Category: Cancer

A Data-driven Approach to Planning Radiotherapy Workforce Requirements

January 26th, 2024. Go to post.

There is no greater source of pressure in the NHS at the moment than staff shortages. Rising demand, growing complexity and lengthening waitlists, combined with high turnover, absence and staff leaving the NHS post-Covid, have created a gap between demand and supply of staff.

Understanding and responding to this gap is a complex problem across the health system. Doing so requires a detailed understanding of future workforce requirements and innovation in model and roles. By partnering with Dearden HR, award winning HR and OD consultants, we are able to combine our robust analytics and understanding of data with bespoke people and OD solutions.

West London, Surrey & Sussex Radiotherapy Operational Delivery Network

One example of our work together was with the West London Surrey & Sussex (WLSS) Radiotherapy Operational Delivery Network (ODN). The ODN, which comprises 4 radiotherapy providers, sought to understand their future workforce requirements and opportunities to innovate and implement a new workforce model to meet demand.

Approach

Our approach revolved around three workstreams. The first two supported the development of a rich evidence base, through modelling of future demand and activity and gaining a detailed understanding of the ODN’s current workforce status. These efforts formed the groundwork for assessing the future workforce requirement and developing an action plan for meeting this requirement. Our approach was designed to ensure that the final outputs are rigorous in detail and evidence, innovative in approach, built off existing best practice and co-developed with providers and ODN leadership.

The modelling was built on anonymised attendance-level data collected from each provider. This level of detail allowed for robust modelling of the workforce requirements of current and future activity, considering changes in complexity, treatment type and pathway. This was supported by workforce data and staff engagement, including a questionnaire and interviews to better understand each Trust’s workforce model, as well as staff motivation and job satisfaction at each of the Trusts.  This multi-faceted approach ensured a comprehensive understanding of the present workforce landscape and laid the groundwork for informed workforce planning and recommendations.

Future demand was modelled based on a range of scenarios, considering changing population, demographics, population health and cancer treatment. This modelling informed future workforce requirement scenarios. An interactive workforce planning tool was developed alongside the final report, enabling scenario analysis for future workforce shortfalls or surpluses based on Trust-specific assumptions.

“Partnering with Edge Health allows us to develop recommendations and an implementation plan which is based on clear and rigorous data analysis.”

Michelle Hodgkinson, Director, Dearden HR   

Outputs

Based on the demand and capacity modelling and our understanding of current staffing levels, we calculated the additional establishment and in-post WTE required to meet the recommended level of staffing. The work also developed a series of recruitment and retention interventions, including regarding:

  • Apprenticeships
  • International recruitment
  • Active retention and support
  • Development roles
  • Flexible working

The combination of quantified workforce gaps and recommended interventions has provided the ODN and each Trust with a strategy for addressing future workforce pressures. This is currently being taken forward within the ODN.



Revolutionising Lung Cancer Diagnosis: The Economic and Clinical Impact of ctDNA Testing in the NHS

January 15th, 2024. Go to post.

Introduction

In 2020, 37,211 people were diagnosed with lung cancer in England. 68% of this population is at an advanced stage and has limited life expectancy. People with advanced lung cancer have complex care needs and often experience high levels of GP appointments, hospital admissions and extended lengths of stay while awaiting diagnosis and treatment.

Timely genomic testing of the tumour can help identify individualised treatments, which can potentially markedly improve the quality and length of life. Delays in identifying specific gene mutations can result in missed opportunities for patients to receive targeted and more effective treatments, ultimately leading to worse outcomes and higher costs for health systems.

Liquid biopsy, a cutting-edge diagnostic method validated through numerous clinical trials, involves testing blood samples for biomarkers like circulating tumour DNA (ctDNA), among others, to detect cancer-related genetic mutations. This less invasive approach offers several benefits, particularly in vulnerable patients with advanced non-small cell lung cancer.

