Publication - Minutes

National Cancer Quality Steering Group: action notes September 2020

Date of meeting: 14 Sep 2020

Minutes from the National Cancer Quality Steering Group's meeting in September 2020.

National Cancer Quality Steering Group: action notes September 2020

Attendees and apologies

  • James Mander (JM), Regional Lead Cancer Clinician, SCAN (Chair)
  • Seamus Teahan (ST), Regional Lead Cancer Clinician, WoSCAN (Chair)
  • Bobby Alikhani (BA), Regional Manager (Cancer), SCAN 
  • Matthew Barber (MB), Consultant Breast Surgeon, NHS Lothian
  • Lorraine Cowie (LC), Regional Manager, Interim (Cancer), NCA
  • Jen Doherty (JD), Project Co-ordinator, National Cancer Quality Programme
  • Hilary Glen (HG), Consultant Medical Oncologist, NHSGGC
  • Angela Jesudason (AJ), Paediatric Oncologist and Clinical Lead for the MSN CYPC Teenagers & Young Adults 
  • Rob Jones (RJ), Consultant Medical Oncologist, NHSGGC 
  • Gerard McMahon (GMcM), Cancer Coalition, Prostate Cancer UK
  • Michael Muirhead (MM), Head of Service, Information Services Division Scotland 
  • Peter Sandiford (PS), Deputy National Clinical Lead, Cancer QPI Review Group, Healthcare Improvement Scotland
  • Lorraine Stirling (LS), Project Officer, National Cancer Quality Programme
  • Catherine Thomson (CT), Service Manager (Population Health), Public Health Scotland 
  • Evelyn Thomson (ET), Regional Manager (Cancer), WoSCAN 
  • Simon Watson (SW), Medical Director, HIS 

Apologies 

  • Lesley Aitken (LA), Senior Reviewer, Healthcare Improvement Scotland 
  • Hugh Brown (HB), National Primary Care Group, NHS Ayrshire and Arran
  • Mary Cairns (MC), Gynaecological Cancer Clinical Lead, NCA 
  • Asa Dahle-Smith (ADS), Medical Oncologist, NCA 
  • David Dodds (DD), Chief of Medicine for Regional Services, NHSGGC 
  • Kevin Freeman-Ferguson (KFF), Head of Service Review, Healthcare Improvement Scotland 
  • Cameron Martin (CM), Gynaecological Cancer Clinical Lead, SCAN 
  • Gregor McNie (GMcN), Team Lead, Cancer Policy, Scottish Government 
  • Hamish McRitchie (HMcR), Clinical Lead Scottish Clinical Imaging Network 
  • David Morrison (DM), Director, Scottish Cancer Registry 
  • Les Samuel (LSa), Colorectal Cancer Clinical Lead, NCA 
  • Nadeem Siddiqui (NS), National Clinical Lead, Cancer QPI Review Group, Healthcare Improvement Scotland 
  • Iain Tait (IT), Consultant Surgeon and Clinical Director, NCA 
  • Stuart Thomas (STH), Consultant Pathologist and Lead Clinician, Scottish Pathology Network 
  • Joris Van Der Horst (JVDH), Consultant Respiratory Physician, NHSGGC

 In attendance

  • Tiffany Bonnar (TB), Programme Manager, HIS
  • Kevin Burton (KB), Gynaecological Cancer Clinical Lead, WoSCAN 
  • Lorna Bruce (LB), Audit Manager, SCAN 
  • Charlie Gourlay (CG), Honorary Consultant in Medical Oncology, SCAN 
  • Janet Graham (JG), Colorectal Cancer Clinical Lead, WoSCAN 
  • Mahalakshmi Gurumurthy (MG), Consultant Gynaecologist, NCA 
  • Rhona Lindsay (RL), Consultant Gynae Oncologist, WoSCAN 
  • Param Mariappan (PM), Consultant Urological Surgeon, SCAN 
  • Mike Walker (MW), Consultant Colorectal and General Surgeon, NCA

Items and actions

1. Welcome, apologies and declarations of interest

a) ST welcomed the group and introduced those in attendance. A note of apologies are listed above. No declarations of interest were noted.

