Barts Health NHS Trust - London Cancer · Frances Hughes to deliver this bid which has the full...

Page | 2 Barts Health Oesophago-Gastric London Cancer Bid

London Cancer Oesophago-gastric (OG) cancer bid

Submission document

Detailed proposals for: Part 2: Specialist OG cancer centre and

Part 1: Local cancer OG unit

Name of Trust Barts Health NHS Trust.

Executive Lead Dr. Steve Ryan, Medical Director.

Clinical Lead Miss. Frances Hughes, Consultant Surgeon, Upper GI.

Strategic Lead Dr. Sarah Slater, Clinical Director for Cancer Strategy.

Date Submitted Friday, 14 June 2013 at 3.00pm

Part 2: Specialist OG cancer centre

Proposed Site: The Royal London Hospital

Part 1: Local cancer OG units

Proposed Sites: The Royal London Hospital Whipps Cross University Hospital Newham University Hospital


Pelham Allen Chair, London Cancer Professor Kathy Pritchard-Jones Chief Medical Officer, London Cancer London Cancer Integrated Cancer System 3rd Floor 170 Tottenham Court Road London W1T 7HA Dear Pelham and Kathy, I enclose for your consideration the bid from Barts Health for the Trust to be designated as a local diagnostic and specialist surgical provider of services for patients with oesophago-gastric cancers. I am personally delighted with the work that Dr Sarah Slater has led in conjunction with Ms Frances Hughes to deliver this bid which has the full support of the Trust Board and our academic partner, Barts and The London School of Medicine and Dentistry, Queen Mary University. As you know, we were extremely disappointed to lose the renal cancer surgical bid; however we have listened very carefully to feedback we received and remain absolutely committed to the London Cancer ambition to provide excellent services for patients including one year survival and understand the need to consolidate surgical services to achieve this. We believe that the designation of Barts Health as both a local and specialist provider for patients with upper GI cancers is the opportunity to achieve this within this tumour group, based on the track record of the clinical team over the last 10 years and the clinical outcomes which are detailed in this bid. I think our organisational learning from the previous processes has also been significant, with the clear mobilisation of clinical leadership to develop this bid and to directly advise the Trust Board. We have considered the domains of the bid in detail. These are covered in the document but I would take the opportunity to draw your attention to the details we have covered particularly around the potential impact of change. We believe that our large patient group will be best served by the on-going evolution of surgical services within the Trust. Given our designation as a Major Trauma Centre we have the opportunity, if we are successful, to provide separate abdominal surgical cover through the synergies that we will achieve through upper GI surgery and hepato-pancreatico-biliary services. This would be in addition to the general surgical rota and we consider this to be a unique opportunity for patients and for London Cancer to support us in developing this service. In addition to this, we believe our excellent clinical outcomes, based on the last five years of clinical audit demonstrate the strength of our clinical team in this area, and we would hope this is an integral consideration in your decision making process.

Peter Morris OBE Chief Executive

Trust Offices Aneurin Bevan House 81 Commercial Road

London E1 1RD


You have asked me to confirm that I am personally confident that the Trust can achieve the plans it outlines and I am very happy to do give you this confirmation. This is a clinical service in which the Trust has significant strength in and whilst the designation of a single service for a large population would indicate a step change in our provision, I believe that we have the foundation to deliver this based on the strong clinical leadership that is evidenced in this bid. We look forward to hearing from you and will be happy to provide any further information or clarifications. Yours sincerely

Peter Morris Chief Executive Barts Health NHS Trust


Contents Statement of intent ................................................................................................................................. 8 Our vision ................................................................................................................................................ 8 Executive summary .............................................................................................................................. 15 Barts Health organisational ethos ....................................................................................................... 18

Leadership and collaboration .................................................................................................................. 18 Exceptional outcomes for patients in other specialities ............................................................................ 18 Our strategy and vision ........................................................................................................................... 19

Audit of current outcomes and patient experience ............................................................................ 21 (a) Surgical outcomes ............................................................................................................................. 21 (b) Patient experience ............................................................................................................................. 24

Communication ................................................................................................................................... 24 Clinical Nurse Specialist (CNS) Service ............................................................................................... 25 Written information .............................................................................................................................. 25 Food .................................................................................................................................................... 25 Patient support .................................................................................................................................... 25

Introduction to oesophago-gastric cancer ......................................................................................... 28 Incidence ................................................................................................................................................ 28 Population ............................................................................................................................................... 29 Ethnicity profile........................................................................................................................................ 31 Social deprivation .................................................................................................................................... 32

Background to OG cancer surgery at Barts Health............................................................................ 33 Reconfiguration of OG cancer services in London ............................................................................ 34 Description of Barts Health local and specialist OG service ............................................................. 36

Clinical governance ................................................................................................................................. 36 Management reporting structure ............................................................................................................. 37 Multidisciplinary team (MDT) leadership roles ........................................................................................ 37

Clinical Lead for OG Cancer MDT: Miss Frances Hughes ................................................................... 38 Academic Surgical and Education Lead: Mr Bijen Patel....................................................................... 38 Director Cancer Pathways and Perfomance: Dr Angela Wong ............................................................ 38 Clinical Trials Lead: Dr David Propper ................................................................................................. 38 Academic Oncology Lead: Dr Thorsten Hagemann ............................................................................. 39 Director of Cancer Strategy/ Clinical Director for Solid Oncology and Cancer Surgery: Dr Slater ........ 39 Barts Health representation on the London Cancer OG Pathway Board .............................................. 39

Patient pathway ...................................................................................................................................... 39 Diagnostic pathway ............................................................................................................................. 39 Appointment to discuss diagnosis ........................................................................................................ 40 Multi-disciplinary team (MDT) .............................................................................................................. 41 Treatment decision .............................................................................................................................. 45 Specialist surgical pathway .................................................................................................................. 46 Co-location of services ........................................................................................................................ 49 Post-operative follow up ...................................................................................................................... 49 Concerns and re-admission ................................................................................................................. 49

Oncology ................................................................................................................................................. 50 Medical Oncology ................................................................................................................................ 50 Clinical Oncology ................................................................................................................................. 50

End of life care ........................................................................................................................................ 50 Rehabilitation and psychology ................................................................................................................. 51

Barts Health vision for the centralised surgical service .................................................................... 54 Future joint working ................................................................................................................................. 54 Future leadership model ......................................................................................................................... 54 Proposed surgical team organisation ...................................................................................................... 54

Principles of in reach model ............................................................................................................... 55 Surgery and on-call rota ...................................................................................................................... 55 Surgical outpatient clinics .................................................................................................................... 56


Clinical nurse specialist interaction ...................................................................................................... 58 Surgical innovation .............................................................................................................................. 58 Future Communication ........................................................................................................................ 59 Future audits ....................................................................................................................................... 59 Timescale for change .......................................................................................................................... 60

Application template covering paper ............................................................................................... 62 Part 2: Outline of proposed specialist OG cancer centre .................................................................. 64 Part I: Outline of proposed Local OG cancer unit .............................................................................. 69 Education and training ......................................................................................................................... 75

Local ....................................................................................................................................................... 75 National................................................................................................................................................... 76 International ............................................................................................................................................ 76 Future education and training .................................................................................................................. 76

Research ............................................................................................................................................... 77 Patient transport ................................................................................................................................... 80

Barts Health non-emergency transport service........................................................................................ 81 Investment ............................................................................................................................................ 84 Implications of loss .............................................................................................................................. 85

For patients ............................................................................................................................................. 85 OG cancer patients .............................................................................................................................. 85 Non-cancer patients ............................................................................................................................ 85

For staff and the Barts Health ................................................................................................................. 86 Loss of education and training ............................................................................................................. 86

Appendices ........................................................................................................................................... 89


Introduction


Statement of intent We believe a single centre is the optimum arrangement to meet London Cancers aspirations to create a world-class Oesophago-gastric Surgical Centre. At Barts Health, we are excited by this prospect and ready to deliver this service. In the staged process involving two centres suggested by London Cancer specification, we will collaborate fully with the other centre to ensure the best care for all of our patients. Patients with oesophago-gastric (OG) cancer have a complex journey, which involves many different professionals. We will ensure that this complexity is not passed on to our patients. Our understanding of the multi-faceted pathway from symptomatic presentation to survivorship underpins this submission. It is our responsibility is to ensure compassionate care of the patient wherever they are within their cancer journey. We do not undertake this lightly. In this application we will clearly demonstrate:

Our exceptional unbroken record of clinical outcomes over ten years in treating patients with OG cancer- our overall five year survival is double that of the European average.