The NHS in England is working towards being a global leader in adopting liquid biopsy testing into a national health service. Recognising the importance of economic assessment and evaluation of the costs and benefits of broader ctDNA testing, Edge Health was commissioned by NHS England to undertake this work to support an ongoing national pilot involving non-small cell lung cancer testing.

Using health economics to understand benefits and costs

Our initial findings in the early phase of the health economics analysis of ctDNA testing combined academic methods with commercial insight and experienced understanding of how the NHS operates to assess the economic implications. This involved collaboration with clinical experts and synthesis of information from various other sources. As a new technology, our analysis considered various clinical scenarios and sensitivities for critical assumptions.

“Implementing ctDNA testing into the routine diagnostic work up of patients with lung cancer is a huge step forward to improving equity of access to state of the art genomic testing for our patients. This will allow patients to receive the best treatment possible for their condition. The input from Edge Health has been invaluable in mapping out a complex pathway, identifying options for ctDNA implementation and their associated cost benefits”.

Professor Sanjay Popat, Consultant Thoracic Medical Oncologist, Royal Marsden Hospital

Outputs from the initial analysis were extrapolated more generally with national data, which helped identify the potential future costs and benefits.

In the context of stage III and IV lung cancer, from early analysis, the application of ctDNA was found to deliver significant benefits relative to its costs. This finding was primarily driven by ctDNA testing enabling earlier blood testing and potentially avoiding tumour genomic testing, which supported patients to access targeted treatments earlier and more consistently – lowering broader system costs. In the next phase of work, pilot data will be analysed to validate these preliminary findings to support the commissioning of the ctDNA test on the genomic national test directory.

Moreover, ctDNA testing is expected to improve equity in genomic testing access substantially, expanding coverage over a broader spectrum of gene mutations and ensuring the inclusion of patients for whom adequate tissue biopsies might not be viable.

Genomics vision

Ultimately, incorporating the latest genomics advances into routine healthcare will help deliver the UK government’s vision in “Genome UK: the future of healthcare”.

“The current work of the ctDNA pilot aligns perfectly with the Genomic Medicine Service goals of delivering equitable genomic testing for cancer patients through accessing cutting edge technology and science.  This technology will hopefully, if commissioned onto the national test directory, ensure that clinical services can make better-informed decisions faster, have access to precision treatments which will improve patient outcomes, ultimately leading to more efficient use of NHS resources. The work from Edge Health is vital in helping to demonstrate that this advance in care is also economically viable”.

Paul Ryves, Programme Director, North Thames Genomic Medicine Service Alliance.

Contact us to learn more about our approach and how we can help you.



Case study: Evaluating the benefits of integrating chemotherapy patient management apps

July 10th, 2023. Go to post.

Challenges in the Existing Healthcare System for Chemotherapy Patients

Cancer patients undergoing chemotherapy have to navigate a complex healthcare system at a particularly stressful point in their lives. Various patient management apps exist to support both patients and providers with this treatment pathway. However, a lack of a single source of information disadvantages both patients and Trusts.

Integrated Solutions for Patient Management and Prescribing Process

In response to this, the industry leader in electronic chemotherapy prescribing developed a product that integrates all aspects of patient management from referral to discharge and simplifies the prescribing process for healthcare professionals. Additionally, another provider created a patient-facing mobile app that brings disparate pieces of information from across the healthcare ecosystem together and delivers personalized support for cancer patients.

A typical Trust will treat between 1,200 and 1,500 new patients with chemotherapy each year. As such there are significant benefits to integrating these two patient management solutions and offering a bundle for purchase by acute providers. Edge Health was commissioned to deliver a report on the potential impacts of the integration. Through a review of existing literature and clinical engagement, we assessed the wide range of benefits throughout the patient journey. By quantifying some of these benefits, we sought to highlight the potential magnitude of the advantages for both Trust’s finances and patients.

Our Analysis of Impacts and Benefits of patient management solutions

Positive Impacts on Patient Care and Risk Management

Many of the identified benefits are felt by the patients themselves. The integrated app and system facilitate the delivery of optimal patient care and minimise chemotherapy treatment’s risks and side effects. The advantages of this integration appear to be most material for patients who may require changes to their treatment, due to adverse reactions or toxicity, or for the rarer cases of more severe illnesses such as colitis and neutropenic sepsis.

