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1999 Health in Scotland

THE CHANGING SHAPE OF HEALTHCARE

The following section sets out some examples of ways in which acute services are changing. It is intended to complement the description of some key services that was developed in Chapter 2. It pays particular attention to the concept of managed clinical networks, service redesign, use of telemedicine and development of supporting services such as blood transfusion and Scotland's Reference Laboratories. The section concludes with a description of some developments in respect of maternity services and services for infertility.

Acute Services Review and Managed Clinical Networks

The Acute Services Review Report was published in May 1998. Implementation is being overseen by a multidisciplinary and multiprofessional Acute Services Group chaired by the Chief Medical Officer. The Review was intended to provide a template for service development over the next 5-10 years and has already resulted in a number of important developments. These include establishment of the Clinical Standards Board for Scotland, the Coronary Heart Disease Task Force, the Scottish Medical and Scientific Advisory Committee (SMASAC) and the Remote and Rural Areas Initiative. Specific service developments in 1999 included the decision to centralise paediatric cardiac surgery in Yorkhill Hospital, Glasgow and establish short-life working groups to advise on neurosurgical services and the transfer of critically ill and injured children. As part of its work SMASAC now holds a horizon-scanning meeting with the CMO's specialty advisers, and has established short-life working groups to develop a model framework for capital spending on diagnostic equipment, describe managed diagnostic networks and consider the recruitment and retention of Medical Laboratory Scientific Officers (MLSOs).

One of the major developments signalled in the Acute Services Review was the concept of managed clinical networks. Pilot projects now being developed include managed clinical networks for vascular services, stroke, cancer (notably gynaecological and colorectal cancer), cleft lip and palate, renal transplantation, home parenteral nutrition and the secondary prevention of coronary heart disease. Great emphasis will be placed on evaluating the benefits of networks for patients and assessing their impact on staff recruitment, training, development and job satisfaction. It is already clear that networks which run within a defined region are easier to develop and sustain than those which transcend regional boundaries, and that enlightened management will be needed to ensure that funding flows and supporting structures are in place when networks involve more than one Trust or region. For selected networks, such as those being developed for renal transplantation and cleft lip/palate, their national size and scope has meant that the National Services Division of the Common Services Agency has been used as the administering and funding agency.

From the outset it has been clear that of managed clinical networks should be introduced gradually as part of an evolving process, and that ultimate success will depend on a strong sense of staff ownership and patient involvement. A robust database is essential for evaluation purposes and will facilitate research and further service development.

Service Redesign in Support of Clinical Effectiveness and Clinical Governance

The Designed Healthcare Initiative is now well established. Two rounds of bidding have resulted in funding for 44 demonstration projects spread across Scotland from Orkney to the Borders. The projects cover a range of topics including the Redesign of Cataract, Cancer, Stroke, Coronary Heart Disease, Paediatric and Mental Health Services.

Pilot projects that are now at the implementation stage include the Redesign of Cataract Services at Ayrshire and Arran Acute Hospitals NHS Trust. The "One-Stop" model has greatly reduced the time required for diagnosis and treatment, reduced the number of visits to different agencies from 7 to 3, and reduced the number of visits to hospital from 4 to one. The model has involved the development of guidelines/protocols for referral and follow-up of patients by optometrists, the introduction of a care pathway, and the development of patient information booklets and GP/Optometrist information packs.

The Designed Healthcare Initiative and the pilots are supported by a comprehensive training and development programme which has focused on how to link service redesign, integrated care pathways, clinical effectiveness, audit and clinical governance. Clinical Governance is locked in as a responsibility of the clinical team when the care process is redesigned and an integrated care pathway is central to its development. Guidelines and standards are built in from the outset and a clinical risk management strategy is implemented so that high/low risk patients are dealt with by different pathways. A "no blame" culture is established with critical incident and near-miss reporting and the clinical team regularly stands back and reflects on their performance along the entire care process, on the clinical outcomes and on any variation from the embedded guidelines/standards. Negative variations and outcomes require investigation while positive variations and outcomes may identify further opportunities for redesign. The model also allows education and training needs to be addressed. A leadership development programme is important if the full benefits of the approach are to be achieved and clinical governance is to be strengthened.

Telemedicine

The White Paper "Designed to Care" and the Report of the Acute Services Review both highlighted the need to develop the clinical application of telemedicine to support a number of strategic changes within the NHS in Scotland. These include facilitating the development of managed clinical networks, improving postgraduate education and training, supporting the 3 health priorities of the NHS in Scotland, and improving patient access, particularly for those living in remote and rural communities.

