Review of Oncologist Establishment

October 2009
1. Introduction

1.1. There have been considerable personnel changes in the oncology workforce at the NNNUHFT
over the last year, reflecting the increase in clinical activity and the complexity of oncological
care.

1.2. 8 years ago, the service across the Norfolk and Waveney Cancer Network (NNUHFT and
JPUHFT) was provided by 4 WTE consultant oncologists, who between them provided a total
of 7.5 sessions of clinics and multi-disciplinary team cover for the JPUHFT

1.3. There are currently 10.5 WTE posts in clinical oncology and 1WTE medical oncologist at the
NNUHFT. 1WTE medical oncologist was also appointed approximately 2 years ago to the
JPUHFT. During this time there has been no increase in the number of hours of visiting
consultants to the JPUHFT, in fact, some would argue that the visiting cover has diminished
over time, in that:

1.3.1. There is no longer cover from the NNUHFT Staff Grade for visiting consultant absence –
she has retired

1.3.2. Some of the visiting consultants are more junior and as such are able to see fewer patients in
clinic

1.3.3. The number of sessions has reduced from 7.5 to 7

2. Current OP activity at the JPUHFT

Three data sources have been used to estimate the current annual oncology OP activity:

• PAS (between January and June 2009),

• Data produced by Medical Oncologist Dr Dernedde, (between December 2008 and May
2009)
• The NNUHFT Oncology Notes system - verified by Dr Roques – Clinical Director,
(between 1st January 2008 and 31st December 2008)

2.1. PAS – Jan to June 09

Consultant Clinic Code New Follow up New Follow up

patients in patients in patients / patients /
6 months 6 months year year
Dr Dernedde DERNJBR 92* 317* 184 634
Dr Epurescu EPURJBR 50 168 100 336
Dr Harnett HARNJBR 87 312 194 624
Dr Wade WADEJBR 78 329 156 658
Dr Martin MARTJBR 46 205 92 410
Dr Martin MARTJET 2 143 4 286
Nurse led GI clinic NURSEGASJ 1 29 2 58
Totals 732 3006
NB *47 NP and 173 FU patients (UGI) seen on Mondays
*45 NP and 144 FU patients (Lung) seen on Fridays

2.2. Data produced by Dr Dernedde’s data (Appendix A)

Clinic Cancer type New Follow up New Follow up

patients in patients in patients / patients /
6 months 6 months year year
Mon am – Dr Dernedde UGI 43 205 86 410
Mon pm –Dr Epurescu LGI 39 121 78 242
Ovarian 14 45 28 90
Wed – Dr Harnett Breast 114 340 228 680
Wed – Dr Wade Urology 57 257 114 514
Gynae 28 127 56 254
Fri – Dr Martin / Dr Dernedde Lung 69 397 138 774
Totals 728 2964
2.3. The NNUHFT Oncology Notes System

2.3.1. Analysis of the Notes system, which collates data on patients attending both the NNUHFT
and the JPUHFT, confirms that there were 3201 new patients registered, 3149 of which were
seen (or had major annotations). Whilst this estimate can be challenged, with possible over
estimates (due to registrations from telephone calls and ward referrals not seen in oncology) or
under estimates (due to recurrences, 2nd primaries seen as New patients), the view of the
Oncology Clinical Director is that this is an accurate assessment of New patient workload for
the two Trusts.

2.3.2. A more detailed breakdown of these 3149 New Patients / year, across cancer body site and
Consultant is shown in Appendix B

2.3.3. An estimate of the number of New patients for the JPUHFT has been calculated by dividing
the total number of registered New patients on the Notes system by 3 (population served by
the JPUHFT is 33% of the total served by both Trusts). An assumption has been made that the
mix of cancer types will be consistent across the Network population.

Cancer Type Numbers of New patients / year Estimated numbers of New Patients
across both NNUHFT & JPUHFT across the JPUHFT catchment
Head and Neck 174 (includes Kings Lynn) 40
Lung 446 149
Upper GI 274 91
Brain 76 25
Breast 683 228
Skin 120 40
Sarcoma 38 13
Haem (including eye) 120 40
Urological 489 163
Lower GI 351 117
Gynaecological 176 55
Carcinoid 8 3
Unknown 71 27
3. Oncology OP Capacity

3.1. The current clinic schedules and numbers of New patient / Follow Up Patients slots currently
available are shown below. NB Some clinics have Staff Grade support.