Financial Benefits to the Healthcare System

There are also clear and direct financial benefits to the NHS. Chemotherapy drugs are expensive and waste is a substantial issue, whilst the costs of treating patients who develop more significant illnesses during their treatment can be very large. Through accurate capturing and sharing of patient-reported outcomes, the integration contributes to cost savings by minimising the expenses associated with treating such complications or illnesses.

The integration of chemotherapy patient management apps offers significant benefits to both patients and healthcare organizations. By streamlining the treatment process, improving patient care, and reducing financial burdens, this integrated solution has the potential to enhance the overall quality of care for cancer patients undergoing chemotherapy. Acute care providers can leverage these apps to optimize their treatment protocols and improve resource allocation, ultimately leading to better patient outcomes and more efficient healthcare delivery.



Improving Cancer Outcomes – Why ICSs Must Tackle Health Inequalities

June 1st, 2023. Go to post.

There is a recurrent emphasis on the need for Integrated Care Systems (ICSs) to address health inequalities, as highlighted by media outlets, conferences, and reports.

Addressing these disparities is a monumental task, especially for the newly established ICSs, which have been tasked with not only establishing new governance and strategies but also tackling an elective backlog and long-standing health concerns like health inequalities.

One crucial area of focus, particularly in relation to the Core20Plus5 mandates, is cancer, as we are aware of inequalities in access impacting diagnosis and survival rates. The ambitious objective set out by the NHS Long Term Plan is to diagnose 75% of cancers at Stage 1 or 2 by 2028.

Lung cancer, where 64% of patients receive a diagnosis at stage 3 or 4, is an excellent example that underscores both challenges and opportunities for ICSs.

Why avoiding emergency diagnoses is key

We examined publicly available data on lung cancer care. Patients referred by a GP are more likely to be diagnosed at an early stage than those in emergency settings.

This relationship can be seen by comparing NHS clinical commissioning groups (CCGs), where a 10% increase in GP diagnoses is associated with a 3% increase in early diagnoses (stages 1 and 2), when adjusting for confounding factors, as shown in Figure 1.

Figure 1. Source PHE 2018

Since patients are over 3 times more likely to survive more than 5 years when diagnosed at stage 1 compared to stage 3[i], detecting cases via referrals from primary care has a direct impact on lowering lung cancer mortality rates associated with a late-stage diagnosis.

Diagnosis RouteStage 1Stage 2Stage 3Stage 4
Primary Care21%10%25%44%
Emergency Department10%5%14%72%
Ohter28%10%20%42%

Table 1. Source NCRAS 2015-16

Reducing variation in primary care referral rates

The challenge, however, lies in the unequal volumes of lung cancer referrals made in primary care, which vary dramatically across NHS regions. We have used Public Health England data and machine learning approaches to uncover the relationship between the number of GP referrals and the percentage of all lung cancer cases diagnosed from these referrals.

As seen in Figure 2, there is a clear positive relationship between the volume of referrals from primary care and early diagnosis, which is particularly strong for areas with low referral volumes.

It follows that if GPs with low referring rates could be supported increase referral volumes, there will be a high impact in driving earlier diagnosis and improving survival rates. This means that increasing referral rates would be very material for the NHS and its patients. In fact, if all ICSs were able to bring all the lowest referring GP services in line with the bottom quartile, as shown in Figure 3, we would expect 700 extra early diagnoses and 100 lives saved per year across the country.

Figure 2. Source PHE, 2018
Figure 3. Source PHE, 2016

How these findings turn into practical implications for ICSs

Variation in urgent suspected cancer referrals and early diagnosis rates is likely a combination of both GP organisation/behaviour and broader patient behaviour. For the former, it is well known that there are pressures on GP numbers and overall workload, which will impact access locally.