Against this background, the Scottish Telemedicine Advisory Forum (STAF) was established during 1999 under the chairmanship of Professor Ray Newton, Consultant in Metabolic Medicine and Postgraduate Dean at Dundee University. STAF will gather information about past and present telemedicine activity in Scotland and further afield, establish and support demonstration projects, and identify and promulgate standards relating to telemedicine (in conjunction with the Clinical Standards Board for Scotland). The overall aim is to move from a largely experimental and ad hoc application of telemedicine to a more coherent use of this technology to support improved health care delivery.

A National Strategy for Blood Transfusion

The Scottish National Blood Transfusion Service (SNBTS) implemented its strategic reorganisation in 1999, the process being closely monitored by the SNBTS Clinical Users Group. The changes will ensure that SNBTS can take full advantage of new technology and respond rapidly to new ways of improving the quality of blood and blood products. Fundamental to the reorganisation is centralisation of processing and testing of blood donations on 2 sites, Edinburgh and the West of Scotland Regional Transfusion Centre at Law Hospital. By March 1999 all donations from the North of Scotland were being processed and tested in Edinburgh or Law Hospital, and SNBTS now has a national supply chain in place that covers all fractions of blood donated in Scotland. New Clinical Directors were appointed in Glasgow, Edinburgh and Dundee, in addition to the appointment of a National Tissue Banking Director. The Transfusion Centre at Law Hospital will be relocated at Gartnavel Hospital by the end of 2000, and SNBTS and the North Glasgow University Hospitals Trust have made a joint consultant appointment in blood transfusion and haematology.

SNBTS also reviewed its Research and Development activities during 1999 and established a Research Advisory Group. The Group is chaired by the Service's National Medical and Scientific Director and its members are drawn from SNBTS and the wider NHS in Scotland. The Group has representation from the National Blood Authority in England and draws on expertise from continental Europe. SNBTS Research and Development is now grouped into 5 themes: Immuno-haematology; Cell-Therapy; Transfusion Transmitted Infection; Products and Components; and Effective Use of Blood.

Effective Use of Blood

The SNBTS's Effective Use of Blood (EUB) Group was established in 1998 to promote the efficient use of donated blood from the time of collection to transfusion. The Group was set up in the context of a falling donor panel and against a background increase in demand of 3-5% per annum. The factors responsible for this increase include technological advances in medical and surgical techniques that require additional transfusion support, and demographic changes, notably a growing elderly population with greater blood transfusion needs. A matter of continuing concern is the very large variation in blood usage by different clinicians, even for identical case groups, and even within a single institution. The overall aim of the EUB Group is to target blood transfusions to those patients who will benefit, bearing in mind that blood transfusion is not risk-free.

During 1999, CRAG's Clinical Effectiveness Programme Sub-Group (CEPS) agreed to fund a clinical effectiveness programme in blood transfusion. This aims to improve the safety and effectiveness of transfusion in Scottish hospitals and evaluate the role of the clinical nurse specialist in transfusion. Funding of £130,000 over a 3-year period has been allocated and the project will commence in January 2000.

The SNBTS Clinical Users Group continues to take a particular interest in the effective use of blood. A joint meeting with the chairs of Hospital Transfusion Committees is planned for early 2000 as a first step to auditing implementation of MEL(1999)9 (see below).

Measures to Enhance Blood Safety

In February 1999, MEL(1999)9 "Better Blood Transfusion" highlighted the greatly increased demand for blood, the downward trend in the donation rate, and the impact on the NHS in Scotland of initiatives such as leucodepletion (removal of white blood cells) and polymerase chain reaction (PCR) testing of blood for hepatitis C. By March 1999 all NHS Trusts where blood is transfused had to have in place a Hospital Transfusion Committees to oversee all aspects of blood transfusion. In addition, Trusts were required to strive to improve the safety of transfusion by participating in the annual Serious Hazards of Transfusion (SHOT) Enquiry. By March 2000 Trusts are also expected to have undertaken work to develop local protocols for blood transfusion and explore the feasibility of autologous blood transfusion.

