National Cancer Quality Steering Group minutes: September 2022

Attendees and apologies

Present

• Seamus Teahan, Regional Lead Cancer Clinician, WoSCAN (Chair), ST
• James Mander, Regional Lead Cancer Clinician, SCAN (Chair), JM
• Lynsey Cleland, Interim Depute Director, HIS, LC
• Jen Doherty, Project Co-ordinator, National Cancer Quality Programme, JD
• 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, Regional Manager (Cancer), NCA, BMcK
• Noelle O’Rourke, National Lead for the Scottish Cancer Network, NO’R
• Lorna Porteous, GP and Clinical Lead Scottish Primary Care Cancer Group, LP
• Peter Sandiford, Deputy National Clinical Lead, Cancer QPI Review Group, Healthcare Improvement Scotland, PS
• Lorraine Stirling, Project Officer, National Cancer Quality Programme, LS
• 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
• Simon Watson, Medical Director, Healthcare Improvement Scotland,SW
• Joseph Woollcott, Health Influencing Senior Officer, Prostate Cancer UK,JW

Apologies

• Lesley Aitken, Senior Reviewer, Healthcare Improvement Scotland (HIS), LA
• Matthew Barber, Consultant Breast Surgeon, NHS Lothian, MB
• Richmond Davies, Head of Service, PHS, RD
• Josephine Elliot, Programme Manager, HIS,JE
• Angela Jesudason, Paediatric Oncologist and Clinical Lead for the MSN CYPC Teenagers & Young Adults, AJ
• Andrew Martindale, Urological Cancers Clinical Lead, NCA, AM
• Gregor McNie, Team Lead, Cancer Policy, Scottish Government, GMcN
• Hamish McRitchie, Clinical Lead Scottish Clinical Imaging Network, HMcR
• Rafael Moleron, Consultant Clinical Oncologist, NCA, RM
• David Morrison, Director, Scottish Cancer Registry, DM
• Douglas Rigg, GP and Deputy Clinical Lead Scottish Primary Care Cancer Group, DG
• Kishore Shekar, Consultant in Oral and Maxillofacial Surgery, NCA, KS
• Nadeem Siddiqui, National Clinical Lead, Cancer QPI Review Group, Healthcare Improvement Scotland, NS
• Carolyn Sunners, Senior Policy Manager, Scottish Government, CS
• Iain Tait, Consultant Surgeon and Clinical Director, NCA,IT
• Nkem Umez-Eronini, Urological Cancers Clinical Lead, WoSCAN, NUE
• Joris Van Der Horst, Consultant Respiratory Physician, NHSGGC, JVDH

In attendance

• Steve Leung, Renal Cancer Clinical Lead, SCAN, SL
• Laura Matia Herreo, Project Support Officer, NSS, LMH
• Jim McCaul, Head and Neck Cancer Clinical Lead, WoSCAN, JMcC
• James Morrison, Head and Neck Cancer Clinical Lead, SCAN, JM
• Anna Morton, National MCN Manager, NSS, AMO
• Azmat Sadozye, Consultant Clinical Oncologist, Scottish Government, AS

Items and actions

Welcome, apologies and declarations of interest

ST welcomed the group. A note of apologies are listed above.

No declarations of interest were noted.

Action notes and minutes from the previous meeting (paper 1)

The group considered the previous action note held on 20 June 2022 (paper 1) and approved as an accurate record.

Matters arising

Ovarian cancer – feedback from NCA on survival analysis action plan

BMcK advised that a further meeting has taken place with radiology colleagues from the five centres who have agreed a consensus guideline for radiological staging. The group also discussed the impact of the guidance for management of stage III or IV ovarian cancer patients and noted that they will all be considered for surgery which is key.

This guideline will now be presented to the regional MCNs for formal approval before being implemented. BMcK advised that there has already been a change in practice within NCA, aligning with the agreed guidance.

BMcK advised in relation to surgical capacity that the third gynaecological oncology surgeon has been appointed in ARI with the fourth remaining post outstanding. It is unknown at the current time as to whether there are plans to re-advertise this post.

Recurrence data

ST advised that he recently chaired the Breast Cancer QPI Formal Review where the feasibility of collecting recurrence data has been discussed. The breast cancer QPI dataset has been reviewed and some items omitted to incorporate a recurrence QPI. ST stated that the feasibility of collecting this data may inform whether it is possible for other tumour groups in the future.