Our vision for expanding this work across London, improving outcomes for a greater number of patients.

The leadership of our clinical team within the hospital and in relation to primary care and public health.

The leadership of our senior management and how they have successfully overseen change and expansion while improving clinical outcomes.

Support for our current services and our vision for OG cancer services in London from clinicians, research and academic partners, local GPs and our partners in public health.

Our vision Our vision is to consolidate a surgical hub and spoke model, where patients would travel to the surgical specialist centre at The Royal London Hospital only for operation, with diagnostic, staging and preoperative investigations, as well as oncology and surgical outpatient visits provided at a local hospital. Barts Health is in a unique position to offer this balance due to configuration of our services providing specialist and local services across a broad geographical area. Co-ordination of this pathway requires a strong team, guided by exemplary leadership. We envisage joint academic appointments to promote innovation and outstanding education and training. Most importantly, we are committed to delivering a seamless compassionate patient experience. Under the leadership of our lead surgeon, Frances Hughes, our vision for all patients with oesophago-gastric cancer provides:

1. Patient-focused, excellent care demonstrated by streamlined patient pathways, with the right clinical intervention at the right time.

2. Integrated healthcare under clear leadership demonstrated by a track record of delivering complex care with exceptional results during times of organisational change.


3. World-class research and education illustrated by the internationally respected work of the Barts Cancer Institute and our close relationship with Queen Mary University London.

4. Improved outcomes for all OG patients in London Cancer.


Further letters of support for the Barts Health oesophago-gastric cancer bid can be found in Appendices 1 to 3.


Executive summary The treatment of cancer, from awareness and prevention in the local community through to surgical and non-surgical intervention, is core to the strategy of Barts Health. We believe that there is a compelling case for the Royal London Hospital to be the OG surgical centre for London Cancer because: Leadership - We have a strong, dynamic surgical team who have and continue to deliver outstanding care, as recognised by independent third parties e.g. Peer Review assessments.

Outcomes - We have independently verified data that demonstrates over a decade of excellent survival outcomes and evidence of collaborative working with our referring hospitals, with patient-centred, integrated pathways of care, utilising elements of the outreach and in-reach principles within a comprehensive hub and spoke surgical model of care.

Patient centred integrated care - Our overriding principle of excellent patient focused care is evidenced by our Peer Review records and patient experiences. We are proactive and respond to both positive and negative patient comments. We have strong partnerships with Primary Care and community services, essential for the delivery of a streamlined patient pathway.

Patient pathway - We are passionate about the development of the optimum OG cancer pathway from early diagnosis to survivorship and seek to drive innovation, as demonstrated through the innovative one-stop diagnostic clinic in Barts Health.

Capacity - Our team has demonstrated that we are able to easily accommodate the number of surgical resections arising from a population of over 3 million. We have a track record which demonstrates that, when other centres were unable to sustain surgical outcomes, we were able to accommodate extra work with no breaches and surgical outcomes remained consistently high.

Organisational support - The Clinical and Management teams within the Trust are totally committed to retaining and developing the Oesophago-gastric Cancer Service and we have the support of Clinical Commissioning Groups.

Transport - We are centrally placed within the London Cancer area with over 60% of London Cancer patients residing within five miles of our surgical centre with excellent transport links to the rest of London and Essex.

Research and Education - Academic and research interests are enhanced by co-location with Global leaders in their fields at Queen Mary University of London, Barts Cancer Institute and the Blizard Institutes Centre for Digestive Diseases.

Location - We have state-of-the-art new facilities, providing all the essential local services required for the management of OG cancer. The co-location of the Regional Hepatobiliary Surgical Service enhances the OG surgical centre. Placing the Oesophagogastric Cancer Centre at the Royal London Hospital will allow London Cancer an opportunity to build a centre of international standing that will benefit the patients of North and East London.

Experience of Service Configuration - Barts Health and specifically the OG group, has demonstrated the ability to amalgamate services and trusts and continue to deliver excellent care. These skills are crucial for reconfiguration of the OG services.


Barts Health

organisational ethos


Barts Health organisational ethos

Leadership and collaboration

Barts Health has a strong history of organisational leadership. The trust undertook the largest hospital relocation ever undertaken in the UK in 2012 when it moved from the old Royal London hospital to its new facilities. This move happened at a time of considerable change as it coincided with the merger of Barts and The London, Whipps Cross University Hospital and Newham University Hospital to create Barts Health NHS Trust. Throughout this period of change, Barts Health maintained its impressive record of achieving strong clinical outcomes as demonstrated by its low standardised hospital mortality record within the top ten performing trusts nationwide, and its low risk scoring from NHS Litigation Authority.

Exceptional outcomes for patients in other specialities

Dr Foster Mortality Measures 2011

Barts Health has shown exemplary organisational leadership nationally and across London in developing and overseeing new clinical networks that have produced exceptional health outcomes for patients with a number of conditions. In 2009 The Royal London was appointed one of eight Hyper Acute Stroke Units in London. In May 2013, the results of an audit published by The Royal College of Physicians showed that the Hospital provides the best care to stroke patients in London. The Royal London Hospital leads the North East London and Essex trauma network and cares for a population of over 5 million people. The team works collaboratively with partner units and rehabilitation services to ensure that every patient receives the best care possible with the optimum outcome. It was this leadership which resulted in clinicians from the Royal London being asked to take a leading role in establishing the London Trauma network in 2010. The Royal London trauma centre is now the hub for the largest network of trauma hospitals in the UK.


The strong leadership and collaborative working partnership that has seen the establishment of these systems with their exceptional patient outcomes will be instrumental in making London Cancers vision for OG cancer surgical services in London become a reality.

Our strategy and vision

With a turnover of 1.1 billion and a workforce of 15,000, Barts Health is the largest NHS trust in England, and one of Britains leading healthcare providers. The trusts five hospitals St Bartholomews (Barts) in the City, The Royal London in Whitechapel, The London Chest in Bethnal Green, Newham University in Plaistow and Whipps Cross University in Leytonstone deliver high quality compassionate care to the 1.8 million people of east London and beyond. Barts Health is committed to providing excellent healthcare and to ending the historic health inequalities of east London. Working with our patients, public health and community partners, we will improve the way we deliver healthcare and support our local communities to live healthier lives. We will create a world-class health organisation, delivering compassionate care to the highest international standards to every patient, every time. Our care will be clinically leading-edge and, through the involvement of our patients, truly focused on the patient experience. We will build an international reputation for excellence in patient care, research and education, and through our key role in UCLPartners, the largest Academic Health Science System in the world, we will ensure that our patients are among the first to benefit from the latest drugs and treatments. We are a health organisation, and we will use every contact with our patients, not just to treat illness and injury, but also to promote health. As a result, Barts Health focuses on the delivery of a comprehensive patient pathway that delivers rapid diagnostics and timely treatment with surgery, chemotherapy or radiotherapy. In addition, Barts Health will work with primary and community services to improve prevention and early diagnosis and provide optimal end of life care, in particular ensuring that where possible patients die at home should they wish. Barts Health is committed to high quality and high volume cancer services as a fundamental part of its overall service and academic aspirations. Barts Health will be an active participant and leader at all levels in the developing London Cancer Integrated Cancer System to ensure patients are provided with the best services possible at the appropriate time in the pathway and in most appropriate location, determined by available expertise and patient choice. Barts Health will review and report all mortality from cancer and compare this with our peers by tumour type (National Oesophago-gastric Cancer Audit).


