Maintenance of cancer surgery: framework

Framework for maintenance of cancer surgery - Version 4: Prioritisation of cancer surgery and new guidance on clinical decision making processes

Actions

Consistent access

• patients are treated and listed for surgery in order of Clinical Priority in the same way across NHS Scotland
• boards work together to ensure patients are offered the earliest available appointment and appropriate escalation routes are available as part of the overarching governance of this framework

Prioritisation of surgery

• capacity needs to be managed in an equitable way, based on this nationally agreed clinical prioritisation framework
• Clinical Prioritisation Groups (CPGs) at local and regional level should oversee cancer, and other surgery services, to provide governance that ensures timely and equitable access for all cancer patients across Scotland.
• there should be national oversight of the number of patients awaiting cancer surgery in each of the regions on a monthly basis
• appropriate clinical intelligence should be used to assess services regionally, particularly for patients where surgery is time critical to outcomes

Implementation

• regional CPGs to provide monthly update to the Scottish Government with summary data on all Priority 2 cancer patients that (i) are awaiting surgery, or (ii) are awaiting a date for surgery, for each tumour site
• regional CPGs will oversee regional flow and capacity and facilitate regional working. This will include understanding the context of clinical intelligence where patients are at risk of breaching the framework.
• local HB CPGs will ensure all patients are prioritised according to local MDT recommendations, within the framework
• a weekly meeting of HB CPGs is encouraged to manage flow and appropriate escalation of patients at risk of breaching the CWT 31-day standard

Safety of service

• care is delivered safely, efficiently and sustainably whilst acknowledging the need to care for COVID-19 patients and other emergency and critical care within the acute hospital sector
• risk of COVID-19 transmission for elective cancer surgery is minimised

Introduction

This updated 'Framework for Maintenance of Cancer Surgery' approved by the National Cancer Recovery Group should be applied across NHS Scotland.

Principles

The framework provides NHS Scotland with clear guidance of how we will maintain cancer surgery whilst ensuring appropriate COVID-19 safety measures remain in place.

The framework sets out key principles suggesting how to:

• identify and prioritise patients appropriately
• maintain equitable access to care for patients across NHS Scotland
• deliver care in the safest possible environment

Since June 2020, NHS Health Boards (HBs) have embedded the National Surgery Prioritisation Framework into operational delivery to ensure patients receive surgery for cancer, based on their clinical risk, within the agreed timescales. This framework has helped manage demand and capacity in the system and helped enable HBs to collaborate where capacity has been impacted by the pandemic.

As we move into a new phase of the pandemic through Winter 2021/2022, this framework will look to support HBs and regional networks with monitoring flow and capacity for elective cancer surgery, and particularly those cancers where surgery is time-critical.

This paper provides further guidance on how HBs and regional cancer networks should work collaboratively to maintain timely treatment for cancer patients and also to upscale surgery capacity that ensures equitable access for all patients that have had their surgery delayed or impacted upon by the pandemic.

Surgical classification for all cancer patients

All cancer MDTs should apply the same clinical prioritisation for all cancer patients listed for surgery that has been endorsed by the Scottish Government and the Royal Colleges:

Patients requiring surgery during the COVID-19 crisis have been classified in the following groups:

• Priority level 1a Emergency - operation needed within 24 hours
• Priority level 1b Urgent - operation needed with 72 hours
• Priority level 2 Surgery – scheduled within 4 weeks (31 days)
• Priority level 3 Surgery – scheduled within 12 weeks
• Priority Level 4 Surgery – may be safely scheduled after 12 weeks

The surgical procedures in each group are defined in the Federation of Surgical Specialty Associations (FSSA) intercollege guidance: Clinical Guide to Surgical Prioritisation During the Coronavirus Pandemic

As of 12 November, the latest update to the FSSA guidance was published 30 April 2021. We monitor and communicate any changes to regional CPGs on a monthly basis for dissemination across boards.

Clinical Prioritisation Groups (CPGs)

NHS Scotland manages competing demands from various surgical specialties to gain access to a limited surgery resource, particularly in the current context.

Health Boards must ensure access to surgery is prioritised by clinical need in line with this framework, with MDT and local and regional Clinical Prioritisation group guidance directing cancer surgery as a priority.

Health Boards must ensure that robust local governance policies are in place to ensure fair and reasonable access to surgical resources, taking account of both post-operative care and where ITU/HDU capacity is available to support.

CPGs should primarily operate at Health Board level with a priority focus on cancer surgery.

