National Cancer Quality Steering Group action note: June 2021

Attendees and apologies

Present

• Seamus Teahan, Regional Lead Cancer Clinician, WoSCAN (Chair) (ST)
• Lesley Aitken, Senior Reviewer, Healthcare Improvement Scotland (LA)
• Bobby Alikhani, Regional Manager (Cancer), SCAN (BA)
• Tiffany Bonnar, Programme Manager, HIS (TB)
• Hugh Brown, National Primary Care Group, NHS Ayrshire and Arran (HB)
• Seona Carnegie, Policy Manager, Cancer Policy Team, Scottish Government (SC)
• Lorraine Cowie, Regional Manager, (Cancer), NCA (LC)
• Jen Doherty, Project Co-ordinator, National Cancer Quality Programme (JD)
• Hilary Glen, Consultant Medical Oncologist, NHSGGC (HG)
• Rob Jones, Consultant Medical Oncologist, NHSGGC (RJ)
• Gerard McMahon, Cancer Coalition, Prostate Cancer UK (GMcM)
• Gregor McNie, Team Lead, Cancer Policy, Scottish Government (GMcN)
• Noelle O’Rourke, National Lead for the Scottish Cancer Network (NO’R)
• Peter Sandiford, Deputy National Clinical Lead, Cancer QPI Review Group, Healthcare Improvement Scotland (PS)
• Lorraine Stirling, Project Officer, National Cancer Quality Programme (LS)
• Elaine Strange, Head of Service, Public Health Scotland (ES)
• Iain Tait, Consultant Surgeon and Clinical Director, NCA (IT)
• Catherine Thomson, Service Manager (Population Health), Public Health Scotland (CT)
• Evelyn Thomson, Regional Manager (Cancer), WoSCAN (ET)

Apologies

• Matthew Barber, Consultant Breast Surgeon, NHS Lothian (MB)
• Asa Dahle-Smith, Medical Oncologist, NCA (ADS)
• David Dodds, Chief of Medicine for Regional Services, NHSGGC (DD)
• Kevin Freeman-Ferguson, Head of Service Review, Healthcare Improvement Scotland (KFF)
• Angela Jesudason, Paediatric Oncologist and Clinical Lead for the MSN CYPC Teenagers & Young Adults (AJ)
• James Mander, Regional Lead Cancer Clinician, SCAN (Chair) (JM)
• Sandra McDougall, Interim Depute Director, HIS (SMcD)
• Hamish McRitchie, Clinical Lead Scottish Clinical Imaging Network (HMcR)
• David Morrison, Director, Scottish Cancer Registry (DM)
• Nadeem Siddiqui, National Clinical Lead, Cancer QPI Review Group, Healthcare Improvement Scotland (NS)
• Stuart Thomas, Consultant Pathologist and Lead Clinician, Scottish Pathology Network (STH)
• Simon Watson, Medical Director, Healthcare Improvement Scotland (SW)
• Joris Van Der Horst, Consultant Respiratory Physician, NHSGGC (JVDH)

In attendance

• Alastair Lawrie, Acute Leukaemia, Regional Clinical Lead, NCA (AL)
• Grant McQuaker, Acute Leukaemia, Regional Clinical Lead, WoSCAN (GMcQ)
• Huw Roddie, Acute Leukaemia, Regional Clinical Lead, SCAN (HR)

Items and actions

Welcome, apologies and declarations of interest

(a) ST welcomed the group and introduced new member Noelle O’Rourke (NO’R) to her first meeting as the National Lead for the Scottish Cancer Network. A note of apologies are listed above. No declarations of interest were noted.

Action notes and minutes from the previous meeting – paper 1

a) The group considered the previous action note held on 9th March 2021 (Paper 1) and approved as an accurate record with exception of the following amendment:

• page 4, paragraph 5: It was also noted that cause specific analysis is more accurate as well as using net survival methodology. It was noted that net survival analysis is generally considered to be more accurate than cause-specific survival

Matters arising

Ovarian cancer – feedback from NCA on survival analysis action plan

LC informed the group that the ovarian cancer survival analysis action plan is going through regional governance via the medical directors group where progress is being reviewed monthly. Malcom Metcalfe, Deputy Director in NHS Grampian has been assigned the role of Improvement Lead and Chair of the MDT and is working with Boards on their improvement plans. It was noted that there has been a challenge with the MDT structure and all Boards are moving onto MS Teams to improve regional discussion and decision making. There are also a number of actions around patient pathways as well as standardised MDT forms to ensure all Boards record the same information. Key Performance Indicators have been implemented around decision making for surgery and there will be appropriate documentation to capture the reasons that patients are not selected for surgical treatment. 
ST advised that the Chairs of the NCQSG will write to Grant Archibald, Chief Executive of NHS Tayside to request if the action plan can now be shared with this group.

