National Cancer Quality Steering Group minutes: June 2022

Attendees and apologies

Present

• James Mander, Regional Lead Cancer Clinician, SCAN (Chair) JM
• Matthew Barber, Consultant Breast Surgeon, NHS Lothian MB
• Jen Doherty, Project Co-ordinator, National Cancer Quality Programme JD
• Josephine Elliot, Programme Manager, HIS JE
• Kevin Freeman-Ferguson, Head of Service Review, Healthcare Improvement Scotland KFF
• Hilary Glen, Consultant Medical Oncologist, NHSGGC HG
• Peter Hall, Consultant Medical Oncologist, SCAN PH
• Bryan McKellar, Interim Regional Manager (Cancer), NCA BMcK
• Rafael Moleron, Consultant Clinical Oncologist, NCA RM
• Noelle O’Rourke, National Lead for the Scottish Cancer Network NO’R
• Peter Sandiford, Deputy National Clinical Lead, Cancer QPI Review Group, Healthcare Improvement Scotland PS
• Lorraine Stirling, Project Officer, National Cancer Quality Programme LS
• Carolyn Sunners, Senior Policy Manager, Scottish Government CS
• Iain Tait, Consultant Surgeon and Clinical Director, NCA IT
• Seamus Teahan, Regional Lead Cancer Clinician, WoSCAN (Chair) ST
• Catherine Thomson, Service Manager (Population Health), Public Health Scotland (PHS) CT
• Evelyn Thomson, Regional Manager (Cancer), WoSCAN ET
• Stuart Thomas, Consultant Pathologist and Lead Clinician, Scottish Pathology Network STH
• Joseph Woollcott, Health Influencing Senior Officer, Prostate Cancer UK JW

Apologies

• Lesley Aitken, Senior Reviewer, Healthcare Improvement Scotland (HIS) LA
• Lynsey Cleland, Interim Depute Director, HIS LC Richmond Davies, Head of Service, PHS
• RD Angela Jesudason, Paediatric Oncologist and Clinical Lead for the MSN CYPC Teenagers & Young Adults AJ
• Rob Jones, Consultant Medical Oncologist, NHSGGC RJ
• James Mansell, Breast Cancer Clinical Lead, WoSCAN JMA
• Andy Malyon, Melanoma Clinical Lead, WoSCAN AM
• David Morrison, Director, Scottish Cancer Registry DM
• Gregor McNie, Team Lead, Cancer Policy, Scottish Government GMcN
• Hamish McRitchie, Clinical Lead Scottish Clinical Imaging Network HMcR
• Nadeem Siddiqui, National Clinical Lead, Cancer QPI Review Group, Healthcare Improvement Scotland NS
• Joris Van Der Horst, Consultant Respiratory Physician, NHSGGC JVDH
• Simon Watson, Medical Director, Healthcare Improvement Scotland SW

In attendance

• Lorna Bruce, Audit Manager, SCAN LBR
• David Cameron, Clinical Director, Scottish Cancer Research Network DC
• Anna Morton, National MCN Manager, NSS AMO
• Brian Murray, Information Development Manager, PHS BM
• Kaz Rahman, Melanoma Clinical Lead, NCA KR
• Shantini Rice, Melanoma Clinical Lead, SCAN SR
• Elizabeth Smyth, Consultant Breast Surgeon, NCA ES
• Mark Strachan, Consultant in Diabetes and Endocrinology, SCAN MS

Items and actions

Welcome, apologies and declarations of interest

JM welcomed the group and introduced new members Rafael Moleron, Consultant Clinical Oncologist, North cancer alliance and Peter Hall, Consultant Medical Oncologist in South east Scotland cancer network.

Co-Chairs of the Scottish Primary Care Cancer Group, Lorna Porteous and Douglas Rigg representing general practice have also agreed to join the group and will attend future meetings.

It was noted that Rob Jones is retiring from the national cancer quality steering group due to work commitments and the group thanked him for all his input in to the quality programme over the previous years.