Nonetheless, there will be opportunities for ICSs to surface data on variation in cancer referral rates and work with practices to understand variation and support where necessary.

ICSs can also lead improvements by understanding how their local population, demographic and health system factors are influencing access. Although this highlights the complexity of the challenge, it also offers multiple sources of opportunity for systems.

In our experience, some of the key actions for ICSs to address the above are:

  • Involve primary care networks (PCNs) and cancer alliances early into conversations about improving cancer detection – we are currently working with a cancer alliance on data-driven research to better understand the drivers of variation in the detection rate and the most effective interventions for addressing them.
  • Provide practices and PCNs with tools to better understand their local population and their health needs (see here for a population health management dashboard we developed for Surrey Heartlands).
  • Plan adequately for workforce, particularly in primary care, to make sure there is enough capacity to boost referrals and avoid workforce overwhelm. Given the falling numbers of full-time equivalent GPs, this is a priority area for ICSs and nationally.
  • Assess secondary care diagnostic capacity, including modelling demand and capacity and promote system-wide initiatives such as new community diagnostic centres, implementing rapid diagnostic services and supporting mutual aid between trust, as we have discussed previously.

As the landscape of healthcare continues to evolve, ICSs have a crucial role to play. The responsibility lies with them to implement innovative strategies, utilise data-driven research, and ensure a robust primary care workforce.
With a concerted effort towards these goals, ICSs have the potential to significantly influence early cancer detection rates and, ultimately, patient survival.


[i] Characteristics of patients with missing information on stage: a population-based study of patients diagnosed with a colon, lung or breast cancer in England in 2013. C Girolam and others BMC Cancer (2018). Volume 18, Page 492



Speeding up cancer diagnosis: how to break the 28-day barrier

January 19th, 2023. Go to post.

Standards introduced in October 2021 mandate that at least 75% of patients urgently referred by a GP[1] for suspected cancer should receive a diagnosis (or be cleared) within 28 days. In September 2022, however, 33% of them – 78,000 a month – did not receive a timely diagnosis. This reduces their chances of survival considerably by preventing prompt treatment.

As shown in Figure 1, from April 2021 to September 2022, the number of patients meeting the 28-day target has dropped from 73% to 67%, and the 75% target has yet to be met. This is likely due to the large increase in the number of referrals registered during the past months which is constraining diagnostics capacity (as discussed in our previous post).

This varies greatly by suspected cancer. The 28-day rate for breast and children’s cancer in September 2022 was in fact close to 90%, while for tumour sites such as gynaecology, skin, lower gastrointestinal and urology (including prostate) it was as low as 50%.

For urological malignancies, the failure to meet the 28-day diagnostic target has a significant impact on the 62-day treatment target. As shown in Figure 2, the longer the delay in obtaining a diagnosis, the more likely patients are to miss the 62-day treatment benchmark. This highlights the crucial importance of timely diagnosis in ensuring prompt and effective cancer treatment.
Furthermore, as the number of diagnostic tests administered increases, so does the proportion of patients who meet the 28-day diagnostic target. This correlation suggests that delays and capacity limitations in diagnostic testing are playing a key role in the decline of cancer care outcomes nationwide[2].

This is not going unnoticed, with trusts racing to implement a number of solutions to reduce pressure on hospitals and provide quicker access for patients. There are three broad groups of approaches to streamlining cancer diagnostics:

  • Creating additional diagnostic capacity using weekends, new diagnostics centres and independent sector diagnostics – For instance, the opening of new community diagnostic centres across England will provide elective diagnostics such as checks, scans and tests away from acute facilities and free up hospital capacity.
  • New population screening programmes – An example of this is the new lung cancer screening programme which aims at improving early diagnosis by running a low-dose CT scan of the lungs on high-risk people and inviting them for further tests if abnormalities are shown.
  • Implementing additional rapid diagnostic services for urgent patients – Like the national roll-out of fast-track testing, which from November 2022 allows every GP team to directly order CT scans, ultrasounds or brain MRIs for patients with concerning symptoms.