The revised Breast Cancer QPIs are due to go out for public engagement. JD advised that there have been ongoing discussions with the Scottish Government around the engagement process which has now been resolved and are awaiting confirmation of dates. ST stated that this will give boards the opportunity to respond noting that there is no additional resource available to collect this data although acknowledged that this is an opportunity for existing resources to be utilised slightly differently.

ET highlighted that regional managers should encourage proactive engagement so that boards are aware of the proposed collection of recurrence data. ET confirmed that breast recurrence is included in the new eCASE system (although not currently collected) while PHS stated that it would be worth including some validation for local teams to assess completeness of data at an early stage. It was noted that there is no similar data from elsewhere being reported around recurrence to use as a benchmark - Regional Managers (Cancer)

Information governance approach for the national analysis of QPI data

JD advised that nominees and a chair are being sought for a separate QPI data governance sub-group to be established to manage and approve relevant data requests. JD has written to Iain Tait, NCA to request if he will chair.

Governance

National head and neck cancer QPI report (2018-2021 – paper 2)

JMcC presented to the group on behalf of the 3 regions an overview of the Head and Neck Cancer QPI performance published by PHS on 10 May 2022. The 2nd cycle of formal review for head and neck cancer QPIs was completed in January 2022.

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

• QPI 4: Smoking Cessation. A challenging QPI with difficulties around data capture/documentation, and inappropriate referrals for some patient groups’ e.g. supportive care. These patients are now excluded through formal review and steps have been taken to improve documentation by amending MDT referral forms and clinic outcome templates
• QPI 5: Oral and Dental Rehabilitation Plan. QPI has not been met across all 3 regions, although many individual boards have achieved 100% for patients having a joint decision made for pre-treatment assessment by Restorative Dentistry and the MDT. Cases not meeting the target are mainly due to the impact of Covid
• QPI 6: Nutritional Screening. Challenges again due to recording of the MUST screening tool result and ensuring audit teams can capture this information. This is now part of the new MDT system within WoSCAN. During formal review a further two specifications were added to the QPI to capture assessment of a) patients at risk of malnutrition at the outset and b) patients who are likely to be at risk following curative treatment
• QPI 7: Specialist Speech and Language Therapist Access. Challenges across the whole of Scotland for this QPI due to workforce pressures. As a result of the pandemic, online SLT consultations with patients were implemented which proved effective. This will continue going forward which will improve results
• QPI 8: Surgical Margins. Target of <10% was met across SCAN/WoSCAN. It was acknowledged that this is a useful QPI and a good marker of quality surgery. Noted that surgical teams should continue to strive to achieve this target. The target was not achieved in NCA (16%) in 2020/21 and ST/JM requested that this should be kept under observation

Noted that in general the head and neck cancer QPIs have performed well over the three year period and where QPI targets have not been met there has been further investigation. With regard to QPI 7 (Specialist Speech and Language Therapist Access) there has been additional funds made available in SCAN to address the issues moving forward. From a WoSCAN perspective, SLT is variable across the region however, changing methods of working and virtual consultations should help improve this QPI going forward.

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

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

National renal cancer QPI report (2018-2022 – paper 3)

SL presented to the group on behalf of the 3 regions an overview of the Renal Cancer QPI results that were published by PHS on 9 August 2022. The 3rd cycle of formal review was completed in June 2022.

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

• QPI 3: Clinical Staging TNM. Overall compliance falls short of the 98% target. The main reason for this is where TNM is not complete at the time of MDT due to cases that may require completion staging. Work has been ongoing to encourage TNM to be highlighted at the time of consultation and decision to treat. Radiology colleagues have also been asked to ensure TNM staging is available at the time of MDT. BMcK advised that these issues have been raised with the teams of the three MDTs in the NCA with the intention of moving to single outcome recording
• QPI 8: 30 and 90 Day Mortality (Cryotherapy). Less than 2% target was not met nationally but noted the small numbers involved. Any cases not meeting the QPI target are reviewed at board Morbidity and Mortality Review meetings and no concerns were raised
• QPI 10: Prognostic Scoring. The 90% target is ambitious and good progress has been made year on year. It is challenging to capture this at MDT. A lot of these patients come under the care of oncologists, however it is also of interest to surgeons regarding cytoreductive surgery. All 3 regions have agreed for consistency to use the HENG standardised tool
• QPI 11: Leibovich Score: The 100% target is not met nationally however there is improvement year on year. Within the SCAN region it was noted that NHS Fife have not been engaging with this particular QPI as they felt patients are not being dis-advantaged by not having a Leibovich Score. However, following further discussion at the Regional Cancer Planning Group, Fife are now submitting data. JM also confirmed that this has now been actioned within SCAN
• QPI 13: Trifecta Rate: The 50% target was almost met across all 3 regions, although there is wide variation noted between results due to the use of cold ischaemia which was not accounted for within the QPI. Following formal review this year the QPI was modified to include cases that require cold ischaemia which is generally those undergoing more complex open surgery