2. Action notes and minutes from the previous meeting – Paper 1

a) the group considered the previous action note held on 22nd June 2020 (Paper 1) and approved as an accurate record. 

3. Matters arising

a) recurrence data

A meeting took place on 22nd June 2020 with Colorectal Cancer Clinical Leads and David Morrison from PHS to discuss the work on recurrence undertaken to date. Outcome for Clinical Leads to discuss undertaking SMR01 data validation exercise within their own regions. JM advised that due to COVID-19 and other priorities this has not progressed as yet. JG agreed that this is a good opportunity, however acknowledged the difficulties in validating the data. Agreed this would be discussed at a future NCQSG meeting in early 2021.

2. Action notes and minutes from the previous meeting – Paper 1

a) the group considered the previous action note held on 22nd June 2020 (Paper 1) and approved as an accurate record. 

3. Matters arising

a) recurrence data

A meeting took place on 22nd June 2020 with Colorectal Cancer Clinical Leads and David Morrison from PHS to discuss the work on recurrence undertaken to date. Outcome for Clinical Leads to discuss undertaking SMR01 data validation exercise within their own regions. JM advised that due to COVID-19 and other priorities this has not progressed as yet. JG agreed that this is a good opportunity, however acknowledged the difficulties in validating the data. Agreed this would be discussed at a future NCQSG meeting in early 2021.

4. Governance

a) national colorectal cancer QPI report (2016-2019) – Paper 2

JG presented to the group on behalf of the 3 regions an overview of the Colorectal Cancer QPI results that were published by PHS on 23rd June 2020. Overall performance is high across a significant number of QPIs with many targets being met on a regional / national level. The following QPIs were noted for discussion:

QPI 6 (Neo-adjuvant Therapy) - performance has dropped within SCAN over the previous 3 years. Results have been discussed regionally and the majority of cases not meeting the target had margins threatened by possible involved lymph nodes. Short course radiotherapy is not currently accepted within the QPI and this should be amended at formal review.

QPI 10 (30 and 90 Day Mortality Following Surgical Resection) - the <20% target for emergency surgery was met in all NHS Boards over 3 years with the exception of Dumfries and Galloway. Noted that small numbers were involved and that emergency surgery is not always carried out by a Colorectal Surgeon. This QPI will be kept under regular review.

QPI 12 (30 day Mortality following Chemotherapy and Radiotherapy) - noted that a small number of Healthboards did not meet the <10% target for palliative chemotherapy. NHS Lanarkshire have carried out a detailed case review where no issues were identified. Local oncologists will keep an eye on future results.

A new QPI has been proposed around colorectal liver metastases linking up the HPB and Colorectal MCNs. Agreed this will be challenging in terms of data collection. Another new QPI around MSI testing has been proposed. ET highlighted that in terms of funding for this testing, the position may now have moved forward. GMcN advised that Chief Executives had supported this and ET advised that she would follow-up for current position.

The group discussed potential areas for archiving during the current review noting QPIs on MDT, Radiological Diagnosis and Staging along with Stoma Care. ST agreed that new QPIs are important and those that are performing well should be archived going forward. JM thanked the Regional Clinical Leads for their contribution and ongoing clinical engagement.

5. Survival analysis

a) ovarian cancer – Paper 3

KB provided an update on behalf of the regions regarding the revised survival analysis for Ovarian Cancer QPI data. The largest issues noted are regional variation in outcomes with patients in NCA (median survival rate of 1.9 months compared with 2.8 years in SCAN/WoSCAN). Differences noted in the number of Stage IV patients within NCA, and also differences in surgery rates.