Most will meet on a weekly basis to ensure patients with a cancer diagnosis are prioritised for surgery in the timescales required. The guidance allows for surgery to be prioritised within the described schedule.

Local CPGs should comprise senior clinicians and managers to facilitate this process. It is imperative that each local CPG has a senior cancer clinician represented, preferably chairing.

A typical local CPG should comprise of, as a minimum, the (i) Clinical Lead (CL) for Surgery, (ii) Clinical Lead (CD) for anaesthetics, (iii) Clinical lead (CD) for surgical cancer services, (iv) Senior manager for theatres and (v) surgery capacity manager or equivalents.

Regional Clinical Prioritisation Groups (RPGs)

Regional CPGs oversee Health Board cancer surgery and support regional working within the three existing regional cancer networks; North Cancer Alliance, South East Cancer Network and West of Scotland Cancer Network.

Each regional CPG assesses pressures to identify the need for cross-Health Board working which may require transfer of patients or staff or both to adjacent and/or co-located Health Boards within the region. Where local solutions are not immediately available, Medical Directors are responsible for escalation and seeking mutual aid within the region. Regional capacity challenges should be raised with Scottish Government for appropriate discussion.

Each regional CPG reflects local and regional geographies and service configurations. The key function of the regional CPG is to analyse intelligence on patients awaiting surgery within the next four weeks (Priority 2) and utilise management information to assess demand and capacity, risk and the requirement for escalation.

The regional CPG is responsible for the collation and submission of cancer surgery data to the Scottish Government on a monthly basis as part of the oversight of this framework. Practically, this should be through each regional cancer network manager or their nominated deputy.

National oversight

Regional cancer networks will provide overall numbers of patients awaiting surgery for cancer as part of a monthly update to Scottish Government to inform national groups as part of oversight of this framework.

Boards will remain accountable for operational arrangements where support is required from health boards outwith their region and appropriate escalation through HB Medical Directors will continue to be the appropriate mechanism for requesting additional support. See section on inter-regional mutual aid SBAR for more details.

Supporting data requirements

Health boards will be required to provide weekly summary updates to regional CPGs, with data on all cancer patients that are:

i. are awaiting surgery

ii. are awaiting a date for surgery, for each tumour site on the Priority 2 surgery cases, as well as total number of Priority 3 and Priority 4 patients.

The starting point, or time zero, for the timescales of the framework is defined as the "Date of the Decision to Treat". This is the date on which the cancer treatment plan (surgical treatment plan if first treatment) was agreed between the patient and the clinician (or delegate) responsible for first treatment. This usually follows an MDT discussion.

Supplementary information on service capacity, delivery and risks of patients breaching the framework is also required as part of regional CPG activity, to inform regional and national oversight of surgery services. This may include:

• patient availability, choice, or clinical fitness
• theatre / workforce capacity
• requirements for additional investigations before surgery.

This data will be collated on a regional basis and submitted nationally on a monthly basis for oversight.

It should be noted that for some patients who have surgery as their first treatment, timescales to surgery are already monitored as part of the Scottish Government Cancer Waiting Times performance monitoring.

This Framework intelligence should be inclusive of all cancer patients who have cancer surgery, regardless of whether this is the first treatment or otherwise.

Regional and national escalation triggers

Weekly reports should be submitted to regional Clinical Prioritisation Groups providing local and regional assurances on the operation of the system in matching demand and capacity. It is expected that boards and regions will work collaboratively to investigate all possible solutions where there are challenges to meeting the timescales required by the framework for patients most at risk.

Triggers that may stimulate the need for a regional collaboration may include:

i. increased volume of priority patients

ii. reduction in cohorts of medical staff (surgeon / anaesthetist) and nursing staff (theatres and wards)

iii. lack of theatre capacity or theatre equipment

iv. lack of critical care capacity.

Monitoring of intelligence on the Priority 2 patients will allow for appropriate escalation where a significant proportion of patients are not receiving surgery within the required timescales.

This escalation should firstly be through regional CPGs to assess capacity elsewhere in the region, and utilising existing cancer network structures to find solutions.

Where solutions cannot be found at this level, this should be escalated urgently to Scottish Government.

Governance

Data collection relating to the Framework will look to assess demand and capacity and therefore no adjustments should be made to waiting times. This includes any periods of self-isolation required or where patients are unavailable for surgery. This should be captured as part of the context of the information but patients should not be excluded from the data returns for these reasons.

Regional cancer networks are required to collect data which explains why any Priority 2 patients are not receiving surgery within four weeks; this should be undertaken on a network-by-network basis.

