Background
In December 2000 the Scottish Executive published Our National Health: A plan for action, a plan for change. It stated:
- By October 2001, the maximum wait from urgent referral to treatment for children's cancer and acute leukaemia will be one month.
- By October 2001, women who have breast cancer and are referred for urgent treatment will begin that treatment within one month of diagnosis, where clinically appropriate.
- By 2005, the maximum wait from urgent referral to treatment for all cancers will be two months.
Improving the quality of cancer waiting times statistics
To support properly informed and effective discussions about performance against the cancer waiting times target, cancer waiting times performance statistics are subject to a programme of quality improvement focusing on consistency and coverage. This needs to be considered when making comparisons between data from different quarters.
Increase in Coverage
At present 9 cancer services and at least 20 different tumour types are included in the cancer waiting statistics. Initially cancer waiting times performance statistics included only breast cancer; in April 2003 colorectal cancers were added; July 2003 ovarian cancer; July 2004 lung cancers; January 2005 melanoma; April 2005 lymphoma cancer and in July 2005 head and neck, upper GI, and urology cancers.
From July 2004 to June 2005, the waiting times statistics covered urgent GP referrals only. From July 2005 the statistics included all urgent referrals: urgent GP referral, GP referral to A&E, self referral to A&E, and urgent dental referral.
From July 2004, exclusion categories were included: patient induced non-clinical delay, patient refused treatment, co-morbidities, and died before treatment.
Over time there has also been an increase in the number of patients being reported each quarter. For example from July-September 2005 there were 2055 urgent referrals recorded in the statistics (including those excluded from the performance calculation). In October-December 2007 the equivalent number was 2655.
Consistency
Further detailed clarification and guidance was issued in January 2007 to ensure consistent application of cancer waiting times definitions, following from a Data Seminar in November 2006 and further consultation with Health Boards. This guidance included six exclusion categories. If definitions are not applied consistently and with NHS-wide agreement, action to address service issues and challenges can be affected.
The impact of Boards applying the detailed guidance is impossible to fully isolate, as it coincides with Boards having longer to submit returns, and underlying changes in level of performance. The SHED detailed guidance sought to clarify the use of the review patient and incidental finding classification and consequently could result in a reduction in the number and proportion of patients recorded as having been referred urgently.
The following exclusion criteria were detailed in the guidance, however it was emphasised that in all cases the responsible clinician would have the final decision. The following analysis relates to July-September 2006 and compares exclusions, before and after the January 2007 guidance:
- Patients who breach the target because medically they require a complex series of investigations as they are a clinically complex case (as opposed to the patient having gone through a circuitous pathway). These are coded as 'Clinical reason' under other reason for delay. There were 39 patients in this category, 9 of which were in Tayside.
- Patients who are urgently referred to one service with a range of symptoms that are not particularly suggestive of cancer, have a variety of inconclusive investigations and are subsequently referred to another service where a series of further investigations are carried out which leads to a diagnosis of cancer. These are coded as 'Initial referral to other specialty' under other reason for delay. There were 11 additional patients in this category.
- Patients who gave prior notice that they could not attend and were unable to attend for a week or more due to particular patient circumstances. These are coded under the existing exclusions 'Patient induced non-clinical delay' or as a 'Co-morbidity'. The number of patients in this category increased from 67 to 82 patients, 13 of the additional patients were in Greater Glasgow.
- Patients who did not attend without prior notice and the resultant delay is a week or more due to particular patient circumstances. These are coded under the existing exclusion 'Patient induced non-clinical delay'. The number of patients increased from 69 to 93.
- The guidance also amended current definitions to include steroids as first treatment for breast, lung, colorectal, gynaecological and upper GI cancers, however it was emphasised that in all cases the responsible clinician has the final decision. These are coded as 'Other therapy' under the mode of first treatment.
The improved quality of reporting and classification of cancer waiting times, combined with more complete data collection and underlying service changes are all expected to have contributed to the rise in overall performance across Scotland reported for July to September 2006.
Submissions from NHS Boards will continue to be monitored closely to ensure data accuracy and completeness.
Current developments
There are two developments currently underway:
- Weekly monitoring of cancer waits was first introduced in October 2006.
- The National Cancer Waiting-Times Delivery Group is to propose the remit for a group to review definitions for the future, to ensure clinical rigour around definitions.
Background information
Annexe 1 Guidance Note on Weekly Performance Reporting
Annexe 2 Frequently Asked Questions in Weekly Performance Reporting
Annexe 3 Weekly Cancer Reporting - Summary of Position
Delivering Cancer Waiting Times Breach Report