KB stated that all the reasons are still not fully understood however differences in the decision making process between the 3 regional MDTs may contribute. This has led to a different proportion of patients having surgery (especially primary surgery as opposed to delayed primary surgery). The benefit of a Scottish wide MDT (particularly for advanced Ovarian Cancer patients) was highlighted however would involve significant change in working practice and coordination of all specialties involved. 

Resources across the networks were discussed with differences in medical oncology, surgical resource and access to other specialties highlighted. It was also noted that age differences may be a contributing factor, however a complete multi-variate analysis is required to determine variance.

Agreed that more robust data collection is required to better understand regional variation along with more timely survival analysis. It was noted that changes have been made and this data is now outdated. 

MG stated that in NCA theatre sessions have been reduced and there is a requirement to increase surgical capacity and operating time. The Medical Directors and Chief Executives have started to look at this data and a meeting to discuss this further will take place on 23rd September 2020.

PHS have an additional 2 years of data from the networks and can update the survival analysis to see if there are substantial changes. The detailed audit for non-surgical patients that was previously carried out is also available to be looked at by the networks in more detail.

ST/JM agreed to write to Chief Executive in NCA outlining the data that has been looked at by the NCQSG/Clinical Leads, noting concerns about MDT practices and resource in NCA for delivering oncology.

Seamus Teahan / James Mander

Agreed that re-analysing the ovarian cancer survival data should take priority over other tumour types.

Catherine Thomson

b) tumour-specific survival analysis

CT advised that PHS is working through a few more checks on the upper GI cancer data (no issue with leading zeros). The focus will be on looking at the previous data collected against the new data that has come in.

Head and Neck survival analysis is also being looked at and no major issues to report. It was confirmed that the Breast Cancer data does have the leading zero issue and the analysis has not restarted as yet. Following this, work will commence with Cervical and Endometrial Cancer checks. 

c) national timetable for survival analysis

The group agreed that ovarian cancer survival data should be the main priority and should take precedence over the other tumour groups.

6. Assurance of national performance

a) proposed options for the cancer quality performance indicator review process 2020/21 – Paper 4

SW provided an overview of the process to date. Reflecting on the ‘Lessons Learned’ event, a revised quality assurance process has been developed going forward which HIS are keen to ensure is workable for all key stakeholders and adds value. 

TB shared the following slides with the group outlining the revised QPI review proposed approach including objectives, steps to be taken in the process, timeframes and reporting (see supporting documents). 

ET raised concern that the proposed process highlighted a sense of similarity with the old process, noting this was lengthy and time consuming. Highlighted that perhaps the process needs to be less rigid, and some tumour types may require less frequent or less intense reviews than others. Also noted the importance of avoiding duplication further to what the regions are doing in terms of governance. 

LC and BA echoed the points raised particularly around the work and time involved for the networks. LC stated that in NCA the Medical Directors look at the data in detail and therefore already has their attention. 

SW agreed that there is no value in duplication of effort and noted that any review should be intelligence led by this group or other stakeholders groups. Also stated that external assurance is an important part of the national governance process and adds separate value for clinical services. 

JM and ST concluded that there requires to be further detail on the frequency of reviews and a clear explanation on what a visit from HIS will entail i.e. who will be involved. The team at HIS to further discuss this with Regional Network Managers / Regional Lead Clinicians in the coming weeks to agree an acceptable process to bring to the NCQSG meeting in December for final ratification. 

Simon Watson

7. QPI reporting

a) PHS dashboard development / improvements – Paper 5

CT advised that the revised dashboard has now been moved from Discovery to sit within the ‘SCRIS’ Dashboard.

CT stated that the team are now looking at improving information on the dashboard e.g. ‘small numbers’ and how this should be presented on the public facing dashboard. Also been discussion on the development of ‘Level 3’ (permitted access) to enable action plans or QPI commentary to be uploaded by the networks.

The progress of development work will be determined by access to eCASE which will allow for the data to be pulled more easily into the dashboards improving efficiency for both the networks and PHS.

