National Cancer Quality Steering Group action note: September 2021

Attendees and apologies

Present

• James Mander, Regional Lead Cancer Clinician, SCAN (Chair), JM
• Lesley Aitken, Senior Reviewer, Healthcare Improvement Scotland, LA
• Bobby Alikhani, Regional Manager (Cancer), SCAN, BA
• Tiffany Bonnar, Programme Manager, HIS, TB
• Seona Carnegie, Policy Manager, Cancer Policy Team, Scottish Government, SC
• Jen Doherty, Project Co-ordinator, National Cancer Quality Programme, JD
• Hilary Glen, Consultant Medical Oncologist, NHSGGC HG
• Bryan McKellar, Interim Regional Manager (Cancer), NCA, BMcK
• Gregor McNie, Team Lead, Cancer Policy, Scottish Government, GMcN
• Peter Sandiford, Deputy National Clinical Lead, Cancer QPI Review Group, Healthcare Improvement Scotland, PS
• Nadeem Siddiqui, National Clinical Lead, Cancer QPI Review Group, Healthcare Improvement Scotland, NS
• Lorraine Stirling, Project Officer, National Cancer Quality Programme, LS
• Iain Tait, Consultant Surgeon and Clinical Director, NCA, IT
• Seamus Teahan, Regional Lead Cancer Clinician, WoSCAN (Chair), ST
• Stuart Thomas, Consultant Pathologist and Lead Clinician, Scottish Pathology Network, STH
• Catherine Thomson, Service Manager (Population Health), Public HealthScotland, CT
• Evelyn Thomson, Regional Manager (Cancer), WoSCAN,ET
• Joris Van Der Horst, Consultant Respiratory Physician, NHSGGC, JVDH

Apologies

• Matthew Barber, Consultant Breast Surgeon, NHS Lothian, MB
• Hugh Brown, National Primary Care Group, NHS Ayrshire and Arran, HB
• Lynsey Cleland, Interim Depute Director, HIS, LC
• 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
• Rob Jones, Consultant Medical Oncologist, NHSGGC, RJ
• Gerard McMahon, Head of External Affairs, Bowel Cancer UK, GMcM
• Hamish McRitchie, Clinical Lead Scottish Clinical Imaging Network, HMcR
• David Morrison, Director, Scottish Cancer Registry, DM
• Noelle O’Rourke, National Lead for the Scottish Cancer Network, NO’R
• Elaine Strange, Head of Service, Public Health Scotland, ES
• Simon Watson, Medical Director, Healthcare Improvement Scotland, SW

In attendance

• Kevin Burton, Clinical Lead, WoSCAN, KB
• Ann-Maree Kennedy, Clinical Lead, NCA, AMK
• Garry Hecht, Information Analyst, Public Health Scotland, GH

Items and actions

Welcome, apologies and declarations of interest

 JM welcomed the group and advised that due to the demand on clinical services at the current time this meeting will take place over two hours as opposed to the normal three hours.

JM welcomed in new member Bryan McKellar as interim Regional Manager(Cancer) NCA in place of Lorraine Cowie who left her post on 1 September and Garry Hecht, Information Analyst from PHS.

Also to note that coalition member Gerard McMahon has moved his position from Prostate Cancer UK to Bowel Cancer UK. The new representative from Prostate Cancer UK will be representing the coalition at the next meeting in December.

A note of apologies are listed above. No declarations of interest were noted.

Action notes and minutes from the previous meeting – paper 1

The group considered the previous action note held on 21 June 2021 (Paper 1) and approved as an accurate record.

Matters arising

Ovarian cancer survival analysis - update

CT advised that the first draft of the ovarian cancer survival analysis of the 2013 to 2016 cohort until September 2020 is almost compete and will be sent to this group in due course.

PHS have received funding for an additional two analysts who have been recruited to support the cancer team.

Other tumour specific survival analysis

CT advised that PHS work has already started with the head and neck survival analysis. The results are required to be shared with the regions in the first instance however, it has been noted that there is a lot of missing data in terms of staging and performance status. This is leading to difficulties in comparisons across the networks due to the differences in completeness of these fields. The group agreed that there is a requirement to get the data complete to before any analysis is run. CT advised that she will forward a list of the missing data to the Regional Managers by the end of the week to allow for the additional data collection.