As part of the ongoing measures to minimise the theoretical risk of vCJD transmission, SNBTS moved over to supply non-UK derived plasma products during 1999. By 31 March all non-hyperimmune IgG products being issued were obtained from non-UK sources, non-UK anti-D was issued by 30 June 1999 and intramuscular hyperimmune products (except rabies immunoglobulin) were issued by 30 September 1999. Intravenous hyperimmune products and intramuscular rabies immunoglobulin were introduced by 23 December 1999. This phased move to non-UK products resulted in the exchange of all stocks of UK plasma-derived products held in hospitals and GP surgeries with a non-UK alternative by the end of December 1999.

Throughout the exercise SNBTS were at pains to ensure that, as far as possible, non-UK derived products were supplied for use to all customers on the same day, regardless of their location. The plans were agreed by Regional Transfusion Centre staff, local hospital consultants (as appropriate), hospital blood banks, general practitioners, the Haemophilia Directors for Scotland and Northern Ireland, and the Primary Immuno-deficiency Association. Patients on home therapy who had been given UK plasma-derived products were not asked to return them. Instead they were notified of the change in arrangements by the staff responsible for their clinical care and offered the chance to change their product before the end of their current course of home therapy.

The other measure to minimise the theoretical risk of vCJD transmission, namely leucodepletion of red blood cells, platelets and fresh frozen plasma, was achieved on target by September 1999. An immense amount of research effort is being applied to develop blood fractionation and processing techniques that might remove the agent responsible for vCJD. Similarly, efforts are being made to develop a diagnostic blood test which can identify the pre-clinical disease and so allow blood donor screening.

Polymerase chain reaction (PCR) testing of plasma pools for Hepatitis C was introduced in the UK in 1998. During 1999 SNBTS began work aimed at applying this test to cellular products such as red blood cells and platelets, prior to release. Formal testing as part of a pilot study will begin during 2000.

Reference Laboratories

The Scottish Reference Laboratories (see accompanying box) are centrally funded to carry out specialised microbiological or biochemical tests on samples referred from all over Scotland, and in some cases, other parts of the UK. The Reference Laboratory Working Group undertook its annual review of these services during 1999. It recommended that current contracts should be extended, with the exception of the E.coli O157 and Campylobacter reference services in Aberdeen. The Working Group shared the generally held view that current Campylobacter serotyping methods do not generate information that is useful in public health or patient management. They therefore recommended that central funding for this reference service should be discontinued pending further research into Campylobacter typing methods. It is emphasised that Scotland will continue to participate in the sentinel surveillance system being set up by the Public Health Laboratory Service in England.

Maternity Services

Audit of Maternity Services

The Scottish Programme for Clinical Effectiveness in Reproductive Health undertook an audit of the quality of hospital and community-based maternity services in 1998. A total of 28 audit criteria relating to non-technical aspects of maternity care were identified from the Provision of Maternity Services in Scotland: A Policy Review (1993) and the CRAG/SCOTMEG Working Group on Maternity Services Reports (1993-96). A structured multidisciplinary site interview was undertaken in all of the 23 consultant-led maternity units and a postal questionnaire (response rate 70%) was sent to a sample of post-partum women. The main findings in the 4 principal subject areas were as follows:

Equipping Women to Make Informed Choice about their Care: The HEBS Pregnancy Book was received by 84% of women, but in only 39% was it received prior to hospital booking. Systems were not yet in place to ensure that women receive the book at the earliest possible stage of their pregnancy. The recommended Unified Health Held Record had been fully adopted in 8 units with limited implementation in all others. In only 8 units had provision been made for a woman's care plan to be written into the main record when she had preferences relating to labour and delivery (58% of women). Despite some shortcomings in the recording of women's preferences, 90% of women did feel that their preferences had been taken into account during their care. Four broad elements of antenatal education had been previously identified but only in 5 units were all these elements in place: 51% of women attended antenatal classes and 94% of them felt well prepared for childbirth while 82% felt well prepared for baby care.

The Role of Different Professional Groups: There has been a shift away from the concept that the obstetrician is the maternity care co-ordinator. In 5 units the midwife was now the sole co-ordinator; 66% of women reported that they had an identified care co-ordinator and in 48% of cases this was a midwife. All units provided women with an opportunity to meet a consultant obstetrician. The reports recommended that the average number of antenatal visits should be reduced from the 1991 average of 15 to 9 visits. Despite this, 7 units still maintained the traditional 15-visit system. Although other units had reduced the number of visits significantly, only 34% of women reported 9 antenatal visits, the median number of visits being 12. Only 4 units had a model of care whereby low risk women could be managed antenatally exclusively by GPs and midwives. Six units had a separate midwifery delivery suite and a further 12 units offered this type of facility within the main labour ward area. Across the 23 units, 94 changes had been made following the reports with particular emphasis on team midwifery, the community role of midwives and community outreach services. Thirty-six barriers to progress were identified, notably professional attitudes, finance and staffing levels. In general, the largely hospital-based staff had little knowledge of local policies for screening for post-natal depression.