A note of apologies are listed above. No declarations of interest were noted.

Action notes and minutes from the previous meeting (paper one)

The group considered the previous action note held on 28 March 2022 (paper one) and approved as an accurate record.

Matters arising

Ovarian cancer – feedback from NCA on survival analysis action plan 

JM advised that concerns raised around surgical capacity to treat ovarian cancer patients have been raised with the National Cancer Recovery Group (NCRG). The NCQSG will continue to monitor survival analysis, Quality performance indicator data and action plans.

In terms of the action plan, BMcK added that a meeting has taken place with radiology colleagues from the five centres to look at a consensus guideline for radiological staging. This has been productive and a further meeting is due to take place in September. An update will be provided to this group thereafter.

Governance review of national groups

JM advised that the membership of this group has been updated as noted above. Subject to agreement this will inform the new National Cancer Quality Improvement Board (NCQIPB) Terms of Reference.

Recurrence data

ST advised that a sub-group consisting of Scottish Government colleagues, Breast Cancer Clinical Leads and key stakeholders met on 25th April 2022 to discuss reporting of recurrence data. It was noted that consensus is required regarding the current QPIs and dataset to agree what will be retained going forward. MB advised that there has been some tweaks made to the proposed QPI for recurrence following discussion with oncology colleagues. The audit team have confirmed that there are no new data items required as these are already within the dataset, although not collected by most NHS Boards at the current time. A further meeting to be arranged before the revised QPIs are subject to formal engagement.

Scottish Cancer Thyroid Network/new QPI requests

A proposal from the Scottish Thyroid Cancer Network (STCN) for new QPIs was discussed at the previous meeting. MS advised that discussion had taken place with the quality team around developing QPIs, where it was agreed these could potentially be incorporated into the schedule early 2023. JD advised that in parallel with this, the thyroid network are required to further scope out data capture processes, permissions, analysis and report maintenance going forward.

AM advised that the Scottish Cancer Network has secured a Business Intelligence Analyst for 6 months from NSS who will scope out these requirements. ET added that the regions would be happy to work with the thyroid network to help inform this, based on their experience. CT added that PHS would also be keen to be involved to ensure everything is aligned in terms of eCASE and reporting etc.

The network will produce a plan based on these recommendations with data collection anticipated around the beginning of January 2024. The group confirmed approval of Thyroid QPIs within the Quality Programme.

JM highlighted the requirement to develop a process for consideration of new national QPIs going forward given the increasing number of requests recently e.g. anal cancer and squamous cell carcinoma (SCC). JD will work with Regional Managers and Regional Leads to develop a paper for discussion at the next NCQSG meeting.

Governance

National breast cancer QPI report (2018 to 2020 – paper two)

MB presented to the group on behalf of the three regions an overview of Breast Cancer QPI performance published by PHS on 5th April 2022. Breast Cancer QPIs are currently undergoing third cycle of formal review.

A number of QPIs were discussed. Some main points are highlighted below:

QPI 6: Immediate Reconstruction Rate. The number of patients undergoing immediate reconstruction during 2020 has been affected by COVID, however it was noted that access is available in all areas and 2022 numbers should be back to pre-COVID level. Timing has improved albeit with smaller numbers. It is hoped this can be maintained as numbers increase again although recognise that Plastics have substantial waiting lists.

QPI 9: HER2 Status for Decision Making. 90% target not achieved in any regions over the three year period although there has been progress. This is mainly due to known resource issues within pathology.

QPI 11: Adjuvant Chemotherapy. Eighty percent target has not been achieved nationally in 2020 due to co-morbidities, patient choice etc. This is based on PREDICT Scoring which looks at the patients’ risk and benefit of chemotherapy and there are some data capture issues affecting the denominator. Regions have reviewed all cases where adjuvant therapy has not been given and these are justified.

