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6. ASSURING QUALITY OF CARE
Multi-disciplinary teams ( MDTs) are internationally recognised markers of quality in cancer services. MDTs discuss all new cases and agree on their recommendations for the optimal treatment(s) available for each patient. This means that patients can be confident that decisions made about their treatment and care derive from the collective knowledge and expertise of medical, nursing, pharmacy and other relevant healthcare professionals, working together in an integrated fashion.
Cinical standards for breast, lung, colorectal and ovarian cancer were set out by the Clinical Standards Board for Scotland 4 in 2001. These will be updated by NHSQIS in 2008. In addition, NHSQIS will publish new clinical standards for all cancer services during 2008 which will allow a greater range of services to be subject to external independent scrutiny. Clinical audit is essential to measure the quality of care, enable meaningful comparison between and across multiple services and to provide the information needed to support any action required to ensure continuous improvements in cancer services.
Cancer networks are responsible for assessing the quality of care provided across cancer services and there are many examples of this across all tumour types and throughout NHS Boards. For example, using CSBS clinical standards, assessments of the quality of services provided have been carried out by breast and colorectal cancer networks. Such nationwide collaboration and comparison across cancer clinical networks will continue to be a key feature of our approach to quality assurance. It is therefore important that we develop more formalised arrangements to enable us to benchmark care against that provided in other countries and make such quality data publicly available in a meaningful and understandable way.
Research/Clinical Trials
There is significant evidence that outcomes are improved for those patients treated in environments where research is the norm or for those patients who are involved in cancer trials. At any one time there are a variety of new treatments and novel drugs being tested in the NHS to establish whether they offer benefits over the current standard therapies. Through the Chief Scientist Office ( CSO) cancer research is well funded with £55 million being spent in support of research carried out in Scotland in 2006-07 (14% of UK total). During that year CSO also spent £2.9 million on directly funded research projects and initiatives as well as £10 million to support cancer research within the NHS.
Our aim is to integrate research into routine care and improve patient care by speeding up access to best care and treatment across the country. In 2001, evidence suggested that with the exception of haematological malignancies (particularly childhood leukaemia), relatively few patients with cancer participated in clinical trials. The Scottish Cancer Research Network ( SCRN) was therefore established with the aim of at least doubling entry to cancer trials and latest figures confirm that it has helped increase participation from 3.7% of cancer incident cases in 2002-03, to 13.9% in 2005-06. SCRN has also increased the number of patients outwith the major cancer centres able to take part in a clinical trial. However, it should be noted patient participation in cancer trials fell quite significantly in 2006-07, both in Scotland and across the rest of the UK. In addition, considerable differences are still apparent when recruitment to trials in different tumour types is examined, e.g. 30% of breast cancer patients are taking part in trials compared with 6% of prostate cancer patients or 3.1% of lung cancer patients.
Waiting Times
Cancer in Scotland confirmed that "to increase the probability of treatment success while at the same time minimising patient anxiety and stress, delays in investigation, diagnosis and subsequent treatment of cancer must be eliminated wherever possible".
Considerable progress has been made in recent years in improving waiting times for cancer services and most NHS Boards now meet the 31 day waiting time targets for urgent referral to treatment for children's cancers and leukaemia. The 31 day target from diagnosis to treatment for breast cancer target is subject to variation in some instances but is also normally met in most NHS Board areas.
In 2008-09, NHS Boards will continue to assess their performance against the various national waiting times targets for cancer services, including the maximum 62 day wait from urgent referral to treatment for all cancer types. This target has proved extremely challenging over the past few years, but improvements have been made, particularly over the past year and it is predicted that the target will be met for the first time from the end of 2007. This will be enormously beneficial in terms of reducing periods of anxiety and uncertainty for patients, their families and carers.
Both in the context of improving patient experience and the potential benefits for outcomes of earlier diagnosis and treatment, we will be looking at options for new cancer waiting times targets. These must be designed to be as inclusive as possible and meaningful for our patients.
Issues to Consider
- Which aspects of the suggested quality assurance programme should be prioritised to ensure continuous improvements in the speed of access to and quality of care for people with cancer? What more needs to be done to eliminate variations in practice across cancer centres and/or specific tumour services?
- How might we best formalise a publicly reported quality assurance programme for cancer services using comparative clinical audit?
- Is there a need to look at the way cancer audit is organised in Scotland and determine if the current configuration will enable us to meet the challenges to cancer care over the next few years?
- What information should be routinely available to the patients and carers to allow them access to data on service quality and how should this be presented?
- How could we encourage greater participation in clinical trials?
- What further opportunities do you see for taking this forward through cooperation and collaboration between the NHS and its partners, e.g. the third sector?
- In looking at options for new cancer waiting times targets, how could efforts be targeted to be more inclusive and meaningful for clinicians and patients, secure rapid access to diagnosis and treatment and at the same time ensure sustainable, equitable and qualitative improvements in cancer care?
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