JM stated that there is a requirement for Clinical Leads and Regional Managers to take this issue back to audit teams within the regions for improvements going forward. CT advised that this data is for 2014 to 2017 so there may be an improvement in terms of the recording and quality of data.

Following this, work will re-commence on the upper GI cancer survival analysis. At present PHS have almost all the variables validated. In addition, PHS will be requesting regional updated data for Lung Cancer as agreed at the last meeting and will be following up on obtaining the specification for HPB Cancer.

Publication of survival analysis – paper 5

CT advised that the PDF publication of the survival reports cannot be uploaded onto the tableau system. Paper 5 outlines the five alternative solutions for storing the survival analysis reports. The preferred option at this time is option five which consists of saving the reports deep within the website with a URL link that would be not accessible through online searches. Once the clinical commentary

is available alongside the reports they will be made more transparent. BMcK stated that he is keen that Boards get sighted on these reports if there is no clinical commentary alongside the data. The group agreed on option five and once the clinical commentary and actions are agreed this would move to option four where the link to these reports will be promoted.

CT added that the process outlines that reports are sent from PHS to Regional Managers which provides an opportunity for networks to comment/query the data. This will then go through governance structures within the networks to obtain input and sign-off from the Boards within four weeks.

IT highlighted the importance of ownership of the data which ultimately sits with the Boards and the need for their approval. It was noted that Boards sign-off the data for QPI reporting therefore survival analysis is carried out on approved data. It was agreed that it wouldn’t be appropriate to withhold any data and the process should align with the CEL.

CT agreed to liaise with Regional Managers around the current protocol to ensure that the timeframes are still sufficient, and consider adding steps in around obtaining clinical commentary. JM agreed that this protocol should be signed-off by Regional Managers and Clinical Leads and brought back to thismeeting for ratification.

Population survival results

Presentation by Tom Godfrey, Information Analyst at PHS on the findings of the general cancer population survival results carried forward to next meeting.

Matters arising

Ovarian Cancer – feedback from NCA on survival analysis action plan (paper 2)

BMcK informed the group that the medical directors group are overseeing the progress on the ovarian cancer survival analysis action plan and advised that he will seek an update if this action plan can now be shared with this group.

GMcN provided a summary of the current position and the actions identified on the action plan. Two of the key issues have been addressed around standardisation of staging in NCA with the other two regions and access to surgery and patients not being referred to MDT where they had successful chemoradiation treatment and may be eligible for surgery.

BMcK added that although there is advancement in the two areas addressed there is still more work to do. In terms of MDT’s there are still logistical challenges to overcome with having three centres. A MDT pathway coordinator will be employed to optimise the use of MDTs and monitor patients through their journey on a three centre basis.

KB agreed that the role of the pathway coordinator is key due to the complex pathway for ovarian cancer patients. KB added the importance of looking at variance not just around the networks in Scotland but benchmarking against other UK and international centres of excellence. It was noted that the resource

in Scotland to deliver complex ovarian cancer surgery is below that of other high performance centres. NS stated that there is a requirement for theatre capacity and dedicated time to provide this service. IT agreed, adding that Scotland’s outcomes need to be addressed against other countries.

ST acknowledged that the QPI process has achieved a lot, however there is a need to be more ambitious for the future. The main priority and focus going forward needs to be on those QPIs which improve outcome.

Governance review of national cancer groups (paper 3)

GMcN spoke to paper three stating that it was time to reflect on the Quality Programme and the next steps to be taken in order to drive improvement i.e. focus on outcomes and benchmark beyond our own boundaries. Discussions have taken place with various colleagues, including HIS and the Scottish Government.

Paper 3 outlines the key changes for the transition of this group to a NCQIB. Existing QPIs range in value and each group should be challenged to define key areas of focus to drive improvements that will influence Boards in terms of service changes.

It was agreed that HIS will also provide support for setting out and and/or carrying on improvement activities where required, at local level. The issue around the data lag time was discussed. Boards own the most ‘live’ data and perhaps HIS could tap into this rather than waiting for national data to show variance.

In conclusion GMcN noted the three actions from this paper to move forwards, a new CEL will be drafted; new Terms of Reference (ToR) for the NCQIB and formally writing to HIS to confirm the specific activities and define the role they will undertake.