Interim solutions for cross Health Board working, and the implementation of regional and national services to support the recovery phase, must follow all HR and governance processes, which may include the need for honorary contracts to facilitate regional working.

Elective cancer surgery should be upscaled in 'green sites' with full adherence to and implementation of national policies for patient and staff testing before, during and after surgery.

Inter-regional mutual aid SBAR

Situation

Current surgical capacity remains significantly impacted by recent systems demands and backlog of cases requiring urgent intervention is growing.

This paper should be used to help facilitate cross regional referrals to those sites where capacity may allow this work to proceed, subject to necessary clinical governance and organisational arrangements.

It should be used alongside the Framework for Maintenance of Cancer Services and provides further guidance on inter-regional mutual aid to maintain timely treatment for cancer patients who are at risk of having their treatment unduly delayed or impacted.

This is to ensure that there are transparent processes for boards that need to request mutual aid beyond their network and that there is equitable access to cancer surgery for Priority 2 patients across NHS Scotland.

Background

The Framework for Maintenance of Cancer Surgery, as published by the Scottish Government (XXXX 2021) provides NHS Scotland with guidance for the maintenance of cancer surgery, It sets out the following principles:

• identify and prioritise patients appropriately
• maintain equitable access to care for patients across NHS Scotland
• deliver care in the safest possible environment

This framework emphasises the need for boards and regional cancer networks to work collaboratively to maintain timely treatment for cancer patients and also to upscale surgery capacity that ensures equitable access for all patients that have had their surgery delayed.

Local Health Board Clinical Prioritisation Groups have been established, which are tasked with overseeing theatre allocations on a regular basis to ensure that prioritised patients are apportioned appropriate and preferential access.

The XXXX Regional Cancer Surgical Prioritisation Group was established in XXXX after its Terms of Reference was agreed by XXXX. The group provides a regional forum for boards to maintain oversight of cancer surgery demand and an opportunity to highlight any challenges or issues on a more frequent basis than XXXX.

Assessment

The remit of the XXXX Regional Cancer Surgical Prioritisation Group and its board representatives, in relation to Mutual Aid, is to provide an escalation route for XXXX boards' local clinical prioritisation groups for any issues that may require regional working or collaboration. Where regional support is likely to be required, these issues are escalated to the XXXX Board Medical Directors, who will then in turn liaise with the National Cancer Surgery Programme Board regarding any regional service pressures where a regional action is not able to address the waiting time issues.

This group does not have the authority to move patients or resource across the region and XXXX Medical Directors retain decision making in relation to either mutual aid or the movement of patients.

Triggers for escalation

Local to regional triggers have included:

increased volume of priority patients that cannot be accommodated within local board's capacity

reduction in cohorts of medical staff (surgeon / anaesthetist) and nursing staff (theatres and wards) within a board

insufficient theatre capacity or theatre equipment within a board

insufficient critical care and/or HDU capacity within a board

Inter-regional triggers may potentially include:

• increased volume of priority patients that cannot be accommodated within regional boundaries
• reduction in cohorts of medical staff (surgeon / anaesthetist) and nursing staff (theatres and wards) within a region
• insufficient theatre capacity or theatre equipment within a region
• insufficient critical care and/or HDU capacity within a region

To adhere to the principles set out in the Framework for Maintenance of Cancer Surgery, it is essential that escalation processes are widely communicated to all MDTs/clinical teams and managers. This will avoid delays in patient management and the inadvertent prioritisation of less urgent cases both within and across specialties.

Recommendation

Medical Directors will retain decision making responsibility for mutual aid and any movement of patients and that these short-term measures are subject to review and do not represent substantive change to patient pathways.

Subject to the necessary clinical governance and organisational arrangements, each board will consider the following factors ahead of seeking inter-regional mutual aid:

• appropriate alternative management strategies have been considered
• local prioritisation categories have been validated
• availability of regional capacity has been considered
• availability of resources outwith the region has been investigated
• pathways and communication have been agreed with the board providing mutual aid
• additional factors, such as Neo-adjuvant therapies or symptoms, have been reviewed with the board providing mutual aid

By considering the above factors, XXXX boards will facilitate person-centred, safe and governed services and the transfer of patient management across regional boundaries. It will also ensure that:

• decisions and recommendations are clinically focused to meet the needs of the patient
• referral pathways will be clear to all and are supportive to patient requirements
• appropriate clinical, corporate and financial governance arrangements are in place
• the Regional Cancer Surgical Prioritisation Group will continue to monitor board/regional demand for cancer surgery