QPI 19: Deep Inspiratory Breath Hold (DIBH) radiotherapy: eighty per cent target has not been achieved across any region in 2019/20 although there is steady improvement and the QPI is working well. This is a relatively new technique that does require additional resource.

ES stated there were no major concerns in the North. Noted that additional FISH testing always lengthens the patient pathway and there is now a process in place to email cytogenetics at the end of MDT which provides the result for treatment. ST advised that from a WoSCAN perspective there are no specific issues with the exception of some of the numbers involved in denominators. Work is ongoing to resolve these issues and look at the data more closely.

MB noted that overall the main issue is around initial access to services i.e. radiology capacity. In terms of development, a new drug has been approved, however this requires intensive oncology input which will further affect capacity. ES noted that capacity is very limited within the North.

JM thanked the Regional Clinical Leads for their contribution and ongoing clinical engagement.

National melanoma QPI report (2018 to 2022 – paper three)

SR presented to the group on behalf of the three regions an overview of the Melanoma QPI results that were published by PHS on 7th June 2022. A number of QPIs have met the targets both at a regional and national level.

The following QPIs were noted for discussion: QPI 4: Clinical Examination of Draining Lymph Node Basins: ninty five percent target has not been met at a regional level over the previous two years. There is an issue with documentation recording especially when utilising external providers in SCAN over a number of years. Improvements have been made around better recording following the MDT discussion.

QPI 7: Time to Wide Local Excision (WLE). ninety five per cent target for both specifications have not been met regionally over previous three years due to the eighty four day timeframe. Capacity issues noted in dermatology, pathology, radiology and plastics theatres. Cases not meeting the QPI have been reviewed and noted that these have been appropriately managed. Further steps have been undertaken to increase the pathway flow e.g. referring to plastics at the time of referring to MDT, referral for scan as soon as pathology report is received by the clinician; an increased proportion of patients attend ‘One Stop Clinics’ and stating the predicted MDT discussion date on scan forms so that radiology is working towards an end date.

QPI 9: Imaging for Patients with Advanced Melanoma. All three regions have not met the nintey five percent  target over the previous three years. QPI has been amended for the next cycle following formal review and will now account for upstaging of patients which should increase the number of patients meeting the target. QPIs 7 and 9 have driven requests for a melanoma pathway manager in NHS Lothian, which has not been actioned.

KR added that in NCA there are shared areas of concern e.g. recording issues for QPI 4 particularly in Grampian where there is more outsourcing. Another issue is around QPI 1 (Diagnostic excision biopsy as initial procedure) due to the rural geographic area where the initial diagnostic biopsy is not always carried out by a skin cancer specialist. Historically done closer to home by primary care physicians. This needs to have MDT involvement and work is being undertaken in terms of education along with funding for GP sessions to be involved in the skin MDT.

With regard to QPI 7, KR added that there is now more surgery done on sentinel lymph node biopsies due to changes in guidelines. There is a requirement to fast track patients which involves one stop clinics and adequate pathology reporting. KR discussed the lack of pathology cover within Highland.

The importance of the publication of the HIS report was also highlighted to emphasise to the Boards where issues require action to allow improvement.

JM stated there is concern around the timing for WLE which should be escalated to the NCRG along with the importance of a Pathway Manager in the process. In addition there is a requirement to raise the issues around plastic surgery resources that has been raised for both breast and dermatology services.

JM thanked the Regional Clinical Leads for their contribution and ongoing clinical engagement.

Mutual aid

Update on mutual aid requests

All regions provided an update on the current position. NCA have been tasked with developing a structured process which involves requesting support within the regional centres prior to escalating nationally. Currently testing regional solutions within oncology as well as diagnostics/imaging capacity.

In WoSCAN, there is long standing aid between some Boards e.g. Lanarkshire and Forth Valley Breast Service which is now more of a delivery model. There are imminent pressures for maxillofacial surgery when Forth Valley clinician moves to Ayrshire. NHS Lanarkshire clinicians already support NHS Forth Valley ENT patient management. Oncology mutual aid for Tayside ongoing.