Audit of

outcomes and experience


Detailed outcome data is submitted to the National Oesophago-gastric Cancer Audit. We hold bi-monthly multidisciplinary morbidity and mortality meetings including anaesthetists and intensive care clinicians, where all significant complications are discussed in detail and learning points circulated. The table

below shows outcomes from our unit over the last five years.

Audit of current outcomes and patient experience

(a) Surgical outcomes

Surgical morbidity and mortality

Morbidity and mortality 07/08 08/09 09/10 10/11 11/12 Number of resections 92 93 67 80 60

In hospital mortality 3.7% 4.7% 3.2% 2.6% 0% Surgical cause 2.4% 1.2% 3.2% 2.6% 0%

Anastomotic Leak rate 2.4% 5.8% 8.1% 2.6% 0% 1year survival 87% 91.7% 93.7% 93.3% 91.1% Lymph node harvest (med) 18 17 22 16 Median Hospital stay (days) 12 12 11 12 12

R0 resection rate 90.2% 91.7% 88% 95% 92%

National Recommendations Leak rate 30% (Gut 2002)

Our long term survival figures are a tribute to our multi-disciplinary team and compare very favourably with national and international centres. Analysis of our long term data has shown a 48% five year survival for adenocarcinoma of the oesophagus treated by Ivor Lewis oesophagectomy (open or laparoscopic assisted) and 39% five year survival following gastrectomy. Comparative results from national and international centres are shown in the graph below.


The outcomes for oesophago-gastric cancer surgery from Japan are always considerably better than those attained in the West. There are a number of contributing factors including differences in pathological interpretation: proximal gastric tumours are commoner in Western series and are known to be more aggressive and more advanced staging. The data above shows superior outcomes in the Japanese series for gastric and oesophageal cancer although our results are better than most Western series. Our long-term outcomes following gastrectomy appear to be inferior to those reported by Hanna from Imperial College. However, the average age of our patients was six years older and the disease was more advanced (RLH 49% T3/4 compared with 42% IC and RLH 59% node positive compared with 51% Imperial College).


Analysis of cancer waiting time data for Barts Health over the last 12 months has shown that 94.4% of urgent two week wait referrals were seen within 14 days and 90.9% of OG Cancer patients started their treatment within 62 days of the initial GP referral, achieving the national targets. We recognise that staging completeness data is an important quality marker in measured outcomes for our patients. Via our respective MDTs at Whipps Cross, Newham and Royal London Hospitals, we record this information live at the MDM, on the Somerset database which is accessed by Thames Cancer Registry (TCR). Reported performance for 2012/13 was poor due to low levels of staging of hepatobiliary cases that were included in the Upper GI dataset. Data is now extracted separately for OG and complete stage was recorded for 94% of Barts Health OG cancer cases in the latest available report. We remain confident that our monthly reported performance will remain in the upper quartile and are pleased that our consistent practice of recording staging on our patient notes will be accurately reflected and reported via an electronic process.

(b) Patient experience

An oesophago-gastric cancer surgical centre based at The Royal London Hospital is supported by our patients as evidenced by the responses from surveys of patients from a wide area who have received treatment at The Royal London Hospital over several years, the patient experience descriptions and patients letters of appreciation (Appendix 3). All patient feedback is important to us and we work hard to understand all our patients needs and concerns. The following points relate to the delivery of patient centred care and are relevant in the selection of a centre for the patients of London:

Communication

From the patient survey 2013 all patients who responded to the question were satisfied with the way the cancer diagnosis was communicated to them and their families. They listened to all my concerns attentively and not only answered my queries but provided me with a whole wealth of information to help me understand the pathway to go through, including the risks should I choose to have it. (AA IG11).


Frances Hughes addressing the Oesophageal Patients Association under the watchful eye of Henry VIII

Clinical Nurse Specialist (CNS) Service

The OG surgical CNS is attached to the surgical team at The Royal London. She liaises very efficiently with the other three OG cancer nurse specialists across the Barts Health sites. She has been in post for eight years and is very well thought of by patients. After being given the news that I had cancer, the whole team in charge of my care have been second to none, and being able to contact the nurse specialist at any time was of great comfort and help. The knowledge and information given was able to put my mind at ease and give me confidence. Anon - patient survey 2012. The 2012 patient survey at Royal London hospital showed that 91% of respondents were satisfied with the overall care provided by the specialist nurse.

Written information

We offer all patients written information about their condition and the services and assistance available. Literature produced by Barts Health includes booklets about transport and accommodation, the multidisciplinary team (Appendix 4), surgical pathways and operations. Our 2013 patient survey showed that all patients were offered written information about their cancer and surveys over the years have shown that patients are satisfied with the amount of written information they receive in relation to most treatment Where we have received unfavourable feedback, such as in 2011 when the patient survey suggested that information was lacking about radiotherapy, we acted quickly to produce a new booklet.

Food

Comments about the hospital food were sought in the 2013 patient survey; half of the patients commented. I found the food very nice and hot a plenty to eat. Anon - patient survey 2013 Food was good or satisfactory 11/22 patients. We did not receive any negative comments about food.

Patient support

We are advocates of the Oesophageal Patients Association and encourage our patients to attend the informative meetings. Several members of our team have addressed the Oesophageal Patients Association and produced informative literature (Appendix 5). We offer all surgical patients the opportunity to be introduced to a similar patient who has undergone the proposed operation - a buddy. This seems to be well received often with long term friendships forged.


OG patient support group at Whipps Cross

Joan quickly befriended me and was tremendous help and support before and after my surgery- five years on, we still meet regularly often discussing matters related to our new piping. Anon Oesophageal Patients Association In March 2013, to ensure that we interacted with all our patients by providing a range of fora, which they may find useful, we set up the patient support group. This was a successful meeting and officers are being appointed to develop an on-going programme of meetings.


Oesophago-gastric cancer Introduction Background Reconfiguration


Figure 1.4: Age standardised (European) incidence

rates, oesophageal cancer, by sex, GB, 1975-2005

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Figure 1.4: Age standardised (European) incidence

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Introduction to oesophago-gastric cancer The incidence of oesophago-gastric (OG) cancer is increasing faster than any other cancer in the Western World.

Incidence

The UK lags behind many developed countries in terms of survival with oesophago-gastric cancer. Findings from the most recent EUROCARE study shows that one and five year survival rates in England, including those for oesophageal and stomach cancers, remain significantly lower than the European average.

Age standardised (European) incidence rates,

oesophageal cancer, by sex, GB, 1975-2005

The table below shows the one and five year survival for gastric and oesophageal cancer in England and Europe and Barts Health for comparison. The EUROCARE data includes patients diagnosed between 19951999 from the EUROCARE-4 study followed up until the end of 2003, age-standardised % relative survival (five-year, one-year). Barts Health data, shown in red, is from our own prospective database of all cases treated in the Centre between September 2003 and March 2012.