Paper 5 outlines the aspirations for the QPI Dashboard and the group agreed this proposal in principle although noted the difficulties in determining resource requirements to support this. LC stated that consideration is required to be given to updating tumour specific action plans that are fluid and noted that this would be duplicating work on both the website, workplans and dashboard. CT advised that this will be further explored with Regional Managers.

b) reporting prostate cancer surgical volumes using cancer audit data – Paper 6

JD spoke to Paper 6 which outlines the method of reporting surgical volumes in Prostate Cancer QPIs and the proposal to change from using SMR01 data to cancer audit data. This follows concerns around the accuracy of using SMR01 data for this particular QPI. 

Audit data has not been able to be used in the past mainly due to the ‘Watch and Wait’ patients as they are not captured within the year of diagnosis. However, a change was made at Formal Review in relation to surgical margins which means all surgeries are now captured including delayed surgery out with the audit period.

There was agreement by all the regions at the recent National Cancer Quality Operational Group (NCQOG) meeting. Final ratification was given by the NCQSG for reporting surgical volumes using cancer audit data.

c) review of clinical trials & research access QPI – Paper 7

Reporting Clinical Trials was discussed at the NCQOG in terms of reporting, value for clinicians and the 15% target which is rarely met. The QPI is measured using data collected by the Scottish Cancer Research Network (SCRN) on various regional versions of their EDGE database involving a lot of manual manipulation involved for accuracy.

The clinicians are not able to interrogate the figures properly and there are also difficulties in understanding how improvements can be made i.e. recruitment to trials from data. There is also very specific criteria about what trials are included and which ones are open. 

Formal Review of the QPI was previously undertaken in 2017 where changes were made from patients ‘enrolled’ to ‘consented’ to widen the scope. SCRN network managers confirmed they do not use the results from the QPI but use data from their EDGE database where data can be further manually manipulated.

The group agreed that Clinical Trials should remain on the national agenda and are open to other more efficient ways of collecting the data and avoid ways of duplicating effort. JM agreed that there are not enough patients recruited to clinical trials and advised that a view should be sought from David Cameron, Clinical Director of the SCRN.

Jen Doherty

d) Systemic anti-cancer therapy (SACT) 30-day mortality

JD advised on the position to date to establish consistent QPI reporting using Chemocare data for SACT 30-day Mortality reporting in place of audit data. A SLWG has been established with regional SACT representatives, and PHS which met for the second time in July following a short delay due to COVID-19. 

JD stated that there is still further work to be done in achieving consistent reporting due to the numerous versions of Chemocare and the resource required to undertake regional reporting until a national solution is in place. WoSCAN has a report in place which has been shared and agreed with the other two regions. NCA colleagues are undertaking work at present to try and replicate this report for their 3 regional areas with the aim of producing one report for the North. SCAN are looking at various measures to achieve this and in the meantime looking at data extraction with a more automated process for the longer term.

The aim is to produce regional reports for Breast Cancer in late 2020. A process has still to be established for Regional Audit Managers to obtain the reports, as well as ensuring a process is in place for checking the data by relevant oncologists.

8. Information governance approach for the national analysis of QPI data – Paper 8

a) CT spoke to paper 8 which underpins the eCASE development and outlines the proposed approach to Information Governance to facilitate national analysis by PHS by allowing direct access to the QPI data platform.

CT advised on the new Scottish Government National Data Sharing Accord between any NHS organisations. This will allow data to be shared without the need for working through any individual data sharing agreements as long as it is for the patient/public benefit and used for core business (not for research purposes).

For PHS to obtain the data they would require to have joint controllership. CT reassured that the Health Boards are the owners of the data and a Memorandum of Understanding (MOU) would be put in place. This will be approved and developed jointly between Regional Cancer Networks and PHS. The group agreed support for the proposal in order to progress.

ET suggested writing on behalf of the NCQSG to colleagues in NSS (co-signed by Aileen Keel) around the criticality of getting the new eCASE development work completed. Although this work has been prioritised within NSS it is being diverted due to the COVID-19 work. Funding has been obtained from IHDP to allow for this development work but requires to be reinforced on the NSS priority list.