The examples provided above are just some of the latest initiatives aimed at cutting down waiting times for cancer patients across the NHS. In our experience, however, one approach has already shown huge potential for effectiveness: mutual aid between Trusts. In the next blog post, we’ll dive into the details of data-driven mutual aid and demonstrate the vast impact it can have on diagnostic and treatment efficiency and speeding up recovery.

[1] Along with patients referred by their GP with breast symptoms where cancer is not initially suspected; or referred by the National Screening Service with an abnormal screening result.
[2] The data used include both diagnosed and non-diagnosed patients. With more specific data this correlation is believed to be even stronger.



Why more patients than ever before are missing NHS cancer waiting times targets

December 2nd, 2022. Go to post.

In England, 40% of new cancer diagnoses come from an urgent referral from a GP [1]. NHS hospitals are required to start cancer treatment for everyone who’s been urgently referred within 62 days. These cancer waiting times standards help ensure people are rapidly diagnosed and treated – critical for long-term outcomes such as survival.

More patients than ever are now waiting more than 62 days for treatment. Of all completed pathways, the number of patients waiting longer than 62 days to receive treatment has almost doubled [2] from 6,242 in September 2019 to 11,910 in September 2022 – 39.5% of 62-day pathways, meaning that only 60.5% of patients are meeting the 62-day target. What factors are contributing to this?

Referrals are at record highs

After a drop in urgent referrals [3] in 2020 due to the Covid-19 pandemic, demand for cancer services is now at its highest since 2019 (a 38.0% increase from September 2019, corresponding to 249,994 urgent referrals in September 2022). There are several possible reasons behind this increase – from changes in referral patterns to the “missed” referrals during the pandemic that are now coming back to the system.

As shown in Figure 1 below, there seems to be a positive correlation between the increase in the number of 2 weeks wait referrals and the decrease in the percentage of patients meeting the 62-day target.

Figure 1

Diagnostics capacity is a bottleneck

The faster diagnosis standard, introduced as part of the long-term plan, ensures that people urgently referred from a GP [4] receive their diagnosis by day 28 of their pathway. From April 2021 to September 2022, the number of patients meeting this standard has dropped from 73% to 67%. This suggests that increased referrals are also constraining cancer diagnostics capacity. We can’t say for sure without patient-level data, but likely, many of the same patients who miss their diagnostic target (33%) also miss their treatment target.

Hospitals are working through their backlogs

Figure 2 illustrates that while capacity has been constrained throughout the pandemic, 5.1% more patients are now being treated every month compared to the 2019 average (27,332 vs 28,735). This suggests that Trusts are working hard to increase their capacity to meet the increase in demand.

Figure 2

There has been an increase in the number of extremely long waiters treated, with the percentage of people waiting longer than 104 days doubling from 5.5% in September 2019 to 12.9% in September 2022.

Trusts are focussing their increased capacity on their longest waiters – temporarily decreasing performance, but an indicator that Trusts are working to reduce their backlogs.

Managing increased referrals will continue to be a challenge for Trusts in the months to come. How will they meet this challenge?

In our next three blog posts in this series, we will explore potential solutions – including approaches to streamlining cancer diagnostics, the potential of mutual aid and strategies for identifying and reducing health inequalities.

———————–
[1] As of 2016, https://www.ncin.org.uk/publications/routes_to_diagnosis

[2] Grown by 90.8%

[3] Note that the two-week wait (2WW) appointments are a proxy for incoming referrals. Referrals may be higher given that only 73-78% of 2WW appointments have been within the standard from July-September 2022.

[4] Along with patients referred by their GP with breast symptoms where cancer is not initially suspected; or referred by the National Screening Service with an abnormal screening result.



System-wide Cancer Pathway Management – CanCollaborate, a tool to monitor and risk-assess PTLs

July 13th, 2022. Go to post.

Since the start of the pandemic, the number of cancer patients treated has decreased, while the number of patients breaching the 62-day recommended target has risen. The risk of breach is particularly high for patients on complex pathways – partially due to the administrative time required for Trusts to exchange information on pathways and agree next steps.