% 5-year Survival % 1-year Survival

Sitea 'European average'

England EC4 19951999

Royal London Hospital 2003-2012

'European average'

England Royal London Hospital 2003-2012

Oesophagus 11.1 9.9 22.8 35.8 32.9 56.4

Stomach 24.5 16.1 29.2 46.3 38.0 59.8

Population

The populations quoted in the table below show the population treated by each of the three OG cancer specialist centres within London Cancer. Between 2004 and 2011, we provided a surgical service for the Inner North East London Boroughs, Colchester and Southend, amounting to a population of 2.08 million. In 2010, this population increased to 3.3 million with additional referrals from North Central London. We look forward to resuming this level of activity.

As a specialist centre, 32% of our patients were tertiary referrals so a high number were treated with curative intent; 54% stomach cancer and 49% oesophageal cancer.

http://www.nature.com/bjc/journal/v101/n2s/fig_tab/6605399t1.html#t1-fn1#t1-fn1


Borough and population statistics Inner North East London - Royal London Hospital

Borough Population

Hackney (incl. City) 273,000

Tower Hamlets 243,000

Waltham Forest 271,000

Newham 333,000

TOTAL: 1,120,000

Outer North East London - Queens Hospital

Borough Population

Barking & Dagenham 182,000

Redbridge 264,000

Havering 252,000

TOTAL: 698,000

North Central London - University College Hospital

Borough Population

Barnet 356, 400

Camden 220,300

Enfield 312,500

Haringey 254,900

Islington 206,100

TOTAL: 1,350,200

Source: Population Statistics - Source: Population Census 2011

Sum total of London Cancer population

12 boroughs 3,168,200


Ethnicity profile

East London has considerable racial diversity and significant socio-economic deprivation with two of the poorest London boroughs, Tower Hamlets and Hackney within the Barts Health area. Diversity poses significant challenges for healthcare providers. Black and Minority Ethnic groups often have problems in accessing healthcare with factors such as language, culture and the attitudes of healthcare professionals compromising their likelihood of receiving the care they need. The graph below shows the ethnicity profile of the non-Caucasian population of London Cancer.

Source: ONS population estimates by ethnic group 2009


Social deprivation

North East London is steeped in a legacy of historical deprivation and has some of the worst health outcomes and starkest health inequalities in London. Significant deprivation affects much of the local population with 50% of people living in the most deprived quartile nationally. Incidence and mortality from stomach cancer are strongly related to social class and measures of deprivation, with higher rates in socially and economically deprived groups.

Worse than England Average

In Line with England Average

Better than England Average

Data Unavailable

Source: Association of Public Health Observatories (APHO) 2012

The following graphs show that the incidence of OG cancer increases with rising social deprivation. The age standardised incidence rates per 100,000 European Population for patients diagnosed with oesophago-gastric cancer in England between 2003 and 2007, according to deprivation quintile.

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Life expectancy: Male

Life Expectancy: Female

Early Deaths: Heart Disease and Stroke

Early deaths: Cancer

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with diabetes


Background to OG cancer surgery at Barts Health In 2003 The Royal London Hospital was designated as one of two centres for OG surgery within the North East Thames Cancer Network. At this time, we served a patient population of 1.2 million, encompassing referrals from Whipps Cross, Newham, Homerton and Southend Hospitals. In 2005, the Trust was approached by the Colchester MDT clinical lead, leading to referral of these patients to The Royal London Hospital for major OG surgery. With an existing provision for Southend patients, our referral patient population increased to 1.8 million people over a two year period. In 2010, as a result of high operative mortality (19%) the OG surgical service at University College Hospital (UCH) was suspended. The Medical Director of UCH asked Barts Health to take up all OG surgical cases from North Central London Cancer Network (NCLCN), increasing the catchment patient population to over three million. Between September 2010 and March 2011, we accommodated the surgical patients from NCLCN. There was seamless transition of services with no breaches in cancer waiting times and post- operative mortality fell for the fifth consecutive year as shown in the surgical morbidity and mortality data on page 21. This work was repatriated with the appointment of a new lead surgeon at UCH. Essex referrals were repatriated to their centre in Chelmsford at the beginning of 2012, returning our referral patient population to just over one million.

http://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Click%20on%20image%20to%20zoom&p=PMC3&id=3274437_1471-2407-12-11-3.jpg


Reconfiguration of OG cancer services in London The Model of Care published by London Health Programmes in 2010 recommends four centres in London, each serving a minimum population of two million. London Cancer has a population of 3.5 million indicating that resolution into a single site is appropriate. Complex cancer surgery is currently provided at three sites within the London Cancer Integrated Cancer System:

Queens University Hospital, Romford.

University College Hospital.

The Royal London Hospital. The Association of Upper GI Surgeons has provided evidence-based guidance on minimum organisational and surgical volumes, recommending that the ideal service would require four to six surgeons, each undertaking 15-20 procedures per year for a patient population of one to two million. None of the existing surgical centres within the London Cancer area is compliant with this guidance. Augis suggests that a population of 1million should generate 52 OG resections annually. The graph below shows the observed and expected number of resections in each of the existing specialist centres in the London Cancer area . The 148 resections represent 91% of the expected resections, although there appears to be heterogeneity across the 3 centres. There are a number of possible explanations for this; some patients may be coming from outside the area and some may choose to go out to be treated in a different centre. In the new specialist centre, we will monitor this, to ensure that the right patients are getting the right treatment in the right place. Number of resections expected according to population served 2012-2013

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OBSERVED

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Description of Barts Health local and specialist

oesophago-gastric service


Description of Barts Health local and specialist OG service We currently provide a comprehensive integrated pathway for patients diagnosed with oesophago-gastric cancer at all the Barts Heath sites and Homerton University Hospital. In the following sections we describe the existing patient pathway with particular reference to provision of patient centred care, the Barts Health OG team leadership and our vision for the future. As with the previously cited examples of organisational leadership, the OG cancer surgical team has strong support from the Trust Board, Clinical Commissioning Groups, public health, clinicians within this Trust and other referring trusts (Appendix 1). National Peer Review has consistently commented on the strong leadership of the OG cancer team with integrated patient pathways for all patients from our legacy trusts and with hospitals in Essex (Appendix 6). We have excellent relationships with Homerton University Hospital, supported by joint surgical and oncology appointments. We have always sought to deliver local care where possible, and centralised expertise where necessary with seamless transition of care across sites. This model of joint working across sites will be the basis of future developments of the service.

Clinical governance

Upper Gastrointestinal Surgery Cancer Clinical Governance: Structure and Reporting

Trust Medical Director

Dr. Steve Ryan

Surgery Clinical Academic Group Director

Dr. Andy Morris

Upper Gastrointestinal Clinical Lead

Miss. Frances Hughes

Multi-Disciplinary

Mortality and Morbidity

Bi-Monthly Clinical Review Meeting


Management reporting structure


Barts Health Specialist MDM

Multidisciplinary team (MDT) leadership roles

Clinical Lead for OG Cancer MDT: Miss Frances Hughes

Frances Hughes (FH) was appointed in 2003 to develop OG cancer surgery at The Royal London Hospital. She set up a hub and spoke pathway with outreach clinics in Southend. She co-ordinated the centralisation of cancer surgery for the inner east London group of hospitals at The Royal London and led the developments of local surgical clinics, collaborating with surgeons in Homerton and Whipps Cross.

Frances has led a well-established regional centre with excellent outcomes, having co-ordinated care across up to eight referral sites over the last ten years. She became the clinical lead for general surgery at The Royal London in 2010 and became cross site lead for UGI and HPB surgery in 2012. Frances was the vice chairman of the North East London Cancer Network (NELCN) OG Tumour Advisory Board for seven years and is an active member of the London Cancer OG pathway board.