Providing a Choice of Type of Intrapartum Care: Home births and Domino Delivery accounted for 0.3% and 0.8% respectively of all 1997 births. Domino is an acronym for Domiciliary In And Out. In this system the community midwife provides complete antenatal care, delivery within a hospital setting and postnatal care after early discharge (normally within 6 hours of delivery). Three units indicated that they no longer offered Domino Delivery and a further 7 units had imposed a quota system. Of the survey respondents, 98.8% of women received hospital care and only 0.8% of these women left hospital within the 6 hours post-partum period (defined as part of the domino scheme). Staff reported an average length of stay of 2 to 3 days for uncomplicated vaginal delivery and 4 to 6 days for caesarean section. Of the respondents, 42% reported a length of stay of less than 2 days, 87% felt that their overall length of stay was appropriate, and 83% felt that the hospital facility was sufficiently homely. In terms of community support to ensure safety, 11 units operated an obstetric flying squad and an integrated hospital and community approach had been developed to meet the need for the 72-hour neonatal examination.

Providing Continuity of Care and Carer: Named midwife and team midwifery models of care have been introduced across Scotland in a variety of ways. In the review, 68% of women reported that most of their antenatal care was provided by one or two individuals, but only 12% received intrapartum care from a midwife known to them.

Termination of pregnancy

The number of therapeutic abortions performed in Scotland are calculated from the notifications made to the Chief Medical Officer in accordance with the Abortion Act, 1967. A total of 12,125 abortions were performed in 1999, a decrease of 360 (2.9%) on the previous year. The proportion of abortions performed at less than 10 weeks gestation rose from 61.8% in 1998 to 65.8% in 1999, and the trend since 1968 has been generally upwards. In 1999, 92% of all terminated pregnancies were of less than 14 weeks gestation and 98.3% were under 18 weeks gestation; these proportions are consistent with the general trend since 1968.

Over the last 30 years the number of abortions has generally increased along with a change in the age group distribution. The percentage of abortions undertaken in women aged 30 years and over declined from 47% of the total in 1968 to 20.9% in 1990, but has since increased to 27.8% in 1999 (except in the 40 and over age group). The percentage of abortions in women aged 20 to 29 years was 38.2% in 1968 rising to a peak of 52.1% in 1988 and decreasing gradually to 48.6% in 1999. In those younger than 20 years of age, the percentage has gradually declined from a peak in 1984 to remain relatively stable at approximately 23% since 1994.

Prior to 1991, terminations of pregnancy were performed by vacuum extraction, dilatation and curettage, or uterine evacuation precipitated by oxytocics. In July 1991 medical methods of termination became available for abortion at less than 10 weeks gestation. The proportion of terminations performed surgically has since gradually decreased (from 83.6% in 1992 to 56.7% in 1999) with a corresponding gradual increase in medical terminations (from 16.4% in 1992 to 43.3% in 1999).

Infertility Services

Clinically effective treatments are now available for many causes of infertility. The Clinical Resource and Audit Group recently convened an Expert Advisory Group to advise on the provision of infertility services throughout Scotland. The report entitled Evidence and Equity: A National Service Framework for the Care of Infertile Couples in Scotland was completed in 1999. It offers a model specification to promote the equity and quality of service throughout Scotland and is consistent with the concept of a Managed Clinical Network. It provides a clear statement of the current scientific evidence regarding effective and efficient interventions, an account of the present service provision and a model for the proposed service that is based on a network offering 3 Levels of Care.

Level 1: This involves both partners in initial investigation and management by the primary care team. It includes basic history taking and clinical examination to confirm that the woman's health status is appropriate for conception and specific investigations to confirm anovulation and semen quality. Support and advice is given regarding knowledge of reproduction including the hazards of smoking and alcohol, and the need for folic acid supplementation. The process should also identify those who would benefit from accelerated referral to Level 2 care (ie women who are older than 35, have an abnormal menstrual cycle or pelvic abnormality, and men with urogenital morbidity).