CT raised the question of how PHS will fit into this new model. ET advised that QPIs will remain and existing datasets will be retained as well as continuing the work to develop the new eCASE system. There are no plans to change the current systems that are in place and survival data is also going to be crucial going forward.

Seamus Teahan / James Mander / Gregor McNie

Governance

National cervical and endometrial cancer QPI report (2017-2020 – paper 4)

KB presented to the group on behalf of the three regions an overview of the Cervical and Endometrial QPI results that are due to be published by PHS on 14 September 2021. It was noted that the Cervical and Endometrial QPIs are currently undergoing formal review with the initial meeting taking place on 17 September 2021.

The following QPIs were noted for discussion:

Cervical Cancer

Overall the majority of targets have been met across the regions for a number of QPIs for Radiological Staging; PET/CT; MDT and 56 Day Treatment Time for Radical Radiotherapy.

QPI 4: Radical Hysterectomy – some regional variation with target only met in NCA, however small numbers affect this in all regions with only a total of 25 patients across Scotland. From a WoSCAN and NCA perspective, the patients not undergoing radical hysterectomy were often due to incidental findings. It was noted year on year that the numbers of cervical cancers are decreasing across Scotland perhaps reflecting uptake of the HPV vaccination.

QPI 5: Surgical Margins – the 95% target is narrowly missed with SCAN falling short at 80%. Again in WoSCAN/NCA where margins were involved, this is in patients where there has been no anticipation of cervical cancer rather than due to technique or mis-selection. In addition it was noted that staging has changed which is not yet reflected within the QPI measurement.

QPI 7: Chemoradiation – met at a national level (84% against a 70% target), however there was regional variation noted in SCAN.

Action: JM to contact Cameron Martin, Regional Lead in SCAN enquiring around the reasons for lower performance within SCAN.

JM asked the question around the areas of quality around cervical cancer care that are not being addressed by the QPIs. KB stated that future challenges are around recurrence, volumes and outcomes i.e. retaining skills with small numbers. AMK also stated that there is support to take forward a new QPI on brachytherapy. It was noted that survival analysis had been undertaken and no significant differences across the regions had been identified.

Endometrial Cancer

QPI targets have been met at a national level for Radiological Staging; Hysterectomy for Endometrial Cancer; Laparoscopic Surgery, SACT/Hormone Therapy and Surgical Mortality. KB added that there has been significant advances in laparoscopic surgery in the west with the purchase of robotic platforms to facilitate a higher volume of more complex surgery.

QPI 1: Radiological Staging has been met broadly over the previous three years however there is some variation identified between the regions.

QPI 2: MDT discussion – WoSCAN narrowly missed the target in year six due to one of the exclusion criteria that was removed at formal review for grade 1 cancer. Initially had agreed not to discuss these and have had to reverse this decision which has taken time. This will be discussed further at the forthcoming formal review meeting.

In relation to QPI 5: Adjuvant Radiotherapy it was noted that NHS Tayside results were lower than the other Boards. AMK agreed that there was some improvement year on year but not as much as the other Boards. AMK agreed to have some further discussion with colleagues and report back to this group.

NS flagged that in the west they are seeing more advanced presentations of endometrial cancer. There is concern that in 12 months there may be a difference in the data particularly in terms of survival.

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

Assurance of national performance

Assurance of national performance – HIS review process 2021 update

LA provided an update on behalf of HIS and advised on the first tumour specific group to undergo review for Melanoma. The refined key lines of enquiry will be sent to the networks later this week and dates set for review visits in approximately 6 weeks (end of October/ November 2021) giving as much notice as possible.

The initial key lines of enquiry have been established for Acute Leukaemia and will be sent to networks next week with a potential a review visit to be arranged for January 2022.

Cervical and Endometrial Cancer will be looked at together with a team meeting to discuss within HIS planned for 8 October 2021 to review the findings. If there are any issues with timescales for clinical time these can be re-arranged to suit.

LA advised that she welcomed the comments discussed above around international benchmarking and noted this is of special interest to Peter Sandiford at HIS. NS added that he was impressed with the quality of data that has been submitted which has been focussed and easy to navigate.

JM advised that the networks have provided all the information that is available for each of the tumour groups to date and any further queries from HIS would likely now require individual Board input.