New Follow Up
Day Session Consultant Slots Slots
Monday AM Dr Dernedde 2 8
PM Dr Epurescu 3 6
Wednesday AM Dr Harnett 3 9
PM Dr Harnett 2 3
Wednesday AM Dr Wade 3 9
PM Dr Wade 6 16
Friday - Weeks 1, 3, 4, 5 AM Dr Martin 4 18
Friday - Weeks 1, 3, 4, 5 PM Dr Martin 4 18
Friday - Week 2 AM Dr Martin 3 13
Friday - Week 2 PM Dr Martin 3 13
Friday PM Dr Dernedde 2 8
Totals 35 121

3.2. The total capacity:

3.2.1. The theoretical capacity (based on 52 weeks / year) = 1820 New Patient slots / year and
6292 Follow Up slots / year

3.2.2. Being more realistic, assuming each consultant is operational for 42 weeks / year (based on
6 weeks Annual Leave + 4 weeks Study Leave), the actual total capacity available = 1470
New Patient slots and 5082 Follow Up slots / year.

3.2.3. Comparison of the OP activity presented in 2.1, 2.2 and 2.3.3 with the realistic capacity
available (3.2.2) gives an appreciation of the level of mismatch between demand and capacity.
The comparison is shown below

Data source New Patient slots New Patient slots Difference (+/-)
required available – based on 42
weeks / year
From PAS data 732 1470 +738
From Dr Dernedde data 728 1470 +742
From Oncology Notes 991 1470 +479
data
Follow Up Patient slots Follow Up Patient slots Difference (+/-)
required available – based on 42
weeks / year
From PAS data 3006 5082 +2076
From Dr Dernedde data 2964 5082 +2118

3.3. Utilisation of New Patient and Follow Up Patient capacity.

3.3.1. Analysis of the PAS data allows us to determine how many of the New and Follow slots
were used on each day. The results for each consultant are show in the dot plots below.
E.g. there were 5 occasions in which 4 New patient slots were used and 8 occasions when 13 FU
slots were used.

NB The number of occasions in which no New or Follow Up slots were used confirms that in most
cases Oncologists have provided cover for at least the assumed 42 weeks / year.

Numbers of Patients Attending Ne w & FU Clinics / Day- Jan to June 09

Dr Harnett - New

Dr Harnett - FU

0 3 6 9 12 15 18 21

Numbers of Patients Attending New & FU Clinics / Day - Jan to June 09

Dr Martin - New

Dr Martin - FU

0 6 12 18 24 30 36 42
 Numbers of Patients Attending New & FU Clinics / Day - Jan to June 09

Dr Epurescu - New

Dr Epurescu - FU

0 2 4 6 8 10 12

Numbers of Patients Attending New & FU Clinics / Day - Jan to June 09

Dr Wade - New

Dr Wade - FU

0 3 6 9 12 15 18

Number of Patients Attending New and Follow Up Clinics / Day Jan to June 09

Dr Dernedde - NP

Dr Dernedde - FU
0 2 4 6 8 10 12
Data
 4. Current Waiting Time Performance

4.1. Waits for New Patient appointments

4.1.1. The number of days wait between referral and initial OP appointment for each of the visiting
consultant oncologists between January and June 09 are shown in the graphs below.

Days wait for Initial OP - Dr Harne tt

60 1

50

40
UCL=35.20
ait

30
aysW

20
D

_
X=13.03
10

-10 LCL=-9.14

1 11 21 31 41 51 61 71 81 91
Observation

Days Wait for Initial OP Appointme nt - Dr M artin

40 1
Days Wait for Initial OP Appointme nt - Dr Epure s cu
100
1

30 1
80
1 UCL=75.9
UCL=22.93
sWit

20
a

60
a
Dy

ait

10 40 _
aysW

X=8.52
_
X=25.4
20
D

LCL=-5.89
0
1 6 11 16 21 26 31 36 41 46
Observation
-20
LCL=-25.1

-40
1 6 11 16 21 26 31 36 41 46
Observation

Days Wait for Initial OP Appointme nt - Dr De rne dde

100 1

1
80

60
1 1
it

UCL=46.5
a
sw

40
a
Dy

20 _
X=12.6

-20 LCL=-21.3

1 10 19 28 37 46 55 64 73 82 91
Observation
 Days Wait for Initial OP Appointme nt - Dr Wade
1
40
1

