Tayside Breast Cancer Independent Advisory Group: final report

Governance - a "Once for Scotland" approach

12. As stated above, the Group is keen to pursue a "Once for Scotland" approach wherever possible, including the development and implementation of cancer Clinical Management Guidelines (CMGs).

13. The NHS Tayside staff and patients and their families we met were strongly supportive of this during our interactions with them. The Group discussed the new governance arrangements which are now being implemented in the NCA, and the equivalent processes in place in SCAN and WoSCAN. It was agreed that there was scope for aligning these arrangements. The Group therefore recommends that the three regional networks should undertake a mapping review of the terminology being used in governance structures, with the aim of achieving, where feasible, more consistency across NHS Scotland. (Recommendation 3).

14. The Group heard evidence which strongly suggested that the core principles underpinning the establishment of Managed Clinical Networks in NHS Scotland (laid out in MEL (1999) 10) were not being adhered to in NHS Tayside, and possibly more widely across Scotland. The Group therefore recommends that all NHS Scotland staff (particularly clinical staff) be reminded of the requirements of MEL (1999) 10, and the need to engage with the governance arrangements covered in section 8 (Recommendation 4). In the case of consultant staff this would include attendance at relevant advisory groups, e.g. tumour specific meetings. Such attendance should be included in the individual's job plan in consultation with the relevant Medical Director. (Recommendation 5). An extract from the relevant section of MEL 1999 (10) can be found in Annex C1.

15. The Group also recommends that Scottish Government should consider whether para 1.43 of CEL 30 (2012) (which covers the safe delivery of chemotherapy) requires clarification as to where the balance of governance lies, locally and regionally. The need for revision of the CEL has already been agreed by the Scottish Cancer Taskforce. (Recommendation 6). An extract from the relevant section of CEL 30 (2012) can be found in Annex C2.

16. The Group reviewed the new NCA processes for the development of CMGs and SACT protocols, and the equivalent processes in SCAN and WoSCAN, including escalation processes through constituent Boards. In the event of lack of clinical consensus around a CMG, the Group believes that Board Medical Directors should be directly involved early in those processes, to facilitate resolution. The Scottish Association of Medical Directors should be used to raise awareness of this report and provide direction and leadership to ensure implementation of the recommendations in this report. (Recommendation 7).

17. The Group believes a properly resourced multi-professional National Clinical Management Guidelines Oversight Group should be set up for the development and monitoring of compliance with CMGs, and ensure consistency across NHS Scotland. (Recommendation 8). The current regional network CMG development processes would continue, but the new national group would consider any issues of variation between the regional CMGs and would also develop a system to oversee implementation and monitor compliance. The Group accepts that the establishment of the oversight group will take some time and will require sufficient resource (e.g. a national secretariat) to run and maintain its activity. In advance of that happening, it was agreed that regional cancer networks should formalise the process of sharing CMGs across NHS Scotland, in the interests of national consistency, governance and shared learning. (Recommendation 9).

18. The NCA have already started a review of all of their extant CMGs, and the Group believes that this should also take place in the other two networks (SCAN and WoSCAN). The process should also ensure associated Systematic Anti-Cancer Therapies (SACT) protocols take into account the existing evidence base (e.g. SMC and SIGN Guidelines) and must include escalation procedures where consensus is not reached. If variation exists, this needs to be explained and justified (Recommendation 10).

19. The Group further recommends that the National CMG Oversight Group should hold an annual consensus conference to facilitate and embed a "Once for Scotland" approach that encompasses cancer CMGs. (Recommendation 11). Tumour group leads in the three networks should confer prior to these conferences to identify priority areas to be covered and ensure multi-professional attendance. The conference should focus on the development and implementation of CMGs, and any relevant associated issues - for example including, but not limited to - benchmarking, workforce issues, compliance and research which can contribute to the evidence base. The Group felt there would be real benefit in involving patients in the planning and delivery of the national conference.

20. These new arrangements for cancer CMG development and monitoring should be communicated to NHS Scotland through a new CEL. (Recommendation 12).

21. The National Cancer Quality Steering Group currently oversees the implementation of the national cancer Quality Performance Indicators (QPI) programme. The QPIs are widely recognised as being a powerful mechanism to improve cancer outcomes by benchmarking of cancer services within NHS Scotland to internationally acceptable standards.

22. Annual review of the QPI data and revision processes are important in driving forward service changes and improving clinical quality and patient outcomes. Each tumour group within the regional network is expected to hold an annual regional meeting to discuss the previous year's results and develop an action plan for the forthcoming year. In addition, each tumour specific QPI is reviewed every 3 years. The Group heard that funding for these meetings can be challenging to identify and that not all Boards send representatives to the meetings. The Group therefore recommends that adequate resource be allocated in each of the networks to hold these meetings and that the networks, along with their constituent Boards, must all be represented at the meetings in order to give proper consideration to the QPI data and complete the audit loop. (Recommendations 13 and 14).

23. The opportunities for patient involvement in cancer regional network meetings vary across the country. The Group agreed that the perspective patients can bring to such discussions is important. The Group reflected on the possibility that if patients/lay persons had been involved in the group discussion of the decision to vary practice by the NHS Tayside oncologists, there may have been a different outcome. For clinical governance to be effective, it is crucial not only to have good governance processes in place, but also to develop systems that are capable of evolving over time, and ensure adherence. In this context, the Group believes that would be mutual benefit if the three networks found ways to observe at first hand the meetings and processes in place in other regions, including levels of patient involvement.

24. The Group therefore recommends that NCA, SCAN and WoSCAN officials take the opportunity to observe at first hand the operation of each other's networks, including patient involvement processes (Recommendation 15).