Level 2: This is usually be provided by a special interest team in a district general hospital. Tubal patency in investigated by a hysterosalpingogram (HSG) and for those women with an abnormality or equivocal HSG or a history suggestive of tubal damage, a diagnostic laparoscopy with dye transit is recommended. A second semen analysis is required. Independent advice and counselling is given at this stage. Given that appropriate expertise and monitoring facilities are available, treatments that may be initiated include:

• Ovulation induction with clomiphine citrate and gonadotrophins;
• Pulsatile gonadotrophin-releasing hormone therapy;
• Controlled ovarian stimulation with intrauterine insemination;
• Surgical treatment of polycystic ovarian syndrome and endometriosis; and
• Treatment of male infertility factors.

Level 3: At this level a specialist tertiary referral centre provides assisted conception techniques (which require an HFEA licence), some other specialised diagnostic and therapeutics interventions, and level 2 care for local patients. Key elements include:

• Endocrine assessment, genital tract imaging and semen microbiology;
• In vitro tests of sperm function and testicular biopsy;
• Selective salpingography and fallopian tubal catheterization;
• Male genital tract surgery;
• Female tubal surgery;
• Ovulation induction and ovarian stimulation using gonadotrophins;
• Gamete intrafallopian transfer;
• In vitro fertilisation (IVF) including intracytoplasmic sperm injection (ICSI) and donor insemination (DI).

The report has developed eligibility criteria for NHS-funded assisted conception in an attempt to balance evidence-based effectiveness and efficiency with equity and the welfare of children. Eligibility criteria are as follows:

• Infertility with an appropriately diagnosed cause of any duration or unexplained infertility of greater than 3 years duration;
• Female partners less than 38 years old at time of treatment;
• Neither party sterilised;
• No child living with the couple in the home;
• Less than 3 embryo transfers from any source.

It is recommended that each couple is entitled to a maximum of 3 NHS-funded assisted conception cycles and to a minimum of 2 transfers of fresh embryos

The profile of current service provision and opinions was collated using the previous Gynaecology Audit Projects, provider and user surveys, and a questionnaire to all Directors of Public Health. An attempt was made to describe the extent to which current services met the proposed model.

Level 1: 60% of GPs arranged to see both partners but only 21% of partners were actually seen together and only 50% had a serum progesterone measurement to confirm ovulation. Only 12% had rubella status notified, 34% to 43% had one semen analysis in primary care and 15% to 21% had inappropriate investigations carried out.

Level 2: Only 31% of gynaecologists requested that both parties attend their clinics. In the event, 54-71% were actually seen together on their first visit, and; 79-85% had a diagnostic laparoscopy as the initial test of tubal patency. Of the 31 laboratories undertaking semen analysis, only 5 were using the WHO guidelines and only 2 undertook external quality control measures. Endometriosis was treated with medical therapy in 35% to 44% of cases.

Level 3: Tubal surgery was performed by 56 consultants in 26 gynaecology units but only 19% utilised microsurgical techniques.

From the survey of Directors of Public Health it was apparent that while all Health Boards funded IVF, only 12 funded donor insemination and only 9 funded ICSI. Eleven Health Boards funded an average of 3 cycles per couple (range 1-3) and the age criteria for treatment ranged from 37 to 40 years, the average being 37 years. The minimum duration of infertility required for referral ranged from less than one year to 5 years, the median being 4 years, and the IVF waiting list ranged from 9 to 60 months.

CANCER CARE

Each year, 23,000 Scots are diagnosed as having cancer and around 15,000 will die of the disease. As the risk of death from heart disease falls, cancer has now become the commonest cause of death in Scotland. Over a lifetime, 4 out of every 10 Scots will develop cancer and this risk has increased over the past few decades. The increasing risk is, in part, due to the fact that Scots are living longer and cancer is much commoner in old age. However, survival has improved substantially over the past 25 years and nowadays more than half of all patients who are diagnosed as having cancer are alive five years after diagnosis. This represents a significant improvement from 25 years ago. For testicular cancer, more than 90% of men are alive after five years and large increases in survival have also been seen for malignant melanoma of the skin, leukaemia and large bowel cancer. Some cancers which have always had a comparatively poor survival, such as stomach and oesophageal cancer, have shown considerable proportional increases in survival over time while cancers such as lung cancer have always had a poor prognosis and have shown no great increase in survival for many years. A detailed analysis of recent trends in cancer incidence and survival in Scotland will be published by the Scottish Cancer Intelligence Unit of ISD in the year 2000.