UCL=32.95
30

20
sWit
a

_
a
Dy

10 X=10.36

-10
LCL=-12.23

1 9 17 25 33 41 49 57 65 73
Observation

4.1.2. Waiting times for New patient are seen as important by Oncologists – although there is no
national target, the NNUHFT have set an internal target of <7 days between referral and
appointment.

4.2. Waits for FU appointments

Data is available to track the waiting time for follow up appointments but it is acknowledged that
the data is of little value. It is important that patients have access to emergency advice on the same
day and urgent advice within 7 days. Waiting time graphs are included in appendix D

5. Further potential demands on Oncologists

Discussions with oncologists have identified a number of national and local initiatives / changes
which need to be considered when planning future oncology establishments. These include:

5.1. Ensuring that patients are seen at the most appropriate hospital setting

5.1.1. Discussions with NNUHFT Clinical Director for Oncology confirm that it is appropriate for
the JPUHFT in future to provide an out-patient oncology service (New and Follow up patients)
for the majority of specific cancer types – there are a number of exceptions, those being:

• New Head and Neck cancer patients

• Head and Neck cancer patients in the 1st 6 months of follow up
• Brain cancer patients
• Skin Cancers – (although it is appropriate for BCC and SCC to be seen at JPUHFT)
• Patients with sarcoma
• Patients with carcinoid
• Patients with other rare cancers

5.1.2. With this in mind, if the New Patient activity associated with the cancer types referred to in
5.1 is deducted from the total estimate of 991 New patients cases, the remaining New Patient
activity expected for the JPUHFT is in the order of 860 New cases / year.

5.1.3. The 131 New patients associated with the cancer types listed in 5.1.1 are already seen by
Oncologists at the NNUHFT
5.1.4. The three data sources used to assess current OP activity have produced very similar
estimates. For the purposes of future planning, the Oncology Notes system has been confirmed
by the Oncology Clinical Director as the most reliable.

5.1.5. The analysis of the Oncology Notes System data does not extend to Follow Up activity so
estimates of Follow Up activity associated with New Patient numbers have been prepared by
two methods:

5.1.5.1. Using New to Follow ratios provided by Dr Dernedde

5.1.5.2. Using a New to Follow ratio of 1:5 (It is estimated (from a Joint Collegiate Council
for Oncology report – Dec 2000) that an average DGH population of 250,000 will have
1,000 new cancer registrations each year. If 75% of these were seen by an oncologist, there
would be 750 new cancer patient consultations each year. The ratio of follow-up patients to
new patients is found to be between 3 and 10:1 (Richards, MA and Parrott, JC, 1996) a ratio
of say 5:1 would mean 3,750 follow-up consultations each year.)

Cancer type New Patient Conversion used FU slots required- FU slots required
slots required – based on Dr based on Dr based on JCCO
Dernedde data Dernedde guidance
conversion
UGI 91 4.7 428 455
LGI / Ovarian 117 3.2 374 585
Breast 228 2.9 661 1140
Uro / gynae 218 4.5 1071 1090
Lung 149 5.2 775 745
Skin / Haem 60 3 180 300
Head & Neck Estimate 100 Estimate 100
Total 863 3489 4415

5.2. Rising incidence of Cancer

5.2.1. Future capacity planning should also take into account the increasing cancer incidence,
estimated at approximately 8% every 5 years (NRAG – based on projections of the future
changes to the population profile in terms of age and gender). With this in mind the following
slots need to be available.