ST highlighted that progress has been made in ovarian cancer and the MDT solutions will help make change and improvement. GMcN advised that there is now a requirement to formally update the new cabinet secretary on this issue. Further discussion took place as to how the NCQSG address any similar issues around variation in the future in terms of accountability. Wider discussions are required to take place with key colleagues to formulate a plan ideally before the HIS review programme commences over the summer.
Seamus Teahan / James Mander

Ovarian cancer QPIs – PHS report

Following discussion at the last meeting on the National Ovarian Cancer QPI Report (2016-19), there was an action for SCAN in relation to QPI 4 (Patients with early stage disease have an early staging operation). The QPI was met in NCA and WoSCAN, however SCAN remained below target. Cameron Martin, Clinical Lead in SCAN advised that all patients that did not meet the target had been reviewed and the majority were managed appropriately. This has been raised at the SCAN MDT and Regional Priority Group where a commitment has been made to ensure that all patients are discussed and listed for appropriate staging at the earliest opportunity. There is also some focussed work around this QPI being undertaken and it is anticipated there will be improvement going forward.

National upper GI cancer QPI report

LC advised that low volume surgery is still an ongoing programme in the north. There have been issues both within HPB and UGI cancer and to help support these groups a workshop with clinicians will take place by the end of July. This will look at a model for the future based on getting it right first time as per NHS England. LC also noted that someone will be commissioned to externally review the data.

NO’R agreed this will always be a challenge in the north and updated that the HPB cancer network has funding in place nationally to improve the patient pathway which will help to inform what is required for the management for low volume cancer surgery in general.

Governance review of national cancer groups

ST advised that there has been a lot of discussion over the last few months in relation to the governance review of the national cancer groups. This concluded that the NCQSG should evolve into a quality and improvement group. Further meetings around this will take place offline and it is hoped that there will be a proposal outlining the support which is required to move forward with the broader role as well as a refreshed Terms of Reference. 

Seamus Teahan / James Mander / Gregor McNie

Governance

National acute leukaemia QPI report (2017-2020 aggregated data over the 3 year period) – paper 2

GMcQ presented to the group on behalf of the 3 regions an overview of the Acute Leukaemia QPI results due to be published by PHS on 22nd June 2021. The QPIs are currently undergoing the 2nd Cycle of Formal Review. Noted that some of the denominators are small and therefore can often skew results. QPIs relating to clinical trial recruitment were noted as a common theme which has been particularly challenging for SCAN/WoSCAN in comparison to NCA which has done well in this area.

The following QPIs were noted for discussion:

• QPI 1: complete Diagnostic Panel – target has been achieved in NCA and SCAN. Although the target has not been met in WoSCAN there has been significant improvement over the last 3 years. Methods have been implemented in the Boards to make sure audit staff can identify samples stored for future testing
• QPI 3: MDT Discussion – again the target has been achieved in NCA and SCAN. In WoSCAN, there are some patients who may be discussed elsewhere and have reminded Boards of the need to ensure all patients are discussed at formal MDT within 8 weeks
• QPI 5: early Deaths / QPI 7: Deaths in Remission – small numbers greatly impact both of these QPIs and there was discussion around potentially reporting these on a national basis in future
• QPI 8: clinical Trials with Curative Intent – NCA have performed well against the high 60% target for clinical trial recruitment. Failure to meet the QPI target is dependant on trial availability and it was noted that trials have been suspended at various times over the 3 year period. Another issue is that trials are now far more selective in their recruitment and this is going to impact on results going forward in all regions. Trial recruitment also affects other QPIs e.g. QPI 11: Clinical Trials with Non Curative Intent and QPI 14: Clinical Trials and Research Study Access. It was highlighted however that performance against QPI 14 is still much higher across all regions than other tumour types.
• QPI 9: tissue Typing – significant improvement year on year particularly in WoSCAN
• QPI 10: intensive Chemotherapy in Older Adults – target achieved in most Boards with the exception of NHS Ayrshire and Arran who fall slightly short of the target. Cases have all been reviewed and appropriate management confirmed. NHS Ayrshire and Arran perform higher than other areas in QPI 12: Palliative Treatment, suggesting there may be frailer patients being treated

The difference between intensive chemotherapy and treatment with curative intent was highlighted and this will be addressed at formal review to ensure accurate measurement of the QPIs going forward. CT stated that the National SACT Group have agreed the terms they are using are curable and non-curable.  GMcQ agreed this is clearer.