Cancer survival in Scotland is often thought to compare poorly with countries in the rest of Europe. However, there is no evidence to suggest that Scotland has a higher mortality from cancer when compared to other parts of Europe as a result of poor treatment. International comparisons are difficult to interpret because many countries in Europe do not have full population coverage for their cancer statistics. Many countries underestimate cancer mortality as a result. For example, patients diagnosed in one part of France may move to another part of France and not have death from cancer registered. Scotland's cancer registry covers the whole population and has a very high data accuracy as a result of close collaboration between the Cancer Registry and the Registrar General who collects information on causes of death. We can be confident that our cancer incidence and mortality statistics in Scotland are more accurate than those of many countries in Europe.

There are two particular aspects of cancer that determine whether or not a patient can be cured. The first is the stage of presentation of patients who have the disease. There is some evidence that patients in Scotland tend to present with more advanced disease than people living in some other countries. This tends to reduce the chance of a patient surviving five years or more. The second adverse influence on outcome is socio-economic deprivation. For many cancers, incidence is higher and survival is lower in patients from socially and economically deprived areas. Recent evidence suggests that for breast cancer at least, lack of access to services is not the explanation for poor outcome. Although late stage at presentation and larger tumours tend to be found among deprived patients, it can be shown that later presentation does not account for all of the increase in mortality amongst the poor. It seems likely that deprivation produces other biological effects, perhaps associated with smoking or poor diet, that reduce the ability of people from deprived areas to fight off cancer. Clearly this area needs further research to increase our understanding of the problem and help develop interventions that will reduce the poorer survival experienced by deprived patients.

Organisation of Cancer Services

Scotland's cancer strategy is shaped and directed by the Scottish Cancer Group. This is a group of clinicians from different parts of Scotland. It advises Ministers and the Chief Medical Officer and the Scottish Executive Health Department on a variety of cancer issues. Over the past three years, a number of strategic developments have been commissioned by the Scottish Cancer Group.

Managed Cancer Clinical Networks are being developed to ensure that patients have access to the best possible care regardless of where they live. Clinicians normally work across institutional and geographical boundaries to share clinical expertise and to improve access for patients. Where clinicians become professionally or geographically isolated, it is difficult for them to keep abreast of good practice. Networks provide a framework of peer support and peer review to ensure that every clinician involved in treating cancer has access to the best available clinical advice for his or her patients. The heart of the Managed Cancer Network is prospective audit. Peer review carried out in a supportive manner can spot differences in clinical practice between clinicians, can investigate the reasons for those differences and, where appropriate, can offer advice on improving care. With this approach, the quality assurance of cancer care is being developed initially for breast, lung, colorectal and gynaecological cancers. Managers are being appointed to help clinicians develop these audit and quality assurance systems and to ensure that clinical networks are linked into clinical governance committees within Trusts.

Progress on the development of these networks has varied across Scotland. Prospective audit for the four main cancers is being carried out in most Trusts. CRAG has generously supported a number of prospective audits for other cancers. Audit of oesophageal and gastric cancer has been carried out across Scotland over the past two years and useful data have been collected. This audit will influence the way these tumours are treated and it is hoped that the Audit Steering Group will form the basis of a Managed Clinical Network for these cancers in future. Similar audits of head and neck cancer and urological cancer have been commissioned. CRAG has also supported the work of the Scottish Melanoma Group and the Scotland and Newcastle Lymphoma Group. These audit groups form natural alliances of clinicians around which to develop Managed Clinical Networks and in the coming years it is anticipated that most cancer patients in Scotland will be managed on a Network basis.

Over the past year, the Scottish Cancer Group Quality Assurance Sub-Group has worked closely with colleagues in the Clinical Standards Board for Scotland. Groups of clinicians have developed draft standards for breast, colorectal, lung and ovarian cancers and for palliative care. These standards have been subjected to a wide-ranging and open consultation. This consultation process has included patients and carers and the standards are now being piloted in preliminary inspection visits across Scotland. The development of inspection visits for cancer services represents the final part of the quality assurance framework that begins with cancer networks setting standards and supporting and commenting on audit. Audit information will then be discussed with Trust Chief Executives who have a legal responsibility for the quality of cancer care and inspections by the Clinical Standards Board will ensure a degree of accountability in that whole process.