Cancer type New Patient slots required FU slots required FU slots required
(Additional 8%) (Additional 8%) (Additional 8%)
Dr Dernedde JCCO conversion
conversion
UGI 98 462 490
LGI / Ovarian 126 404 630
Breast 246 714 1230
Uro / gynae 235 1157 1175
 Lung 161 837 805
Skin / Haem 65 194 325
Head & Neck Estimate 110 Estimate 110
Total 931 3878 4765

New Patient New Patient slots Diff

slots required available – based on (+/-)
42 weeks / year
931 1470 +539

Follow Up Follow Up Patient Diff Follow Up Follow Up Patient Diff

Patient slots slots available – (+/-) Patient slots slots available – (+/-)
required – based on 42 required based on 42
(Dr Dernedde weeks / year (JCCO weeks / year
conversion) conversion)
3878 5082 +1204 4765 5082 +317

5.2.2. The Oncologists currently work within three teams:

5.2.2.1. Team A specialising in Head & Neck, Lung, Upper GI and Brain

5.2.2.2. Team B specialising in Breast, Skin, Sarcoma and Haematology

5.2.2.3. Team C specialising in Urology, Lower GI, Gynaecology and Carcinoid

5.2.3. Assuming the Oncologists continue to work within this team structure then these slots need
to be apportioned across the three teams as follows:

Team Number of New patient Slots Number of Follow Up Patient

required slots required
Dr Dernedde JCCO
conversion conversion
A 259 1409 * *1405
B 311 908 1555
C 361 1561 1805
Total 931 3878 4765

* Includes an estimated 110 Head & Neck follow up appointments

5.2.4. Based on 42 available weeks the gap between slots available and slots required is:

Team Consultant New Patient Slots available Gap

currently
A Dr Dernedde 168
Dr Martin 320
Total Team A 488 +229
B Dr Harnett 210
Total Team B 210 -101
C Dr Wade 378
 Dr Epurescu 126
Total Team C 504 +143

Team Consultant Follow Up Slots Gap (+ / -) – Dr Gap (+ / -) –

Available Dernedde JCCO Conversion
Conversion
A Dr Dernedde 672 + 575 + 579
Dr Martin 1312
Total Team A 1984
B Dr Harnett 504 - 404 - 1051
Total Team B 504
C Dr Wade 1050 - 259 - 503
Dr Epurescu 252
Total Team C 1302

5.3. The business case for Radiotherapy at JPUHFT

5.3.1. This business case has been presented to the JPUHFT Trust Board and Governors and is
currently with local commissioners. A decision has yet to be made and recent guidance
suggests that no decision will be made until waiting time targets for radiotherapy treatment
have been reviewed nationally. The timescale for this is unknown.

5.3.2. It is worth remembering that the case does however include 2 WTE consultant oncologists
and 1 WTE Consultant Radiographer. This should be considered alongside any proposed
additions to the establishment.

5.3.3. Provides future scope for daily on-site presence of oncologists

5.4. Acute Oncology Service

5.4.1. The NCAG report mandates setting up of an acute oncology service in every hospital with
an A&E department. The principle drive for this is to provide assessment and treatment of
patients with complications of chemotherapy but the service is also expected to ensure the
rapid and appropriate management of patients presenting with previously undiagnosed cancer.

5.4.2. At the NNUHFT, the expectation is that the acute oncology service will:

5.4.2.1. Improve outcomes for patients with complications of cancer therapy

5.4.2.2. More efficiently assess patients with complications of known cancer

5.4.2.3. Assist in compliance with NICE metastatic spinal cord compression guidance

5.4.2.4. Provide a more efficient palliative radiotherapy service

5.4.2.5. Help provide better advice for patients with known cancer under other clinical teams

5.4.2.6. Reduce in-patient stay and compliance with NICE guidance for patients with cancer
of unknown primary site
5.4.3. The proposal under discussion at the NNUHFT includes an additional 10 sessions of
Consultant Oncologist time and 1 WTE Clinical Nurse Specialist covering the acute oncology
service via a dedicated bleep

5.4.4. Discussions regarding an integrated approach to the development of the acute oncology
service across both Trusts have just commenced. The Anglia Cancer Network is also now
beginning to take a co-ordinating role

5.4.5. Arrangements for the JPUHFT are therefore unclear at this stage and may have some
bearing on the JPUHFT oncology establishment later.

5.5. Review of patients on chemotherapy

5.5.1. It has been reported that due to lack of clinic capacity, breast cancer patients on
chemotherapy are not being reviewed by the consultant oncologist, even patients with an
urgent need for review. Waits of 2-3 months (previously even four months) to see a consultant
are reportedly not uncommon, whereas all other patients have access to their consultant at the
very next clinic, if problems arise.

