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CANCER IN SCOTLAND: ACTION FOR CHANGE

04. RAPID ACCESS TO DIAGNOSIS AND TREATMENT

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.

We know that many patients currently wait less than two months for treatment but we also know that improvements still need to be made. Our National Health therefore pledged that new maximum waiting time standards for cancer will be put in place:

• 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 April 2002, a major service redesign initiative aimed at improving the patient journey from referral to treatment will be in place.
• By 2005, the maximum wait from urgent referral to treatment for all cancers will be two months.

These commitments are evidence of our determination to alleviate patient and public concerns and to improve diagnosis and treatment services by driving down waiting times for everyone with cancer. To achieve them we need to ensure that every part of the care pathway from first referral, through investigation, diagnosis and subsequent treatment is carefully examined and appropriate changes made to secure real and lasting improvements.

REFERRAL PROCESS

First, we need to look at patients' experiences before they are referred for specialist investigation and treatment. We know that in many instances patients are immediately referred to hospital for advice whenever they seek the advice of their GP about worrying symptoms, but we also know that sometimes people wait too long.

The first point of contact with the Health Service is most often when people consult their GP and although there are many thousands of people diagnosed with cancer each year, individual GPs are unlikely to see more than half a dozen people a year who are found to have cancer. For the rarer cancers, some GPs may see not more than one or two in their working lives.

• Referral guidelines will therefore be developed for GPs to help them identify those patients requiring urgent investigation to confirm or otherwise a diagnosis of cancer. A Sub-Group of the Scottish Cancer Group will be tasked to prepare guidelines for urgent referral by 2002.

CLINICAL INVESTIGATION AND DIAGNOSIS

Following referral, the next step is investigation to achieve a definite diagnosis as quickly as possible. The journey of care from referral to treatment may often be complex and at each stage delays may be experienced. For some patients the symptoms may not be immediately suggestive of cancer and only after a variety of investigations will a hitherto unexpected diagnosis of cancer emerge. This is particularly characteristic of some cancers such as cancer of the pancreas and of the ovary.

A variety of tests is often necessary including blood tests of different kinds but also invariably radiology, including, for example, image guided biopsy. Before a diagnosis can be confirmed, biopsy specimens are normally examined by pathology departments to confirm the type of cancer and how far, if at all, it may have spread to other parts of the body.

One Stop Clinics have significantly improved peoples' experiences of rapid access to investigation and diagnosis across the country. Our National Health confirmed that where possible we will continue to develop more of these facilities for people who may have cancer.

Radiology and Pathology workforce

There has been a substantial growth in demand for diagnostic investigation services for patients suspected of having cancer, particularly for radiology and pathology. Both of these services have had to face significant increases in workload as a result of developments in cancer care. These increased demands have largely been absorbed without any parallel increase in resources, particularly for staff.

Changes in treatment options in recent years have required more detailed reports from pathologists and radiologists to allow the most appropriate decision for each patient's care. Our ability to confirm a cancer diagnosis and support treatment must come up to the standards of the best.

• The number of posts in pathology and radiology has not kept pace with the number of patients attending for specialist assessment. We know we need more. The questions is how many. A review of multi-disciplinary pathology workforce requirements is already underway. As a high priority reviews of radiology and other specialist workforces will be undertaken by a new Human Resources Sub-Group of the Scottish Cancer Group. Relevant professional groups will be involved in this process.

Imaging technology

Examination of waiting times across the care pathway have confirmed that in a number of areas and for some imaging modalities in particular, Magnetic Resonance Imaging (MRI), there can be significant delays, whether as part of diagnostic investigation or treatment planning and follow up. It is essential that every effort is made to eliminate such blockages.

As part of that process we also need to ensure that there is sufficient capacity of modern imaging equipment to meet current demands and new developments within each regional network.

• Targeted additional investment has already been made in new imaging equipment to aid cancer diagnosis.
• In addition, separate investments are also being made in MRI and/or Computerised Tomography (CT) scanners for Argyll and Clyde, Lanarkshire and South Glasgow hospitals.

We are already investing in key equipment where it is needed most. That is however just a start. There is much more still to do.

New imaging techniques such as Positron Emission Tomography (PET scanning) appear to be making a significant contribution to cancer care in the United States. It is important that NHSScotland is abreast of such developments.

• The Health Technology Board for Scotland (HTBS) is undertaking a review of PET scanning technology. Future investment decisions will need to take account of their advice.

In addition to the above vital investments in human resource planning, in equipment and in assessing the effectiveness of emerging technological developments, it is essential that we do not lose sight of day to day routine processes and systems, all of which may also contribute to unnecessary delays for patients. Every part of the care pathway has its own part to play in patient care and in patients' experiences of their care. It is therefore necessary that a "whole systems" approach is taken to pull together all of the various aspects of care.

• Regional Cancer networks will oversee all stages of the patient journey through a process of prospective audit. They will also be charged with taking appropriate action to remedy any deficiencies identified.
• Service redesign through tumour specific cancer collaboratives will provide a platform for simplifying this process and eliminating unnecessary delays (see Chapter 5).
• The Scottish Cancer Group will commission the development of models for capacity planning for radiology, pathology and other relevant services in light of the forthcoming report of the Scottish Integrated Workforce Planning Group.

Through this comprehensive package of measures involving equipment, staff and patients we expect to see significant improvements over the next few years. Waiting times will continue to be regularly monitored to assess progress towards the overarching targets for reducing waiting set out at the beginning of this chapter.

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