James Mander / Seamus Teahan

9. QPI formal review process

a) formal review process – 2nd cycle update

JD provided an update on progress with the 2nd Cycle of Formal Reviews which are now re-commencing following suspension during COVID-19. Reviews already underway include Upper GI cancer which is almost complete, lung cancer which is at finalisation stage, and colorectal cancer which is preparing for engagement. 

Lymphoma, brain/CNS and ovarian cancers are the next tumour groups to commence over the coming weeks. 

10. Scottish bladder cancer QPIs – influencing outcomes, prognosis and surveillance

a) Param Mariappan, Consultant Urological Surgeon, SCAN

PM provided the group with a presentation on outcomes and surveillance in Bladder Cancer.

PM highlighted the first milestone in 2012, with the implementation of the national QPIs for Bladder Cancer. A Scottish clinical collaborative with colleagues was formed that has collected outcome data for around 75% of patients. There has been a recent publication on early outcomes, and further analysis for longer term (3-5 years) is ongoing. Phase 2 will allow data to be analysed for 5-7 year outcomes.

In tandem, through the Scottish Access Collaborative, new surveillance protocols have been developed which have allowed refinement of surveillance pathways. In 2018 through Trackcare in NHS Lothian a proforma was created which will be rolled out across Scotland in 2020.

ST highlighted that Trackcare is not used within all Boards therefore not all patients would be picked up, and also noted that clinicians may follow the NICE follow up guidance which is less intensive than the national surveillance protocol.

Funding of £50k was made available from the Scottish Government for a national database, housed by PHS and NSS to collect this surveillance data. PM raised the question to the group if the national database can be built on the current QPI process. CT advised that the preferred option would be to include within eCASE and eventually bring all the cancer datasets together under one ‘Cancer Intelligence Portal’ for capturing the patient pathway. ET stated that eCASE has the capacity to develop but presently has a back log of new developments that has still to be completed.

The group were supportive in principal, however the complexity of a QPI for recurrence was highlighted and further information is required on measurability. In addition, concerns were highlighted around resource issues as this would be significant and needs to be sustainable as it affects all different tumour groups.

11. NCQSG workplan 2019 – 2021 – Paper 9

a) the updated workplan was circulated for information. JD highlighted one area on the workplan around the future use of Patient Experience QPIs. Acknowledged that these are not utilised within the regions for a number of reasons. These QPIs are not mandatory for reporting and there is no additional resource for data collection, also more significantly there are now electronic tools available for PROMS/PREMS which are being utilised across many NHS Boards. Furthermore, there is also the National Scottish Patient Experience Survey which has been carried out twice and is due to be repeated in 2021.

The group agreed that patient experience is a very important quality issue, however the QPIs are not the best way to address this and therefore it is now time to retire them from the suite of QPIs.

11. Risk and issues log – Paper 10

a) resourcing issues within PHS was highlighted. A proposal has been submitted to the Scottish Executive for additional 2.5WTE analysis resource to help with the data, dashboards and survival analysis work for consideration as part of the cancer recovery plan. CT advised that discussions had taken place between Scottish Government, Aileen Keel and SCRIS colleagues to ensure all requirements are resourced including QPIs.

12. AOCB

a) QPIs

ST discussed the reporting off all QPIs during the COVID-19 pandemic and if the QPI reporting process could be streamlined temporarily for this year. 

RJ stated that Boards will want to know the impact on QPIs during the pandemic and results will provide this important information. ET agreed and raised concern about retracting from the QPI data which could result in having data for short term use as opposed to QPI outcome data. BA echoed this and stated the importance in looking at all the various cancer data including QPIs.

ST agreed with the responses and strength of opinion regarding the importance of continuing the QPI process at the current time. 

Date of next meeting

Monday 21st December 2020, 10:00am – 1:00pm by MS Teams

Proposed CQPI Review Process

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