5.5.2. There is a view that delays in review of patients present a clinical risk with potential for
serious complaint.

5.5.3. A search of the “bookwise” electronic booking system in the Sandra Chapman Unit,
between 1st June 08 and 31st May 09, identifies the need for approximately 320 additional
follow up slots if the existing number of breast cancer patients are to be reviewed every third
cycle of treatment. The data that supports this is available in appendix C

5.6. Leadership

5.6.1. Historically there have been excellent consultant links across the surgical and medical
specialties between the JPUHFT and the NNUHFT.

5.6.2. Oncologists employed by the NNUHFT have provided on site services at the JPUHFT,
covering OP clinics three days / week and MDT meetings by video link or on site.

5.6.3. The Medical Oncologist employed by the JPUHFT also has sessional commitments at the
NNUHFT but is usually too busy to attend

5.6.4. There appears however to be confusion over oncology leadership at the JPUHFT –
specifically who takes clinical responsibility for the services strategic development. There is a
widely held view that this is a significant problem.

5.6.5. Oncologists have described a “walk in / walk out service” where they “don’t get known” at
JPUHFT. They are keen to be more involved in teaching / giving presentations. There is also
interest in supporting the case for development of Nuclear Medicine at the Trust.

5.7. Outreach services to Beccles

5.7.1. Outreach services were provided up until approximately 2 years ago, with twice monthly
clinics scheduled immediately after the JPUHFT clinic and run by Dr Ostrowski.

5.7.2. It is reported that the Trust has some interest in re-initiating this service
5.8. Ratio of Medical to Clinical Oncologists

5.8.1. The Joint Collegiate Council for Oncology has recommended a ratio of 2 clinical
oncologists to every 1 medical oncologist but also recognises the important contribution both
specialties make towards comprehensive cancer care. The balance will also be influenced by
the site-specialised interests of the oncologists and the tumour types for which the cancer unit
is accredited.

5.8.2. With regard to OP clinic sessions, the ratio at the JPUHFT is 3 medical oncologist sessions
to 6 clinical oncologist sessions.

5.9. The view is that the current establishment of oncologists makes it impossible to cover
consultant absence. If the consultant is absent for any reason then clinics are cancelled. This
reportedly is the norm across the Trust.

5.10. Even without cover, the consultant oncologists provide a service with comparatively short
waits for New Patient clinic slots. These waits do however exceed the local target of < 7 days
set at the NNUHFT. See section 4.1

5.11. During these discussions there have been “requests” to have cover arrangements for Lower
GI and Urology as well as Breast appointments.

5.12. Suggestions have also included Nurse / Radiographer led Follow up for Breast patients –
with there being potential for approximately 400 slots / year to be seen by a Nurse

5.13. There is a view is that the workload for Breast cancer is sufficiently high to warrant input
from a 2nd Consultant, either running clinics side by side with the existing clinic or on another
day. Input to the MDT could be actual or via video link

5.14. Potential for Oncology Clinics alongside other cancer clinics

5.14.1. The Wednesday pm Breast clinic currently runs alongside the surgical Breast clinic – new
patients can then if required be referred from the surgeons for an oncological opinion.

5.14.2. There is enthusiasm to run a joint Gynae-oncology clinic between Dr Wade and Mr Nieto

5.15. MDT cover

5.15.1. The importance of oncologist input to MDTs has long been recognised and is a key
recommendation of the Calman Hine Cancer Report.

5.15.2. The table below provides a picture of the MDTs established and the contribution made to
them by Oncologists. This contribution can be from either Trust (video links) and is not
constrained to those visiting the JPUHFT