In terms of challenges, SL highlighted the issue of Clinical Nurse Specialist provision which is variable across regions and is instrumental in improving outcomes for patients. From a SCAN perspective there are challenges with capacity delivering surgical care post Covid and are hoping to appoint a 4th kidney cancer surgeon. Also highlighted the challenge in SCAN around access and timing of radiological scans for cases that are highly complex. HG suggested liaising with MDT Co-ordinators for opportunities to improve recording at MDTs.

Moving forward, JM suggested that if there is no regional representative available for the tumour specific discussion, a short written narrative of any areas of concern should be submitted. ST thanked the Regional Clinical Lead for his contribution and ongoing clinical engagement.

Governance review of national cancer groups (paper 4)

Transition to national cancer quality improvement programme board (NCQIPB) (paper 4)

ST presented to the group a few slides to commence discussion on the transition of the NCQSG to a National Cancer Quality Improvement Programme Board (NCQIPB). Noting the 12 domains of quality in cancer care, it is acknowledged that many of these are being addressed by other groups e.g. guideline adherence, waiting times, safety errors etc. ST outlined the proposals in paper 4 stating the need to identify key QPIs which are most linked to improving outcomes, and work alongside HIS to target ongoing assurance to drive improvement in that particular service.

JM highlighted that equity of access is an important area to be reviewed along with the non QPI areas of quality (which may be difficult to measure) and would be keen to engage with the Scottish Cancer Network around patient pathways, and P Hall regarding PROMS.

HG agreed around the difficulties of measurement and stated that clinicians are keen to drive forward PROMs, Prehab etc. however it is difficult to take forward ideas whilst there are resource and staffing pressures. ST acknowledged this challenge and suggested that themes could be identified which get the most benefits across many tumour types. NO’R also noted that QPIs had been an excellent foundation however due to the focus on newly diagnosed patients, there is a gap in the overall picture of quality in terms of recurrence, and end of life care.

SW advised the skills available within HIS could be deployed in a more coherent way within cancer and in the context of the National Cancer Plan. Paper 4 highlights the renewed approach and responsibility to focus on areas where there is variation between ideal quality and current care provided.

Again, there is no additional resource within HIS and clarity will require to be sought within the organisation on how best to utilise that resource. SW highlighted that there is a need to prioritise and that it would be better to do in one area of key clinical importance. LC added the importance of a joined up approach and targeting where HIS can have the biggest impact. The merit in working alongside NO’R was noted in terms of compliance with Clinical Management Pathways and highlighting areas of concern to HIS.

Ensuring appropriate escalation and governance was noted. ET suggested that the group could be used as a potential forum for escalation to HIS, since Clinical Leads are attending to present their QPI data and discuss challenges etc.
SW/LC advised that further focussed discussions will take place within HIS and thereafter with the Scottish Cancer Network, NCQSG Chairs and Scottish Government to clarify the next steps in moving forward with transition. - Healthcare Improvement Scotland / Chairs NCQSG/Scottish Government

The order of the agenda was changed at this point going forward.

Assurance of national performance

Cancer quality performance indicator review process 2022 update

KFF provided an update on the reviews undertaken to date and confirmed that HIS will not be starting any further QPI reviews until the way forward has been agreed.

To date HIS has completed reviews for melanoma, head and neck, cervical and endometrial cancers along with acute leukaemia. The cervical and endometrial cancer report is almost ready for publication while further work is still required for both acute leukaemia and head and neck cancer reports. The melanoma report is currently undergoing final QA and additional assurance checks around integrity of the report prior to publication. KFF advised that reports will be issued as soon as possible and that pressures within HIS has contributed to delays.

It was noted that going forward, reporting needs to be slicker and repetition of QPI discussion reduced.