New Service Developments

Cancer Genetic Services

Breast, colorectal and ovarian cancers are genetically determined in some patients. Patients with a number of family members who have developed one of these cancers at an early stage in life may need investigation by cancer genetic services. Additional funding for genetics Associate Specialists in each of four regional genetic centres was announced recently and all of these staff members are now in post. This system is unique in the United Kingdom in that it provides agreed standards for investigation and pathways for referral for patients who are concerned about their genetic predisposition to cancer.

Cancer Screening

There are currently national screening programmes in Scotland for the early detection of cervical and breast cancer. A demonstration project to establish the feasibility of colorectal cancer screening will be established in 2000 in the East and North-East of Scotland. There has also been considerable interest in the possibility of screening for prostate cancer. The use of a blood test for a protein called Prostate Specific Antigen (PSA) has attracted wide attention and considerable public interest. The levels of this protein are elevated in the blood of men with prostate cancer. What is not widely appreciated by those pressing for the use of PSA screening is the fact that a great many men who develop prostate cancer and who have an elevated PSA do not in fact go on to develop clinical signs or symptoms of the disease. The tumour remains within the prostate and does not grow or spread. A large number of men therefore might be treated inappropriately if PSA testing were to become commonplace. Of further concern is the fact that the treatment of prostate cancer is not without problems. Operative treatment with radical prostatectomy has a number of recognised complications and the benefits of radiotherapy in prostate cancer need still to be tested in randomised clinical trials. The disadvantages, therefore, of a screening programme are that many men who would otherwise remain well are adversely affected by being told they have this cancer and some may go on to have treatment which causes significant impairment to health.

The Scottish Cancer Group is forming a group of specialist oncologists and urologists to consider how prostate cancer should be tackled within Scotland. This group will consider the need for development of specialist skills and training requirements necessary to support the development of an effective system for treating prostate cancer within Scotland. It is hoped that the group will also provide advice on the research and development issues which require to be taken forward in clarifying the best way to tackle this disease.

Expanding Services for Patients

Equipment

Early in the life of the Scottish Cancer Group it became apparent that a considerable amount of radiotherapy equipment in the Scottish Health Service was at or near the end of its useful life. £13.2 million is being made available by the Scottish Executive following a joint review of equipment. The review group included Cancer Centre Directors who are members of the Scottish Cancer Group. Replacing linear accelerators is not a trivial exercise. These are precision machines that focus beams of radiation on to tumour sites which have been carefully scanned and marked out. The beam of radiation has to be calibrated to ensure that damage to normal tissue surrounding the tumour is minimised. Not only is the equipment expensive but the housing within which the linear accelerator is kept is expensive and complex to build. The housing consists of thick shielding which prevents the radiation leaking out of the room and so potentially damaging patients and staff elsewhere. The first tranche of replacement linear accelerators is on order and the bunkers in which they will be located are being built. The next stage in planning is to consider where additional machines might go to reduce the length of time that patients have to wait for radiotherapy.

The Use of Chemotherapy

Public concern is frequently expressed about the availability of the drugs used to treat cancer. These are often expensive and clinical trials may suggest that the benefit to be obtained from using these drugs may be marginal. Health Boards can vary in their willingness to pay for drugs which seem, on the face of it, to have limited effectiveness and at times it has been suggested that equity of access to treatment has been compromised by funding decisions that have been made in Scotland. The Scottish Cancer Group has a small group of experts reviewing the current use and cost effectiveness of cytotoxic drugs. By demonstrating the benefit to be obtained to patients in a Health Board area from the use of the drugs and making explicit their cost, it is hoped that Health Boards will be in a better position to agree with oncologists which drugs should be provided and at what cost. Better information will lead to better commissioning of services and hopefully to a reduction in any inequities that remain in the system. The Scottish Cancer Group has also considered how oncology drugs are administered to patients and in the course of the year 2000, standards for the administration of cytotoxic drugs will be issued to the Service.

Waiting Times

Considerable concern has been expressed by patients and doctors about the length of time people have to wait in order to be seen when they have sinister symptoms. The Scottish Cancer Group has taken the view that to offer a waiting time guarantee to be seen at an out-patient clinic is useful in itself but does not tackle problems of longer waits for investigation and treatment. Work is being carried out to identify where in the Health Service delays are more likely to occur in the investigation and treatment of cancer patients. It is anticipated that new investment will allow waiting times to be brought down to levels that are acceptable to both patients and the clinicians responsible for their care.

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