Cancer
Body Site Day / Time Type of MDT Consultant Comment
Suggestions have been made
regarding the need for an
Breast Wed On site – JPH Dr Harnett additional MDT / week at JPUHFT
Lung Tues (12-1) Video linked with Dr Martin / Covered by NNUHFT team in
NNUH Dr absence of Dr Martin
 Dernedde
Dr Radiotherapy patients seen at
Colorectal Monday Lunchtime On site – JPH Epurescu NNUH
Radiotherapy patients referred to
NNUH. TWR from NNUH also
Video linked with Dr attends. Radiotherapy referrals
Upper GI Friday lunchtime NNUH Dernedde made by UD to TWR
No oncologist present at MDT
even though Dr Wade is at the
JPUHFT on Wednesdays.
Specialised urology (penis / testis)
Urology Wed morning On site – JPH Dr Wade seen at NNUH
Dr
Video linked with Epurescu /
Gynaecology Thur lunchtime NNUH Dr Wade Dr Biswas also from NNUHFT
New patients seen at NNUH
Head & Joint MDT with Dr Roques / Martin from
Neck Wed morning NNUH Dr Martin NNUHFT
Mon lunchtime Video linked with Dr Roques / Martin from
(Thyroid) (fortnightly NNUH Dr Martin NNUHFT
Video linked with All new patients seen at NNUH
Lymphoma Tues morning NNUH ANH and HMS from NNUHFT
No link with All new patients seen at NNUH
NNUH or Video links needs to be established
Brain None Cambridge with Addenbrookes
There is a JPUHFT MDT on
Video linked with Friday pm with no Oncology input
Skin Mon morning NNUH Dr Harnett – noted at Peer Review
Video links with
NNUH / supra-
Informal – regional in Dr Takes place every two weeks on a
Sarcoma developing development Stebbings Friday – HMS

5.15.3. Gaps highlighted through discussion are:

5.15.3.1. Colorectal MDT is attended by a Medical Oncologist only; as such there is no

specific radiotherapy input to the discussion from a clinical oncologist.

5.15.3.2. The JPUHFT Urology MDT meets without input from any Oncology expertise

5.15.3.3. There is no Oncology input to the JPUHFT Skin MDT

5.15.3.4. There are no video links from Addenbrookes to JPUHFT and NNUHFT so although
local patients are “managed very competently by the Addenbrookes team”, local clinicians
do not have the opportunity to be involved in Brain MDT’s

5.15.3.5. The potential need for a second weekly Breast MDT – a counter argument exists for
expansion of the existing weekly MDT or a more efficient MDT.

5.15.4. Standards for MDT’s

NICE has published Improving Outcomes Guidance for many tumour types which specifies
oncology input to local MDT’s:
5.15.4.1 IOG Skin (p45) – Local skin MDT – Not every local Skin MDT will have a clinical
or medical oncologist available but if local circumstances allow they should part of
the local Skin MDT arrangements

5.15.4.2 IOG Colorectal (p45) – Whenever elective surgery is considered for patients with
rectal cancer, a clinical oncologist should be involved in discussion about each
patient before surgery is scheduled. In view of the current shortage of clinical
oncologists in the NHS, teleconferencing may be appropriate to enable this
discussion to be held. A medical oncologist may also be included in the MDT if
available

5.15.4.3 IOG Breast (p77) – Oncologists should devote at least 3 sessions / week to breast
oncology. Newly appointed oncologists should have at least one years experience in
an established breast unit. Where the oncologist is a medical oncologist, a firm link
must be established between the core team and the clinical oncologist from the
centre to which patients are referred for radiotherapy.

5.15.4.4 IOG Urology (p27) – Oncologist with expertise in radiotherapy and chemotherapy
for patients with urological cancers. The oncologist, who is likely to be a member of
the specialist urological cancer team from a linked cancer centre, should cooperate
with other specialist oncologists in the network

5.15.5 Peer Review

A peer review team visited the JPUHFT on 22/09/09 and reviewed gynaecological diagnostic
services and skin LMDT. For the skin team they verbally raised a concern regarding the lack of
oncologist attendance at the LMDT held here at the Trust. Whilst there was some disagreement
locally about the need for oncologist input for the type of patients discussed, the peer review team
upheld the measure.

No formal documentation available until the report is finally issued in December 09.

6. Conclusions

6.1. The PAS and Dr Dernedde data sources provide comparable estimates of current OP activity.
The estimates they give though are slightly lower than that obtained from analysis of the
NNUHFT Oncology Notes system.

6.2. It is also possible that a proportion of OP activity has been omitted from the PAS totals
presented in section 2.1, with a number of New Patients and Follow Up patient slots being
provided in “review clinic” templates.