Cutaneous melanoma national follow-up guidelines (paper 5)

Cutaneous melanoma national follow-up guideline (August 2022)

ST spoke to paper 5 which outlines the Cutaneous Melanoma National Follow-up Guideline that has been developed in collaboration with the three regional cancer networks to promote consistency of practice across NHSScotland. Attention was drawn to the schedule of surveillance noting that a considerable number of scans are required to be undertaken over a five year period. Agreed that resource demands should not deter clinicians from producing evidence based guidance in order to try and achieve best practice.

It was noted that the NICE guidelines are currently under review and it is anticipated that these will reflect this guideline. BMcK stated that from a NCA perspective that the guideline has to be submitted through the national MCN however, the regional clinical lead has been involved in the development and does not anticipate any issue.

The NCQSG endorsed this Cutaneous Melanoma National Follow-up Guideline for publication and ST advised that this will now be circulated to regional groups in due course.

National cancer quality programme – highlight report (paper 6).

Highlight report

• JD spoke to paper 6 which outlines a progress update on a number of key areas within the Quality Programme. These items are discussed in detail at the National Cancer Quality Operational Group therefore the only items which are required to be highlighted this this group are where there are challenges, action required, or issues for escalation. The following areas were noted:QPI Formal Reviews – challenges noted with the delay in engagement process which is now resolved as discussed under item 3(b) affecting both breast and testicular cancers. The prostate cancer meeting was cancelled at short notice due to clinical pressures and it is taking time to secure another suitable date
• no issues to report with survival analysis or dashboard updates/reporting

ST suggested that moving forward as a more targeted approach there is an opportunity at QPI Formal Reviews to engage clinicians in identifying which particular QPIs require most focus for improvement.

SACT 30-day mortality (process and schedule for reporting) (paper 7)

CT provided the group with an update noting that the proposal and schedule for reporting SACT 30-day Mortality for 2022 data has been agreed by the SACT Programme Board on 9 August 2022.

CT highlighted a few of the main points:

• the first publication of mortality reporting will not separate by treatment intent and this will be released as management information only
• a pilot will be carried out in autumn 2022 using patient data for 2021 which will be quality assured and validated against the local disease trees
• the report will contain all tumour groups, including those not currently represented in the QPIs, as standardised from the local disease trees on CEPAS
• 30-day mortality figures will be based on a 12-month cohort (January to December 2022) and report will be produced in March 2023
• data will be released at NHS board, Regional Cancer Network and NHSScotland level. A narrative will be required to accompany the publication where there is any variance
• PHS will publish report in July 2023 as ‘Experimental Statistics’ on the PHS website

ST agreed that this is a challenging and complex piece of work and noted that the last opportunity for comment on the report will be in June 2023 ahead of publication. It was also agreed that a formal communication strategy should be considered by the SACT Programme Board outlining the schedule for reporting SACT 30-day Mortality. This should be aimed at Clinical Directors and General Managers of the five cancer centres and in addition highlight the importance of accurate and standardised data to those prescribing SACT and using CEPAS as this will be in the public domain.

Also discussed the topic of unlicensed medicines and whether these should be included. Further discussion to be ongoing with the SACT Programme Board - Catherine Thomson

Cancer QPI dashboard (public version) options paper (paper 8)

CT spoke to the various options outlined in paper 8 which require consideration by PHS to avoid potential disclosure issues when creating a public facing dashboard. Currently the cancer QPI dashboard is available within the Scottish Cancer and Intelligence Service (SCRIS) with log in details provided through the User Access System (UAS). A public facing dashboard would eliminate the requirement for the UAS approval process and renewal every six months, however, there requires to be disclosure control for QPI data that would be available in the public domain.

PHS proposed option 3 where numbers are not suppressed as the ‘population at risk’ is not under 1,000 for any board/QPI combination, and regional reports containing all data are already in the public domain. In addition, QPIs are refined by many criteria and it is extremely unlikely that individual patients could be identified. The group disagreed and proposed that numbers less than five should be suppressed as there is a need to protect confidentiality particularly in smaller boards within NCA. It was noted that this aligns with regional reporting where denominators less than five are marked with an asterisk.

CT advised that this may prevent many indicators from being reported. This will be looked into further along with discussion with Regional Networks as to whether a public facing dashboard is the best option. CT noted that they do not wish to revert back to producing written national reports - Catherine Thomson

Risk and issues log (paper 9)

The risk and issue log was circulated for information.

Any other competent business

No other business was noted.