003)
“We are lucky enough as well, we always mention about YY. He used to be the cancer network director but he’s still running the clinical – he’s actually running the clinical network now so cancer’s one of it and he is very good at bringing people together … YY actually helped us – helped myself and some of the key people learn how to work together and now when you see that come along we actually knew how to do it and we could take it forward. YY is absolutely crucial.” (Site 2, 006)
CMO 3. A clear understanding and acceptance of the aims of the project, including the legitimacy of research data and the process of pathway development (context), provides a basis for agreement (mechanism), which facilitates a pathway incorporating research evidence (outcome)
“Yes, we were aware that late diagnosis was a significant problem; in fact it still is across the entire health service and in our area in particular. We could see that there were areas doing better than us and this was reflected in mortality statistics we were getting from public health.” (Site 2, 009)
“There was some concerns as to how realistic the project was in its overall aims, could we actually make a difference in such a short time and then measure it and I think we all had concerns about that … there was an aim to get it rolled out across the whole of [site 1] how realistic was that to influence how GPs practice, ‘cos we know it’s very difficult to change people’s practice and to change everyone in [site 1] to suddenly changing pathway was quite an ask, and how robust therefore the data be so I think we were a bit concerned that the methodology, whether it was actually robust.” (Site 1, 008)
“In terms of, you know, spending anyone’s money on the lung cancer part of this I thought that probably wasn’t the most prudent way to do it and I’d much rather been given a chunk of money and been told to go and do some social marketing to try and influence things … I think we needed to shape it because it would have been even worse, wouldn’t it, if none of us had turned up.” (Site 1, 013)
“There’s public health involvement which to my mind was quoting figures that I didn’t recognise … I think you have to use very well validated data to show what the problem is … I know that our data is very robust and I can tell you exactly how many cases of lung cancer I saw last year presented as an emergency and it’s not many.” (Site 1, 013)
CMO 4. The research team take a minor, non-directive role in the reference group (context), which encourages local ownership (mechanism) and leads to proactive pathway design and support for implementation (outcome)
“It felt very much like we were being told you have to do this rather than here’s a project, here’s our aims, we’d like to do this, can you support us and help us, you know, let’s do this together. I think there perhaps wasn’t so much of a collaborative kind of feeling in the way it was done. It was always a bit vague.” (Site 1, 002)