ET highlighted the main pressure is around SACT delivery. National work started to align SACT Clinical Management Pathways, however this will take time. Current focus is looking at how to alleviate pressure on front line services.

JM advised that SCAN is currently providing breast radiotherapy and brachytherapy for gynaecology patients in Tayside. The region have also been asked to consider providing oncological support for prostate, renal, upper GI, and germ cell patients as well as palliative care support for the Borders.

ST stated that there are broader discussions ongoing in relation to a National Waiting Times framework running in parallel with mutual aid. Agreed the biggest issues are with SACT, and diagnostic and surgical capacity. HG and RM both confirmed that with regards to SACT there are no oncology teams that are well enough resourced to absorb any additional cover. IT stated that the concept of mutual aid was good during COVID, however there is now a need to construct service models which are fit for purpose.

JM noted that the role of this group is to highlight to NCRG concerns around the impact of workforce pressures and areas impacting on quality of care.

Survival analysis

Ovarian cancer survival analysis – update

CT advised that PHS have received ovarian cancer data from October 2018 to September 2020 from all three networks. Survival analysis has been completed until the end of March 2022 and a draft report is available. PHS to set up a meeting to review results and agree timescale for the report.

Other tumour specific survival analysis

CT advised on the following tumour specific analysis:

• head and neck cancer – meeting took place at the end of April with clinicians and network managers to discuss the initial analysis for 2014- 17 data. Agreed there is a requirement for more recent data to be analysed due to the improvements in data capture
• lung cancer – data has been received from the networks and final refinements to be agreed to the specification prior to carrying out the analysis. The national lung cancer meeting is taking place on 18th November and it is hoped that the analysis will be finalised for this date
• HPB cancer – data is available and undergoing final validations before starting the analysis. PHS are working towards the 25th November for the network Mortality and Morbidity meeting
• upper GI cancer – PHS are looking at the validations and have had an offer of support from a surgical registrar

The group agreed the requirement to prioritise the lung cancer data which is required to be presented and discussed at the national meeting in November followed by HPB cancer.

National dashboard and reporting requirements (paper four)

CT spoke to paper 4 highlighting the significant time and effort required from PHS to update the QPI dashboards whilst there remains a low number of users across the regions. BM provided up to date figures of 154 users across Scotland with the majority being non-clinical users. As the eCASE development work progresses, it is opportune to consider the wider reporting needs and re assess other technical options to facilitate national reporting. It was noted there is limited resource which needs to focus on areas of highest priority. The group were asked to consider whether a short term pause would be acceptable in order to explore more efficient alternative options. Various members of the group agreed that survival analysis is the main priority at the current time and if a pause could accelerate this there would be wide support.

PS confirmed that HIS require the most up to date data for reviews and the additional functionality of the funnel plots is useful. The net survival publication was suggested as another useful source.

JM concluded by stating that the group is keen for survival analysis as a priority and would support a pause in the dashboard to reflect on alternative options which are more efficient. Interim arrangements will also need to be considered e.g. where data is required for national meetings, HIS reviews etc.

Assurance of national performance

Assurance of national performance – HIS review process 2022 update

KFF provided an update on the reviews undertaken to date and confirmed that the melanoma report would be circulated this week. It was acknowledged that this has taken longer than anticipated and the reporting process requires refining to improve the timeframes. In addition, the acute leukaemia, cervical and endometrial reports are undergoing final checks and the review meetings for head and neck cancer have now commenced.

Following this, a further assessment of the process will be undertaken. It was agreed this is important along with confirming the interaction between the NCQSG and the HIS process going forward.

KFF advised that the process will be reported to the Cancer Coalition in September with a view to obtain third sector input to reports in the future.

