Tayside Breast Cancer Independent Advisory Group: final report

Discussion

1. This section deals with the consideration behind each recommendation listed in Table 1 below. Recommendations have been grouped into key themes of Governance, Clinical Processes and Patient Informed Consent and are presented in the order that they appear in the body of this report, which does not imply any order of priority.

2. The HIS report expressly excluded coverage of cultural issues within the NHS Tayside breast oncology team and NoSCAN (now the North Cancer Alliance – NCA), which this Group quickly identified as a potential area of concern, and in need of consideration. Key to public trust being regained and relationships rebuilt, will be understanding and addressing the wider issues at play in this area, to avoid a similar situation arising in the future.

3. The Group gave consideration to whether the current organisation of cancer services delivered in Scotland through three regional networks should be replaced with delivery through a single network. On balance it was felt that this would not only present significant logistical problems, but would also diminish access to local knowledge and accountability to local Boards. The Group therefore believes that the optimal arrangement is to maintain the three regional networks, but with improved Governance and better pan-Scotland working across the networks.

4. The Group strongly believes that in a country the size of Scotland, it should be feasible to take a more country wide approach to cancer service delivery. Some pan-Scotland approaches are already in place, e.g. in the case of the cancer Quality Performance Indicators (QPIs) which are developed by the National Cancer Quality Steering Group and then monitored by HIS. The move to a "Once for Scotland" approach is covered in more detail below.

5. In the course of its work, it also became evident to the Group that to look at the NCA in isolation would not provide adequate reassurance that a similar instance could not occur elsewhere in Scotland. It therefore undertook to consider national processes that could be applied across the country.

6. The Group heard evidence of the need for cultural and organisational change (including identification of those with good leadership skills) within NHS Tayside, and more widely across Scotland, to ensure that clinical governance processes are not only explicit, but adhered to in the future. It was noted that in order to deliver a world class service in any clinical area (including cancer), all units and teams need to have the ability to offer self-criticism. The Group believes that this is more likely to happen when the local talent pool is refreshed by external appointments, and/or where team members spend time in different locations.

7. The Group benefitted from discussion with an expert in Organisational Development, and heard about a number of recent actions already underway in NHS Tayside in this area. It was noted that positive leadership is a prerequisite for the development of strong, well-functioning teams. These in turn are associated with better patient care and outcomes. Leadership is not the same as management, but encompasses any individual who has an influence over others. Work is already underway to improve relationships and trust within NHS Tayside, across the NCA region and across Scotland. NHS Tayside consultants have complied with direction from NHS Tayside to offer the higher dose FEC-T regime to all new breast cancer patients at the start of their treatment, and also to use the Molecular Pathology Evaluation Panel (MPEP) recommended Oncotype DX test to identify which patients with early breast cancer should receive chemotherapy after surgery.

8. It was further noted that a collegiate approach will be crucial if the NCA (and its constituent NHS Boards) is to operate well in the future. The Group commended NHS Tayside on its approach to offering support to relevant consultant staff and the wider department. A positive working environment is essential, not only for staff morale and welfare, but also because a positive working environment for staff has been shown to improve the patient experience.

9. To support the development of a more collegiate approach across the country, the Group recommends that a separate longer life group be created to ensure implementation of this report's recommendations, particularly those relating to long term changes in organisational culture across cancer networks in NHS Scotland. (Recommendation 1). This new group should report directly to the Scottish Cancer Taskforce.

10. The Group has identified a number of recommendations that will require additional resource if this report is to be implemented effectively and in a timely fashion. The Group therefore recommends that sufficient resource is provided to the Regional Cancer Networks to ensure all recommendations in this report are delivered in full. (Recommendation 2).

11. It is crucial that patient trust in NHS Tayside and relationships across the NCA continue to improve. While we believe that both the Board and the NCA have made significant efforts in this regard, it was evident from patient and family members that more needs to be done as a priority. Further comment on patient support appears later in this report in paragraphs 27 to 29.