6.3. Based on JCCO estimates, where they estimate that a population of 250,000 would see
approximately 1000 new cancer cases / year, the NNUHFT Oncology Notes system provides a
reliable data set and has been proposed as the preferred “planning tool.”

6.4. There is significant variation in the numbers of New and Follow Up slots available to
consultants in their clinic templates. (Refer to section 3.1) The number of New Patient slots can
vary from 2 to 6 per clinic and the number of Follow Up slots can vary from 3 to 18 slots per
clinic.
6.5. The data presented in 3.2.3 shows that the current total allocation of New and Follow Up slots
in clinics is in excess of what is required for the current demand. Even with the highest
estimate of New patient demand (991 patients from the Oncology Notes System source) there
is an excess of nearly 480 New patients slots (and at least 2000 Follow Up slots) across all
consultant clinics – based on 42 operational weeks / year.

6.6. This excess of New and Follow Up slots should not however automatically be assumed to be
slots that are available to be used within the time constraints of the clinics. It is obvious from
discussion that clinics often “run over time” even though slots are not utilised. This implies that
clinic slots are too short.

6.7. Section 3.3 provides useful information on how the allocation of New and Follow Up slots has
been used. If we discount 0 entries (clinic not open) and look by consultant at the most
common number of New patients and Follow Up patients seen / day (or ½ day) alongside the
range, then the results are;

6.7.1. Dr Harnett most commonly sees 4 New patients / day (range 1-8) and 13 Follow Up patients
/ day (range 8 - 21)

6.7.2. Dr Martin most commonly sees 1, 2 or 3 New Patients / day (range 1-6) and 10 Follow Up
patients / day (range 3 - 44)

6.7.3. Dr Epurescu most commonly sees 2 New Patients / ½ day (range 1-5) and 8 Follow Up
patients / ½ day (range 6 -12)

6.7.4. Dr Wade most commonly sees either 3 or 6 New Patients / day (range 1 – 7) and either 14 or
18 Follow Up patients / day (range 9 – 20)

6.7.5. Dr Dernedde most commonly sees 2 New patients / ½ day (range 1-4) and 7 Follow Up
patients / ½ day (range 2-13)

6.8. On a daily basis there is a relatively high level of consistency across consultants in the numbers
of New and Follow Up patients actually seen in clinics. Dr Harnett sees slightly fewer Follow
Ups / day than his colleagues (because he does not review breast chemotherapy patients) and
Dr Martin tends to see slightly fewer New and Follow Up patients / day than his colleagues. Dr
Martin has the greatest level of variation in his Follow Up numbers – with 4 occasions in which
over 30 patients were seen, once as many as 44 patients.

6.9. Waiting times performance data shown in section 3 ranges between 8.5 and 25 days for New
Patient appointments and between 24 and 149 days for Follow Up appointments. (NB – a high
proportion of 0 days waits for Dr Dernedde skews the lower value of 24 days). Whilst not a
national target, there is an internal target at the NNUHFT to see New Patients within 7 days of
referral (unless there are clinical reasons for a longer delay or the patient wishes to defer an
appointment) and there is a view that this should be the aim across both Trusts.

6.10 Discussions with the Oncology Clinical Director regarding which cancer patients should be
seen at the JPUHFT suggest that approximately 87% of New Patients should be seen at their local
Trust with the remaining 130 New patients being seen at the NNUHFT. There appears to be no
formal agreement between the two Trusts that work should be distributed in this way.

6.11 Assuming agreement is reached and that cancer incidence rises by 8% over the next 5 years,
the minimum activity that should be used for service planning is 930 New Patients and 3800 Follow
Up patient slots (based on Dr Dernedde’s conversion factor.) On these numbers, and assuming 42
operational weeks / year the total number of slots currently available is actually in excess of what is
required – with approx 540 more New Patients slots and 1204 Follow Up slots available than
required. See 6.6.

6.12 There is strong support from the oncologists for the current arrangement of working in three
teams to continue. Although 5.11 suggests that the slot capacity available exceeds that required, it
does not mean that the capacity is in the right place as far as the teams are concerned. Some
adjustments are required, based on the data available:

6.12.1 Team A could theoretically reduce its New slots by 230 / year and its Follow Up by 575 /
year. What is clear from the data in section 2.1 to 2.2 is that Dr Dernedde is seeing a greater
proportion of the patients seen collectively by team A and yet has approximately 30% of the
total New patient and Follow up slot capacity. Either New / FU slot capacity needs to be
redistributed from Dr Martin to Dr Dernedde or the patient workload needs to be more fairly
distributed. Because of the “frailty of Dr Dernedde’s patients, there is a need to have
sufficient OP slots available for patients to be seen quickly rather than defer them to the
Sandra Chapman Clinic – as is currently the case.”