Academic Surgical and Education Lead: Mr Bijen Patel

Bijen Patel (BP) is the academic Surgical Lead for OG Cancer. He established the Masters course in surgical skills and sciences at Queen Mary University London in 2004 and has set up a Virtual Reality Surgical Simulation Centre for training surgeons, based at Barts Cancer Institute. He has obtained recognition from the Royal College of Surgeons of England and the Association of Laparoscopic Surgeons of Great Britain and Ireland to be one of the national training centres in laparoscopic surgery. He has recently become the Clinical Lead for General Surgery at The Royal London Hospital.

Director Cancer Pathways and Perfomance: Dr Angela Wong

Angela Wong (AW) was appointed as OG MDT lead for Barts Health in 2012 to ensure consistent excellence in cancer care across the Trust. Her previous experience as lead cancer clinician for Whipps Cross University Hospital and clinical lead of the Whipps Cross OG MDT afforded her the necessary skills. She has recently been appointed as Director of Cancer Pathways and Performance. Angela has completed the Kings Fund Clinical Directors leadership program.

Clinical Trials Lead: Dr David Propper

David Propper (DP) has been the clinical trials lead for five years and oversees a comprehensive portfolio of National Cancer Research Network trials. He ensures that patients have access to trials at all stages of their cancer treatment, ranging from phase I to III. For metastatic oesophago-gastric cancers the phase I trials are performed in collaboration with Sarah Cannon, Research UK, under his supervision.


Barts Health is unique in having 11 scanners across our sites with capacity for rapid access for staging, follow up and image guided intervention which is backed up by GI, oncology and dedicated interventional radiologists. The majority of our scanners are state of the art incorporating dose modulation, a feature which minimises patient exposure to radiation.

Academic Oncology Lead: Dr Thorsten Hagemann

Thorsten Hagemann (TH), Clinical Senior Lecturer and Honorary Consultant, is the lead for academic medical oncology for patients with upper gastrointestinal malignancies, and has an active portfolio of clinical trials run through the Barts Experimental Cancer Medicine Centre.

Director of Cancer Strategy/ Clinical Director for Solid Oncology and Cancer Surgery: Dr Sarah Slater

Sarah Slater (SS) is an OG medical oncology consultant, leads for Acute Oncology Service for the Trust, is a member of the NCRN OG subgroup, and has recently accepted an invitation to join the Oesophago-Gastric Clinical Reference Group as clinical representative for NE London.

Barts Health representation on the London Cancer OG Pathway Board

FH: Deputy Pathway Director AW: Lead for early diagnosis Matt Guinane (MG): early diagnosis group Raksmi Soni (RS): Dietetics representative Technical Group Members: SS, Ashis Rohagi (AR), BP.

Patient pathway

A flow diagram of the entire patient pathway is included in the Appendix 7. Below we detail the current arrangements for patients diagnosed and treated in the Barts Health Specialist OG Surgery Centre, and how patients will be supported throughout their cancer pathway.

Diagnostic pathway

The diagnostic pathway is represented diagrammatically in Appendix 7. All routine endoscopy referrals are booked within six weeks and urgent cases within two weeks. GPs use the NICE 2ww forms for urgent referrals via the 2ww office. An urgent advice line via email is available. Direct referral for urgent endoscopy from any specialty can be accommodated within one week. Barretts surveillance programmes are in place on all sites. An innovative one- stop consultant service for urgent referrals with an assessment of history, co-morbidity and nutritional status immediately preceding endoscopy was initiated and piloted at the Whipps Cross site, led by Dr Angela Wong. Plans are in place to develop similar services at Newham and Royal London sites. If endoscopic appearances are suggestive of malignancy, the patient is informed, with the upper GI clinical nurse specialist (CNS). If no CNS is available, contact details are given. A staging CT scan is requested; with access to 11 CT scanners within the Trust, we can provide a same day appointment. Dietary supplements or referral to a dietician are offered, if necessary. Blood tests and ECG are performed.


Patients are offered a copy of their endoscopy report which is faxed to the GP within 24 hours with arrangements for follow-up. This is regularly audited. The CNS contacts the patient after their endoscopy for support and lists them for the multidisciplinary meeting (MDM). All biopsies from our diagnostic units are processed and reported at The Royal London Pathology Department by the highly specialised oesophago-gastric pathology team. The availability of staging investigations for our diagnostic units is tabulated below:

Investigation RLH Homerton Newham Whipps Cross

Pathology RLH RLH RLH RLH

EUS RLH HUH RLH RLH

PET Barts Barts Barts Barts

Staging Laparoscopy RLH HUH RLH WXH

RLH Royal London Hospital EUS Endoscopic Ultrasound NUH Newham University Hospital PET Positron Emission Tomography WXH Whipps Cross Hospital HUH Homerton University Hospital

Appointment to discuss diagnosis

Patients are advised to bring a relative or friend to this appointment. Advocates are arranged if required. A consultant (gastroenterologist or OG surgeon) with advanced communication training explains the diagnosis and outcome from the MDM with an upper GI CNS. All core members of the Barts Health MDT have Advanced Communications Skills.

Patients who require further tests such as endoscopic ultrasound (EUS) or positron emission tomography (PET) are given written arrangements. Patients who are referred for treatment or palliation are informed of the named consultant. It is explained that patients may be invited to participate in a clinical trial.

Barts Health has been a driving force in the development of Holistic Needs Assessment (HNA) Holistic needs assessments are undertaken by an appropriately trained CNS with referral to cancer rehabilitation specialists as appropriate.


The clinic letter is faxed to the GP within 24 hours and the patient is offered a copy. Additional written information is provided. Contact with the local CNS is encouraged if there are any queries following this appointment.

Multi-disciplinary team (MDT)

The weekly MDM at Barts Health is a single meeting which functions as a specialist and local MDM, involving St Bartholomews, Royal London, Whipps Cross, Newham, and Homerton University Hospitals by video-link. All new cases are discussed and the MDT co-ordinator records the stage and management plan on the Somerset Cancer database. Co-morbidities and relevant history including nutritional information can be recorded. Letters are typed at the time of the meeting and faxed to the GP the same day. Images from the referring unit are transferred by electronic image transfer. The number of cases discussed in the MDM are shown below.

Chart to show the number and breakdown of MDT discussions between 2009 - 2012

0

50

100

150

200

250

300

RLH Newham Homerton Whipps RLH Newham Homerton Whipps

New patients Follow-up patients

Referring hospital and new/follow up patient

Num

ber

of d

iscu

ssio

n

2011/12

2010/11

2009/10


Barts Health specialist oesophago-gastric multi-disciplinary team members

Lead Clinician Specialist MDT Royal London Miss Frances Hughes Lead clinician Newham Dr Matthew Guinane Lead clinician Whipps Cross Dr Angela Wong Lead clinician Homerton Dr Ray Shidrawi Specialty Lead Radiology Dr Alison Mclean, Dr Aman Parsai Dr Nick Reading Dr H Kamel Dr Peter Bouvida

Pathology Dr Lisa Mears Prof Roger Feakins Dr J Chin Aleong Dr Nilu Wijsuriya Dr V Sheshapanever Dr Rob Owen Dr Costas Konstantinos

Clinical oncology Dr Amen Sibtain Dr Chris Cottrill

Medical oncology Dr Sarah Slater Dr David Propper Dr Thorsten Hageman

Gastroenterology Dr Sean Preston Dr Lisa Das Dr Louise Langmead Dr Angela Wong Dr Sami Hoque

Dr Ralph Greaves Dr Matthew Guinane Dr Elizabeth Carty Dr Ray Shidrawi Dr Alan Watson Dr Vasu Kulhalli Dr Andrew Rochford