 As Trusts move to gain efficiencies through shared learning and mutual aid they need integrated data and tools to inform their decision-making. This is why Edge Health developed CanCollaborate, a tool which allows Trusts and system partners (like Cancer Alliances) to monitor and risk-assess their cancer patient tracking list (PTL) across multiple Trusts. The system-wide solution unlocks information for Trusts and system partners on complex pathways, allowing them to understand and support timely access for patients who are transferred between two or more hospitals.

 CanCollaborate is compatible with all major cancer tracking systems (e.g., Somerset, Infoflex, Dendrite) and uses an approach that allows patients to be linked, while preserving anonymity. It includes both patient-level prediction of breach risk and a summary of breach risk for different tumour sites and patient cohorts linked to specific actions, making it easy for administrators to act based on recommendations. It also provides a weekly demand and capacity forecast 12 weeks in advance to align with staff scheduling, which is used to support system planning and discussions around capacity sharing. By linking demand and capacity forecasting with patient level data, Trusts and systems can easily understand how individual patient pathways contribute to overall demand for services.

 Through development of this tool, Trusts have been able to reduce administrative time, assure equity of access across Trusts in the region, plan in advance through receiving early warnings of incoming tertiary referrals, and flag patients in urgent need of actions. By enabling proactive management of patient pathways and facilitating joint working, Trusts are able to reduce 62-day breaches and improve patient experience and outcomes.



Specialist cancer nurse modelling for Macmillan

September 6th, 2021. Go to post.

Published 8 September 2021

Specialist cancer nurses play a vital role in supporting people with cancer, but their numbers have not kept pace with growing demands. As cancer incidence increases across the UK, there is an urgent/ongoing need to expand the number of specialist cancer nurses working in the NHS.

Macmillan Cancer Support has been supporting nurses to become specialist cancer nurses for many years, but the NHS will need considerable additional investment from UK governments to expand the workforce to the extent needed. To help understand the scale of the need, Macmillan Cancer Support commissioned Edge Health to undertake modelling on the number of additional specialist cancer nurses required by 2030 and the funding needed for training.

Our modelling shows that an additional 3,371 specialist cancer nurses are needed in England by 2030, the training for which would cost £124 million. You can find more details of the work on Macmillan Cancer Support’s website here.

For further information please contact George on 07980804956 or [email protected]



Developing Intelligence for Cancer Pathway Tracking

October 24th, 2019. Go to post.

Shorter waiting times for cancer diagnosis, treatment, and care improves patient experience and can improve survival rates. Nationally there is a 62-day target for hospitals. This target specifies that 85% – 90%* of referrals where a cancer diagnosis is confirmed should begin treatment within 62 days.

Meeting this target can be challenging for hospital cancer teams. There are many milestones that need to happen before treatment can begin (e.g. establishing a diagnosis and determining the best course of treatment). Missing one of these milestones can cause a ripple effect along the cancer pathway – leading to missed targets and worse experience and outcomes for people on the pathway. To make sure that none of the milestones are missed, cancer teams need to juggle live data from multiple sources and coordinate booking teams, as well as communicate high-level resource needs to senior team members.

Working with the cancer performance team at a Foundation Trust we developed a solution – CanTrack. CanTrack is a single platform that links data from the Somerset platform with data entered by bookers. The risk of missing milestones is RAG rated so that bookers can quickly establish who needs to be urgently booked in for their next appointment. CanTrack is connected to a live data stream so that changes to a person’s appointment status are immediately reflected.

Using the visualisations in CanTrack, senior members of the team can immediately see bottlenecks and support the booking team. There is also a suite of automated reporting tools available to make preparing data submissions to NHSI easy.

Following its successful implementation, end-users have shared positive feedback. While it is too early to see its impact, simply having the data and functionality of CanTrack has helped improve the workflow of the team.

*Depending on whether the referral is a GP referral or screening.