QPI Reporting

Review of clinical trials and research access QPI

 JD advised that following the previous meeting a paper was submitted to the National Trials Resilience Group on 27 August 2021, chaired by David Cameron, Clinical Director, SCRN. This paper outlined the issues with data capture and reporting with a proposal to allow the generic Clinical Trials QPI to be superseded by trial activity work that will be undertaken by the National Clinical Trials Groups.

The national group agreed that it was important to highlight trial activity to Chief Executives and noted the shift in recruitment particularly due to trials being more stratified and targeted. The group acknowledged the issues with the QPI and whilst agreeing there was support for a metric, this should not be a generic tumour specific QPI and therefore should not be part of the QPI process going forward. The Equity of Access working group agreed to scope this out andreport back to the National Trials Resilience Group. JM confirmed that the NCQSG endorse this agreement.

SACT 30-day mortality

CT updated on the current position with the process of reporting. It has been agreed that there will be one annual mortality report run at a certain point for all tumour sites which will be part of the QPI reporting. This will be shared locally until the national dashboard is in place for the SACT data.

One of the main issues is around differences in the disease trees across the five instances of Chemocare. The first iteration of the SACT data will allow clinical engagement and allow for the disease trees to be defined and consistent across the board. PHS will then be in a position for regular reporting for local teams.

CT advised that there is a paper to be finalised on the methodology with input from the Network Managers. This will be presented at the December meeting for final ratification.

Application of QPI process in private sector

ET reported that the Clinical Lead for Breast Cancer in the West was keen to highlight the issue of QPI data collection and reporting in the private sector. Currently patients in the private sector do not have QPI data collected or reported if they have all of their treatment there (they do if diagnosed privately and then go onto have NHS treatment).

There is some clinical representation from the private sector on the Breast Cancer Advisory Board in the West who are keen to participate. As external quality assurance of the independent sector rests with HIS, guidance is required as to the applicability and application of cancer QPIs in this setting. ET outlined some of the associated operational challenges e.g. small numbers, who would collect and report data, how it would be stored/potential to access eCASE, and public reporting and external QA by HIS.

LA and NS agreed with this suggestion in principle however acknowledged that this is not straightforward and logistically could be very complex therefore would require discussion at a higher level with colleagues in HIS.

Information governance approach for the national analysis of QPI data

CT provided an update on the information governance process stating that the associated Memorandum of Understanding (MoU) for all of the cancer datasets has been sent to the Caldicott Guardians six weeks ago. There has been agreement from several Boards with the deadline for responses by 10 September 2021.

CT advised if they have not had all responses by the end of September they will contact the Information Governance Leads Forum. Aileen Keel suggested after that PHS go through eHealth contacts to further push for responses.

When this has been agreed by all Boards PHS will work on the individual dataset appendices specifically around the QPIs drafted for this group in December forapproval.

QPI formal review process

QPI Formal Review second cycle progress update

JD provided an update on the second cycle of QPI formal reviews which are progressing well with colorectal cancer now complete and head and neck cancer undergoing public engagement via the Scottish Government Consultation Hub.

Melanoma has undergone an initial review meeting with a follow-up meeting planned for 21 September to obtain further agreement on amendments. Bladder cancer has also had an initial review meeting and cervical and endometrial cancer is due to take place on 17 September 2021. Acute leukaemia is nearing completion.

Sarcoma and testicular cancer which were both formally delayed are the only two remaining reviews to be undertaken in cycle two. These will take place towards the end of 2021 and beginning of 2022.

JD advised that the programme will then commence for cycle 3 which should take into account some of the suggestions that have been discussed throughout this meeting.

NCQSG workplan 2019 to 2021 – paper 5

JD advised that most items within the workplan have been covered throughout the agenda for this meeting. A new workplan will be agreed as the ToR will be developed for the new NCQIB.

GMcN queried how resilient the workplan is to all the current challenges due to COVID. JD advised that all aspects of the Quality Programme are still progressing well following delays implemented throughout the last year. In terms of QPI reviews, JD acknowledged that extra clinical pressures are being noted again within services which may have an impact. This will continue to be monitored going forward.

Risk and issues log – paper 6

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

AOCB

No other competent business was noted.

Date of next meeting

Monday 13 December 2021, 10:00 to 13:00 via MS Teams.