Dr Laura Morelli Dr Nora Thoua Dr Neil Ikin

Surgery Miss Frances Hughes Mr Bijen Patel Mr Kesava Manur

Mr Ashis Rohatgi

Nurse Specialist Yemi Fuwa Martina Kelly Mahendra Jugmee Lauren Ball, Leslie Bain

MDT co-ordinator Sally Howe Farzana Parbin Anne Lake Sophie Yavo

Palliative care nurse Sue Lepp Judith Londe

Dietician Yasmin Alam Raksmi Soni

Psychological support Mark Barrington Jeanette Marsh Clare Stevenson


Members with specific responsibilities

Service Improvement Lead Dr Sarah Slater Core member responsible for participation in clinical trials Dr David Propper Core member with responsibility for users issues, patient and carer information Ms Yemi Fuwa Core member for reporting cross sectional imaging and interventional procedures Dr Alison Mclean (lead imaging consultant) Core member trained in endoscopic ultrasound Dr Sean Preston Dr Ray Shidrawi Dr Angela Wong Dr Sami Hoque Dr Louise Langmead Core members trained in endoscopic laser Dr Sami Hoque Dr Louise Langmead Dr Sean Preston Dr Angela Wong

Relationships between the MDT co-ordinators and the nurse specialists across the four sites are excellent, allowing seamless transition of information for compilation of the MDM agenda. The images are transferred electronically. The specialist centre CNS remains in regular contact with the patient and the CNS at the diagnostic unit. They can arrange outpatient review, dietetic or palliative care referrals as required. Barts Health has four clinical nurse specialists; cross site working is used to maximise integration of care when patients come for surgery. Urgent cases are discussed between meetings, subsequently ratified and documented by the multidisciplinary team to avoid delays in treatment.

Our MDT is exceptional in that in addition to the essential requirements for Improving Outcomes Guidance compliance, we have four Barts Health gastroenterologists experienced in endoscopic ultrasound and endoscopic mucosal resection for early oesophageal cancer or Barretts oesophagus. We have five specialist gastrointestinal pathologists who specialise in gastrointestinal re-sectional reporting. All Barts Health core members of the specialist MDT have undertaken advanced communications training.

With development of the new specialist centres, we will develop a new arrangement for the specialist MDM. After discussions with the lead surgeons from the other existing specialist centres, we have agreed that there will be one single teleconference specialist MDM for all of London Cancer to discuss all patients to be treated with radical intent. The details of this will be agreed through the OG Pathway Board.

Treatment decision

All patients diagnosed with oesophago-gastric cancer or high grade dysplasia, are discussed, allowing every patient within the inner east London area to be discussed by a specialist MDT. All appropriate treatment options including curative surgery, definitive chemo-radiotherapy, palliative chemotherapy or radiotherapy, endoscopic therapy and clinical trials, are considered at the MDM. The proposed treatment plan will take into consideration the patients general health, quality of life and most importantly the views of the patient and their supporters or advocates. Patient involvement in treatment decisions is a core value in Barts Health. Our 2013 patient survey (Appendix 8) confirmed that all patients who responded to the survey felt that their wishes and those of their family were respected.

The MDT decision is recorded on Somerset Cancer database and filed in the hospital records by the MDT co-ordinator. If the patient is not considered suitable for surgery, they are referred to the specialist OG oncologist at their local hospital for a full discussion about possible therapies. Their long term management depends on the outcome of these discussions, patient choice, and response to any treatment. If laser therapy is considered the optimum palliation, they will be referred to the service at University College Hospital. Patients have access to trials at all stages of their cancer pathway, which range from phase I to III. For metastatic oesophago-gastric cancers the phase I trials are performed in collaboration with The Sarah Cannon Research UK Unit, under the supervision of Dr David Propper. Following the MDM, patients are contacted by their keyworker to ensure appropriate follow up (Appendix 7). The proposed treatment plan will take into consideration the patients general health, quality of life and most importantly the views of the patient and their supporters or advocates. Patients considered suitable for surgical resection will be reviewed by the specialist surgeon in the surgical clinic and offered surgery if appropriate as described below.

Frailty syndrome is a critical issue in older peoples oncology - recognising the increasing age of the population and possibility of co-morbidities that may impact on treatment decision. Barts Health was a pilot site for the recent Macmillan study, and we will develop an integrated care component of the MDT, referring complex patients to our specialist care of the elderly consultants, to optimise the patients health, and ensure all treatment modalities are considered for all (ref Ferrucci, 2003). There is a named clinical lead for Care of the Elderly on each of the Barts Health sites.


Specialist surgical pathway

The Royal London Hospital is the designated centre for OG Cancer surgery in inner north east London where all elective surgery for oesophago-gastric cancer diagnosed at Barts Health or the Homerton is performed. The graph below shows the number of re-sections performed at The Royal London Hospital in comparison to other London providers. Treatment decisions are based on the NELCN guidelines to which all referring sites have contributed. Surgery takes place within 14 days of the decision to treat or between four to six weeks after neo-adjuvant chemotherapy. The surgical pathway is represented pictorially in the Appendix 7.

The existing OG surgical team comprises four specialist OG surgeons skilled in open and laparoscopic surgical techniques: Two full time NHS Consultants

Frances Hughes - Royal London / Southend Outreach Clinic

Ashis Rohatgi - Royal London / Whipps Cross


One Clinical Senior Lecturer

Bijen Patel - Royal London / Barts One Honorary appointment with Homerton Hospital

Kesava Mannur - Royal London/ Homerton -in reach surgeon The team is supported by two specialist upper gastrointestinal anaesthetists experienced in thoracic anaesthesia, who also work as intensive care clinicians, and are active members of the MDT. After the specialist MDM, the Royal London CNS liaises with the CNS in the referring hospital to arrange the outpatient appointment and ensure that the referral package is transferred to the specialist centre (Appendix 9). Where possible, the patient will be seen by a specialist surgeon in the diagnostic centre. A combined outpatient surgical clinic with anaesthetic assessment may be arranged to minimise hospital visits. A booklet describing transport links to the hospital is sent to the patient (Appendix 4). The table below shows the site for outpatient activities.

Site of diagnosis RLH Homerton Newham Whipps Cross

Dietetic appointments

BH HUH NUH WXH

Psychological Support

BH HUH BH BH

Patient support group

BH HUH BH BH

Surgical Clinic

(new /fu)

BH HUH- KM BH WXH- AR

BH Barts Health

In the surgical clinic, the surgeon and CNS explain the proposed surgery and offer information booklets and a copy of correspondence. Holistic and nutritional re-assessment is carried out. Patients are offered the opportunity to talk to a buddy, a patient who has previously undergone similar surgery. The clinical nurse specialist has a list of suitable patient support group members. Psychological support can be arranged. The CNS has level II psychological training. Some patients may require tube feeding after nutritional assessment. Feeding jejunostomy may be required for patients receiving neo-adjuvant chemotherapy. If neo-adjuvant chemotherapy is indicated, patients are referred to the oncology clinic and alerted to the possibility of trial entry. Following completion of chemotherapy, the post- treatment scan is reviewed by the MDT and the patient seen by the surgeon. All patients attend the pre-admission clinic at The Royal London Hospital for pre-operative anaesthetic assessment and cardio-pulmonary exercise testing if required. This allows a decision regarding the optimum post- operative nursing environment: GI surgical ward or critical care, i.e. high dependency or intensive care unit. A visit to the critical care unit with the physiotherapist is offered.