QPI reporting

SACT 30-day mortality

CT provided the group with an update. As agreed by both the SACT Programme Board and NCQSG, reporting and identifying variation in 30-Day Mortality following SACT will be undertaken by the SACT Programme Board annually and presented to NCQSG PHS have been tasked with developing the process in more detail. It has been agreed to include all tumour groups regardless of QPI groupings and also to try and incorporate curable / non curable. A paper will be presented to the SACT Programme Board in August prior to being shared with the NCQSG in September.

Review of clinical trials and research access QPI (paper five)

DC, Clinical Director, Scottish Cancer Research Network attended the meeting to present the proposal for the development of key performance indicators (KPIs) to measure clinical trials activity across NHS Scotland. Work has been undertaken by the Equity of Access to Clinical Trials Group (Chaired by Denise Calder, General Manager, Cancer Services, NHS Lothian) to develop KPIs which would be simple to measure and meaningful for senior management and clinical colleagues.

The proposed measures include the proportion of patients consented and recruited to clinical trials (important to acknowledge where patients are ineligible e.g. due to molecular pathology). In addition, to demonstrate benefit to NHS Boards, the proportion of cancer medicines spend externally funded by trials should also be measured. Finally, information on the number of studies open by phase by Board should be presented. These measures should be reported at agreed intervals by NHS Research Scotland Central Management Team.

PS highlighted the issue around socio-economic factors in relation to access to trials. It was agreed this is difficult to capture at the current time and could present issues with reporting small numbers.

DC noted that targets have not been applied at this time and the intention is to report baseline data initially. Further detail around inclusions/exclusions and denominators will also be required.

The group were widely supportive of the proposals and endorsed the paper. JD will retire the generic QPI from the tumour specific documents going forward. DC to agree with the Equity of Access Clinical Trials Group timeframes for annual reporting on the new KPIs and advise the NCQSG accordingly.

Information governance approach for the national analysis of QPI data (papers six and seven)

BM, Information Development Manager, PHS presented the final draft Memorandum of Understanding (MoU) for analysis of national cancer data between PHS, NHS Boards and National Services Scotland (NSS), requesting endorsement by the group.

This includes an appendix specifically for QPI data which outlines various types of data requests and highlights where these will require separate approvals from the governance group. It was noted that requests for data for UK wide audits were out with the scope of this document as they require additional governance permissions around external data sharing.

It was agreed that a separate QPI data governance sub-group should be established to manage and approve relevant data requests. Membership and Chair of the subgroup to be agreed – this may include a network manager representative and clinical representative from each network and PHS representative.

PHS in conjunction with the subgroup to develop an operational process for information requests and approvals.

QPI formal review process

QPI formal review - second and third cycle progress update

JD provided an update. The final cycle two reviews (sarcoma and testicular cancer) have now commenced. Initial meetings have been held and revisions are in progress. Cycle three reviews for breast and renal cancers are also underway. The process for renal cancer QPIs is near completion with the revised document currently out for approval. A further meeting is being arranged with breast cancer colleagues to further refine changes prior to the document going out to formal engagement.

JD requested agreement from the group to archive the data item that was implemented across all tumour datasets in 2020 to capture where treatment plans were altered due to COVID. It was agreed that there is no longer a use for this and will therefore be removed as and when documents are updated.

NCQSG workplan 2019 to 2022 (paper eight)

The NCQSG Workplan was circulated for information. All main items covered within the agenda and progress discussed.

Risk and issues log (paper nine)

The Risk and Issue Log was circulated for information. KFF requested to provide an update for issue twenty seven (HIS reporting) which contains some information which is no longer relevant. This will be forwarded to JD to share with JM/ST for inclusion.

Any other competent business

National cancer strategy

The group noted the recent National Cancer Strategy consultation which all regions have provided feedback. Given the proposal is for a longer term ten year strategy this further highlights the need to consider the future direction of the quality group and the transition to the Quality Improvement Programme Board. ST suggested that this should form part of the agenda at one of the meetings later in the year.