No other issues were raised and ST thanked the Regional Clinical Leads for their contribution and ongoing clinical engagement.

Survival analysis

Ovarian cancer survival analysis update 

CT advised that the first draft of the ovarian cancer survival analysis of the 2013-16 cohort until September 2020 is nearing completion and will be sent to this group. The group agreed that there would be limited benefit from looking at this data again for a further year as things have moved on since the original analysis and would be difficult to compare.

PHS have secured funding from the Scottish Government for an additional 1.5 WTE resource to support the cancer team. This will allow for the team to be in a stronger position around autumn time with regards to this work.

Other tumour-specific survival analysis 

CT advised that head and neck cancer survival analysis has commenced as well as UGI cancer with extended follow-up.

The group agreed that the additional funding is welcome and discussed the priorities going forward. It was agreed that lung cancer should be a priority given the relatively short survival and also new drugs which are now available. ET added that work had already been undertaken on a specification for lung cancer survival with Brian Murray and the SCRIS team previously. It was also agreed that HPB cancer should be considered due to the service reconfiguration in the north and some of the issues in the west around neo-adjuvant SACT. NO’R agreed that these two groups have short survival outcomes and align with the Scottish Cancer Plan for early cancer diagnostic centres.
PS noted that a number of tumour groups have previously had net survival published which is useful to look at in the first instance where Scotland’s performance is lower than other countries. Agreed that in terms of public health, lung cancer should be a priority.
CT concluded that as well as the additional resource, PHS will also be in a more favourable position once the new eCASE development is implemented which will save a lot of staff time in extracting the data.

Publication of survival analysis

CT advised that the PDF publication of the survival reports cannot be uploaded onto the tableau system. The team are looking at an alternative solution which would upload these reports to a website with password restriction. Further discussion took place on whether these reports should be published in the public domain. Agreement that this information should be transparent and this would be the plan longer term. This will allow everyone involved to be confident that the data is robust, reliable and validated.

CT added that reports would be required to be developed around the clinical interpretation of results that would be visible in the public domain. The forthcoming ovarian cancer report that will be circulated to the group will be an example of the report in a raw state before there has been any attempt at clinical commentary and will give an idea of what will be required. Further discussion will take place at the next meeting.
Catherine Thomson

Assurance of national performance 

Assurance of national performance – cancer quality performance indicator review process 2021 update – paper 3

LA provided an update on behalf of HIS and advised that from 1st May Lynsey Cleland has been appointed as a new interim director replacing Sandra McDougall.

Paper 3 outlines a brief summary of progress for reviews to date including indicative timelines noting that these can be flexible. HIS now have a data analyst in place to carry out further analysis using available data on the PHS dashboard.

The first tumour group undergoing review is melanoma and key lines of enquiry have been drafted. These will be sent out to networks at the beginning of July 2021 with a 2 week return. These will then be further refined and a decision made as to whether further discussion is required. If an area needs further clarification this will be communicated to the network in advance of the review meeting due to take place at the end of August/beginning of September. PS highlighted that HIS will be focussing on statistically significant variation only.

ET discussed the practicalities involved e.g. ensuring that clinicians have at least the required 6 weeks’ notice of any date if they are required to attend a meeting. The group discussed the requirement for clear lines of accountability and HIS’s expectations from the Regions, Boards and Chief Officers. This is an area that needs to be defined so that everyone is clear around the process going forward.

LA advised that the timetable to the end of the year for the reviews has been agreed and corresponds with the most up-to-date data on the dashboards and this will be further discussed with the NCQOG. CT advised that by March 2023, PHS should be in a position with having access to eCASE to update all dashboards annually including national networks.

QPI reporting

Review of clinical trials and research access QPI

 JD advised that following the previous meeting where David Cameron, Clinical Director, SCRN attended, the issue of reporting clinical trials data has been further discussed at the NCQOG. It was agreed that a paper outlining the issues and concerns identified with reporting this QPI should be formally submitted to the clinical trials subgroup. 

The group noted that although the target may be arbitrary, it is still important to highlight where there are challenges with recruitment to trials and encourage improvement.

SACT 30-day mortality

CT updated that PHS have now got agreement from the CEPAS CRG and the SACT National Group in relation to the appropriate methodology to be used for reporting 30-day mortality for SACT. After exploring different options the groups agreed that reporting will be undertaken using day one of the last cycle of chemotherapy for all patients.
Some validation work with the networks for breast and renal cancers has been undertaken. It has been agreed that JD will provide PHS with the overall groupings used currently for each of the tumour groups, although CT advised that initially a high level approach has been taken. This can later be refined in the future with curable / non curable breakdowns. Noted that PHE use a different methodology however this is currently being reviewed which will allow for benchmarking with Scotland’s outcomes in the future. 