Patients attend the designated 25 bedded GI surgical ward (13D) staffed by specialist GI nurses. On the morning of their surgery, they are seen by the anaesthetist and a member of the surgical team. All patients are offered the opportunity to participate in clinical research and are seen by a member of the research team. Male and female patients are nursed in single sex four bedded bays or single rooms on the ward. The male and female sections are completely separate. The nursing staff have a regular teaching programme which includes education about Upper Gastrointestinal surgery and post-operative care. The ward has a designated dietician. Surgery takes place in one of two GI surgical theatres by a specialist OG surgeon or sometimes a pair of surgeons, with a regular theatre team. After the operation, the patient is transferred to the critical care unit or to the GI surgical ward. The post-operative care protocols are attached (Appendix 10). The protocol embraces the principles of ERAS (enhanced recovery after surgery), including early mobilisation and perioperative nutrition with a view to discharge on day 10 for oesophagectomy and total gastrectomy and day seven for subtotal gastrectomy. Post-operative care is provided by the surgical team including the three Barts Health consultants, one specialist registrar (SPR), one senior clinical fellow, two core trainees, one foundation year trainee and one specialist nurse. The patient is reviewed by the Critical Care Outreach team after discharge to the GI ward. Out of hours care is provided by the on-call surgical team and the OG surgeon of the week (Appendix 11). CT scanning and interventional radiology is available 24 hours a day. The consultant pathologist prepares the fresh specimen and removes suitable tissue for research. Pathology turnaround time is within DH and Royal College of Pathologists (RCP) key performance indicators. A regular audit of the quality of pathology reporting compared with the RCP Guidelines is performed and reported to the multidisciplinary team AGM. Hereditary diffuse cancers are treated according to WHO protocol. The histology is presented at the first MDT after surgery. If adjuvant treatment is recommended, the patient is referred to their oncological team, for consideration of chemotherapy or chemo-radiotherapy.

Multidisciplinary ward round


Yemi Fuwa, OG Surgery CNS

Co-location of services

DS had surgery to a gastrointestinal stromal tumour of the stomach and liver and was pleased to avoid transfer to west London or repeated operations at two different centres. In early August 2009 I had an operation on my stomach and liver by Miss F Hughes and Mr Abraham team. (DS E6 1LP)

Post-operative follow up

The surgical patient is discharged from the centre with arrangements for follow up by the operating surgeon either at the specialist centre or in the local hospital. Clinics are held jointly with the CNS. District nurse referrals are made and communication sent to GP, community dieticians and the rehabilitation programme described on page 51. The treatment and support was truly amazing. Both Yemi and Southend Specialist Nurse excellent... She spoke to us all individually and as a group. All of our questions were discussed fully. Regular visits on the ward. And then when I returned home frequent phone calls to see my progress and to see if I had any anxieties. Yemi gave me advice on diet, exercise information on other agencies if I should need them. Yemi was excellent. Anon patient survey 2013

Patients are followed up by the specialist surgeon at three monthly intervals for the first year, six monthly intervals for the second two years and annually thereafter (NELCN guidelines). This follow up is arranged in local clinics wherever possible. Local dietetic follow up is requested in the community.

Concerns and re-admission

If patients have concerns after discharge, they contact the CNS during working hours or out of hours the GI surgical ward at the specialist centre. However, some patients may prefer to go to the GP or local hospital. If the patient requires re-admission, transfer to the centre is arranged or outreach support to the local hospital can be provided as appropriate and according to patient preference (Appendix 4). Patients will be followed up after surgery as outlined in pathway diagram or seen more frequently if clinically indicated.

The model of care and the specification for OG cancer centre did not state any essential co-dependencies for OG cancer. However, some of our patients have benefited from the co-location of Hepatobiliary and oesophagogastric surgeons: Up to 6% of our patients require joint OG and hepatobiliary surgical procedures each year, involving concurrent liver or pancreatic resection at the time of OG cancer surgery.


Oncology

Medical Oncology

There are three GI Medical oncology consultants and two clinical oncologists, who deliver chemotherapy to our patients. There are local oncology clinics at SBH, WXH, NGH, HUH and WXH sites. Chemotherapy can be delivered at NGH and HUH sites, or at SBH. The oncologist who sees the patient locally, will transfer care directly to the centre if this is necessary. Electronic chemotherapy prescribing at all sites within the Trust will be completed at the end of June 2013. The chemotherapy service at Barts Health is open seven days a week with extended hours to allow patient choice as much as possible. A homecare service is being utilised for the provision of some oral chemotherapy, but the strategic direction is for the provision of treatment closer to home, whether that is patients home, local GP centre, local hospital, or possibly at work. Neo-adjuvant chemotherapy is offered to all patients who meet the criteria for this, and who are deemed fit enough to receive this treatment. Adjuvant chemotherapy is considered for those patients deemed fit enough to receive this post operatively and chemo-radiotherapy for patients at high risk of recurrence. Dietician support and advice is available at all sites. Nutritional assessment is undertaken prior to commencement of chemotherapy and jejunostomy feeding may be required in cases with severe dysphagia. This can be rapidly arranged by the surgical teams if required. We have strong clinician engagement with London Cancer with the appointment of Dr Chris Gallagher as its Chemotherapy Expert Reference Group Chair.

Clinical Oncology

There are two upper GI clinical oncologists within Barts Health Dr Amen Sibtain and Dr Chris Cottrill. Both have OG oncology clinics. Chris Cottrill also acts as the co-Chair of the Radiotherapy Expert Reference Group for London Cancer. Radiotherapy provision is at the Barts site. There are five Rapid Arc-enabled Linear accelerators, a Cyberknife, an orthovoltage unit and a microselectron HDR Brachytherapy machine. Intensity modulated radiotherapy is being developed for upper GI malignancies, built on extensive experience on its use in head and neck cancer.

End of life care

End of life care support to our MDT is provided by a palliative care CNS and is closely linked with primary care and community services. Within BartsHealth, there is an inpatient provision at St Josephs Hospice and 12 beds at the Margaret Centre on the Whipps Cross site. An expansion of the whole service is under review, to provide a comprehensive service to all patients, their carers, GP and community services, the following: (a) direct patient access outside normal working hours, (b) telephone advice 24 hours a day and seven days per week, (c) 9am - 5pm service on site seven days a week


Patient on the Tower Hamlets Cancer Survivorship Project

(d) roll out of co-ordinate my care programme (CmC) an electronic data model that shares information on a patients current treatment and medication between hospital professionals, teams in emergency departments and primary care. When trialled in Sutton the use of CmC reduced the hospital admission rate by 40%. We will develop an end of life strategy, which includes a personalised integrated care plan to minimize hospital appointments and strengthen community support. We will develop strong links with Specialist palliative care teams close to their home to ensure complex symptom control. Patients are provided with information about Hospice care and charity groups. Palliative Endoscopic stenting is available on all sites within Barts Health. Patients requiring endoscopic laser are referred to the service at University College Hospital (UCH).

Rehabilitation and psychology

Tower Hamlets Cancer Survivorship Project (Appendix 12) was initiated by the therapies team for Cancer Services at St Bartholomews Hospital (SBH) early in 2011 and was commissioned by Tower Hamlets PCT. It aims to help local residents living with and beyond cancer understand and take charge of their life after cancer and to promote physical health and emotional well-being. It is hoped the programme will mirror findings from USA pilots and improve quality of life and increase physical activity amongst local residents living with and beyond cancer.