Ethnicity data collection

JD informed the group that PHS had received correspondence from the Scottish Government in relation to a commitment to improve recording ethnicity data and making it mandatory within healthcare datasets. This has come on the back of Covid and the effect on ethnic groups. In the first instance PHS have been asked to provide information around whether ethnicity data is collected within any datasets they are involved with as part of a scoping exercise.

The QPI datasets do not collect ethnicity and if this is something that will be mandated, data linkage could be used for any analytical outputs.

CT advised that it is mandatory to record ethnicity in SMR01 but this has only about 85% completeness. The team are looking at the different methodologies that can be used to report nationally e.g. obtaining Information Governance approval to link to vaccination data and a CHI number. RJ highlighted that there requires to be a level of caution when reporting ethnicity in QPIs reports due to the potential identification of patients in those tumour groups with small numbers. 

Upper GI cancer data – proposed collaboration with the national oesophago-gastric cancer audit (NOGCA) – paper 4

ET spoke to paper 4 which outlines the proposal and approach to include Scottish QPI data in the National Oesophageal and Gastric Cancer Audit (NOGCA) to provide comparison with performance in England and Wales. The request is for raw data rather than analysed data which has opened up discussion around the governance requirements.

There has been further discussion with colleagues in NHS England around the compatibility of datasets, data items and the measurability criteria where they have agreed to analyse a subset of data which would allow Scotland to participate. This will be free of cost which is unusual for these types of requests.

ET advised that the paper has been to the National Cancer Data Group where is was agreed that a pilot process would be tested out with one network (WoSCAN) to submit anonymised data this year. Work is underway to establish exactly what analysis can be undertaken, how this will be presented as well as rights of control over what is published. The intention will then be to look at national data.

ET concluded that this request may be one of a number that may come forward in terms of UK audits. The WoSCAN Information Team is undertaking the work around this request however going forward once the automated eCASE process is implemented, this would sit with PHS and would require endorsement by this group.

Information governance approach for the national analysis of QPI data

(a) CT provided an update on the information governance approach and the associated Memorandum of Understanding (MoU) which is required.

The draft MoU is currently being strengthened prior to submitting to the Caldicott Guardians for final sign-off which will allow PHS permission to access eCASE data. The draft MoU has previously been sent to the Information Governance Forum who have agreed the overall approach. Individual dataset appendices still require some further work and PHS have now submitted the SACT appendix to the National SACT Data Group as an example.

CT advised that the MoU is for data sharing in Scotland in the first instance. ET noted that this group will be data approvers and further work will be required around the process for QPI data requests.
Once the SACT appendix is signed off, this will then be completed for other datasets including the QPI data. 

QPI formal review process

QPI formal review 2nd cycle progress update

JD provided an update on the 2nd cycle of QPI formal reviews which are progressing well with lymphoma now complete and ovarian cancer in final stages of approval since the last meeting.

Colorectal cancer is progressing and has undergone two finalisation meetings due to the number of comments received following public engagement. A final document is almost complete with some further work ongoing on the dataset and measurability.

Initial formal review meetings have taken place for head and neck cancer and melanoma, with revised QPIs currently being drafted. Additional work is taking place with other specialties in order to take forward proposals for the head and neck revisions i.e. dentistry, and dietetics.

Acute Leukaemia review meeting is scheduled to take place on 23rd June followed by bladder and cervical and endometrial cancers which will commence in August 2021. A baseline review of mesothelioma is also due in September/October following the 2nd year of reporting.

JD advised that the timetable for the 3rd cycle is now in development which commences towards the end of 2021 with breast cancer. Sarcoma and testicular cancer from the 2nd cycle as requested will be brought forward to be included in the 3rd cycle timetable.

NCQSG workplan 2019 – 2021 – paper 5

 (a) JD advised that most items within the workplan have been covered throughout the meeting. 

In addition, JD noted that national virtual meetings have taken place this year for a number of tumour types which all have been successful. Further meetings are scheduled for later this year as well as early 2022. Actions from these national events continue to be monitored by the NCQOG.

Risk and issues log – paper 6

 (a) ET advised that the Risk and Issue Log was circulated for information.

AOCB

 (a) Cancer Coalition
GMcM advised that the main point from the Scottish Cancer Coalition meeting which took place last week was around transformation of this group in terms of improvement and in particular accountability going forward. 

Date of next meeting

(a) Tuesday 14th September 2021, 10:00am – 1:00pm via MS Teams