The service is based on the American 'Cancer Transitions: Moving Beyond Treatment programme developed in 2006 through a partnership between the Cancer Support Community and LIVESTRONG charities. It uses written materials and formalised exercise to address the long-term effects of cancer treatment and psychosocial needs. The criteria for eligibility are (i) having been treated for cancer at Barts or (ii) being a Tower Hamlets patient with cancer, regardless of treatment centre. In both cases, treatment must have been completed before entering the programme. The majority of Tower Hamlets residents diagnosed with cancer are treated at Barts, which is also a tertiary centre for cancer management accepting patients from across South East England and beyond. Referrals are received from hospital clinical teams, GPs and directly from patients. Not all patients are ready to start the programme at the time of referral - for example their treatment may not have been completed. A list of referred patients is maintained by the service, and information is sent to them (usually by email) ahead of each new course. Patients are invited to book a place on the next course when they are ready, or to let the service know if they are no longer interested in attending. The service aims to run at least eight courses a year, with the potential to increase this to 10 courses a year and has the capacity for up to 12 patients in each group.


The programme is a six week, community / outpatient based programme covering the benefits of exercise, nutrition, emotional support, and medical management. Up to 15 participants meet for a two and a half hour session each week to hear presentations from experts, engage in group discussion, and directly address the emotional and social hurdles they face during the transition period following treatment. Each session includes 30 minutes of group exercise including advice on how to individualise physical activity. The programme also offers a booster session held one month after the programme ends, to reinforce many of the proactive behavioural changes discussed during the core programme. The programme is regularly audited, and the feedback from patients and commissioners is excellent. Comments from our patients: I cant believe what a difference it has all made to my energy and outlook. This group has been amazing! It has given me the confidence to get back exercising again. It has really made a difference to my well-being. Yes, this programme has made me more confident within myself regarding cancer, promoted my exercise tolerance and my future life. I made friends with others in the group and I have become fitter and more equipped for healthy living. The most common cancer diagnoses in Barts Health patients on the programme were upper gastrointestinal (OG) cancer, followed by urological cancer, haematological cancer and breast cancer. Mark Barrington is the Lead Psychologist for Cancer Services and co-ordinates the on-going supervision of level two psychology trainees, which includes our CNS. The team provides psychological support for all patients across Barts Health.


Barts Health vision for centralised surgical services


Barts Health vision for the centralised surgical service

Future joint working

We have excellent relationships with all the OG surgeons in the London Cancer area, many of us having worked together within the NELCN for many years and have shared trainees who are now consultants within our units. We feel sure that we can build on these relationships to develop a single centre for the treatment of patients with OG cancer albeit in a staged process. We intend to extend the existing surgical hub and spoke model, where patients undergo operation at The Royal London Hospital supported by diagnostic services, staging and pre-operative investigations, oncology care and surgical follow up in the local hospitals. Co-ordination of this pathway will require a strong team, guided by exemplary leadership. We are confident that we can provide this care for the population of London Cancer. In the suggested, staged two centre model, the patients who are currently referred to the centre that becomes de-recognised are likely to attend one or other of the newly designated London Cancer centres in accordance with patient choice. We will work with the team at the other centre to ensure that patient pathways are identical. FH has held helpful discussions with the lead surgeons of the other two existing surgical centres to discuss ways of collaborative working. In the fullness of time, centralisation on a single site will be required to comply with the Model of Care.

Future leadership model

We will work together with the pathway board to appoint a London Cancer Leadership structure to ensure a cohesive and successful OG service, which utilises the strengths and talents of all members of staff from all sites across London Cancer. We will have a:

(a) Director of OG Surgery (b) Director of Early diagnosis (c) Director of Oncology (d) Director of Education and Academic Research

These appointments will be through a competitive process.

Proposed surgical team organisation

Currently, there are 10 OG surgeons undertaking re-sectional surgery in the London Cancer area, three at UCH, four at RLH and three at Queens. There will need to be re-organisation of surgeons job plans to allow operating at the surgical centre. Historically, reorganisation of cancer surgical services has resulted in some surgeons ceasing to operate on cancer cases and not participating in the new model. It is possible that some of our surgeons will not wish to disrupt their current working pattern and will not want to be involved. This will require sensitive discussion at the time of centre designation. We describe below the proposed models for centralisation of OG cancer surgery, firstly as a single centre at Royal London Hospital and secondly as one of two centres as part of a staged process to achieve centralisation. Both models involve in reach surgeons, i.e. surgeons contracted to work in the diagnostic units who attend the London Cancer Specialist centre to undertake OG cancer re-sectional surgery.


The number of surgeons in the model described is the minimum number considered to provide the service. A larger number can be accommodated according to the Association of Upper GI Surgeons (AUGIS) guidelines. We will endeavour to accommodate the contributions and wishes of the existing surgical manpower and ensure that all surgeons are undertaking the requisite 15-20 resections recommended by AUGIS.

In either model, we will collaborate with the diagnostic centres and any other specialist team to establish a Joint Specialist Teleconference MDM, at a mutually agreed time. We will work to joint protocols and clinical guidelines. We will undertake joint audit projects. We shall hold specialist annual general meeting with representatives from all the diagnostic centres throughout the London Cancer area. The surgical team, including intensivists and anaesthetists, will meet every two months to discuss morbidity and mortality, research and enjoy an educational presentation.

Principles of in reach model

All patients must be discussed at the specialist MDM. It is not appropriate for in reach surgeons to bring their own patients into the centre without formal joint discussion at the specialist MDM. The in reach surgeon must have a formal contract with the host trust and be appraised in the usual way at that Trust. His long-term and short term results should be subject to the same audit as host surgeons. The in reach surgeon must be a core member of the specialist MDT. The approach to investigations, staging, counselling of patients and provision of information and literature and information about alternative approaches should be standardised and should follow London Cancer Guidelines. The in reach surgeon must be an accepted and full member of the host surgical team and should be involved in the same way as host surgeons in seeing patients for counselling and for early post-operative assessment. The surgical procedures being done in the centre should be as standardised as possible in terms of surgical approach, extent of excision, degree of lymphadenectomy and reconstructive approaches. There should be a formal centre policy with respect to these points. Standard approaches to post-operative management and post-operative follow up should be agreed, documented and adopted. The in reach surgeon should work formally with a single named colleague employed solely within the host hospital so that there are clear that lines of accountability for peri-operative care. The in reach surgeon may operate on his cases jointly with his host colleague to facilitate the continuity of peri and post-operative care.

Surgery and on-call rota

In reach surgeons would attend the centre on alternate weeks for OG operating and participate in the on-call rota on the night that they undertook surgery. These in reach surgeons will be from the existing surgical centres, and would spend most of their working week at the local unit. They would participate in the specialist MDM, either in person or by teleconference. We would pair in reach surgeons with hub surgeons to ensure maximum continuity of care.


In the single centre model we would anticipate five surgeons; three hub surgeons and two in reach surgeons. The in reach surgeon would be on-call on their operating day (1:8 weekday, 1:5 weekends), the hub surgeons 1:4 weekday and 1:5 weekends. We have budgeted for one more full time surgeon at the centre to fulfil IOG compliance for a 1:4 rota if necessary. In the two centre model, each of the newly designated centres will have three hub surgeons and one in reach surgeon, to provide four surgeons for the on-call rota for in house emergencies. A combined rota where one of the centres was on-call would be possible for new tertiary emergency referrals, to direct new cases to the on take centre. This would minimise the additional on-call commitment at the centre for the in reach surgeon, who is likely to stay on the emergency on-call rota at the local unit hospital. The in reach surgeon would be on-call on his operating day (1:8 weekday and 1:4 weekends, centre surgeons would cover OG on the alternate week). Each designated centre would need to resect a minimum of 60 cases per year to fulfil minimum recommended surgical volumes. It will be the role of the London Cancer OG pathway board to decide how best to direct referrals so that the two centres perform equal numbers of cases, although patient choice and geography will be involved.

Surgical outpatient clinics

Irrespective of the selected model, as a designated centre for London Cancer, we would anticipate establishing at least one further outreach clinic, probably in one of the North Lond

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