6.12.2 Team B needs to increase its New slots by 100 / year and its Follow up by 400 / year

6.12.3 Team C could decrease its New slots by 140 / year and needs to increase its Follow Up by
260 / year.

6.13 If the JCCO advice from Dec 2000 is accepted, then the number of Follow Up slots that
should be available for a population of 250,000 is 4650 (using a conservative New to Follow
Up ratio of 5:1.)

6.14 If we use this JCCO guidance on New to Follow up ratio then:

6.14.1 Team A would need 1405 Follow Up slots / year (580 less than it currently has) – includes
110 Follow Up slots for Head & Neck appointments. (Refer also to 6.12.1)

6.14.2 Team B would need 1555 Follow Up slots / year (1050 more than it currently has)

6.14.3 Team C would need 1805 Follow Up slots / year (500 more than it currently has)

6.15 The business case for radiotherapy which includes 2 WTE Clinical Oncologists, presents a
great future opportunity for a 5 days / week oncology presence at the JPUHFT. Success in the
radiotherapy case will undoubtedly influence the outcome of this work but at this point in
time, the two cases need to remain separate.

6.16 The number of visiting consultant sessions at the JPUHFT has not increased within the last 8
years

6.17 Plans for the Acute Oncology Service have clearly been discussed separately at each Trust.
Opportunities to integrate these plans are at a very early stage of discussion.

6.18 There is serious concern that Breast cancer patients undergoing chemotherapy are not being
reviewed as per protocol by an oncologist. (Oncologists at both Trusts are committed to
working to common agreed protocols – including FU frequency, but current staffing does not
support this). This reportedly presents a significant clinical risk with a serious risk of
 complaint which it appears could be reduced substantially by providing a minimum of 320
additional follow up slots.

6.19 There are no clinical leadership arrangements obvious to all those involved in delivering the
service. If this continues then it is unlikely that the Trust will develop and implement an
oncology strategy for the Trust which aligns with that of its “oncology partner” at the
NNUHFT. The absence of an aligned strategy is likely to lead to fragmentation of oncology
services across the Trusts. There is interest from within the Oncology Service to provide
these clinical leadership arrangements.

6.20 The value of providing outreach services to Beccles is questionable. Although it is a very
“patient centred” option, it appears that the service was previously withdrawn because the
number of patients attending was small. It is unlikely to be an efficient way of using
consultant oncologist time in future.

6.21 Based on current working patterns of 6 sessions of clinical oncologist time and 1 session
visiting + 2 resident medical oncologist, the JPUHFT complies with the JCCO recommended
ratio of clinical to medical oncologists. The reality is that any shortfall in OP capacity could
be addressed by employing either medical or clinical oncologists (or even nurse /
radiographers for Follow Up). Given the interest in providing a radiotherapy service in future,
it maybe more sensible to employ additional clinical oncologist sessions.

6.22 The data presented in section 3.3.1 confirms that there were very few occasions in which
weekly OP clinics did not take place. One consultant was available for 46 weeks and the
remaining consultants were available for between 40 and 42 weeks of the year. Ideally, all
consultant absences should be covered by a colleague with the same team, but this has
certainly been impractical in the past. With waiting time performance for New Patients
between 8.5 and 25 days across all consultants, and therefore exceeding the desired target of
seeing New Patients within 7 days, the case for additional consultant cover is strong.

6.23 The advantages (to patients and clinical staff) of running Oncology clinics alongside surgical
clinics have been proposed by at least two of the oncologists. The principle is a good one
although there may be practical difficulties in aligning schedules of the relevant surgeons and
oncologists. If this can be achieved without loss of clinic capacity then it makes sense to do
so. There appears to be particular value in joint clinics for Head & Neck (already taking
place), Skin and Gynaecological cancers.

6.24 The absence of a clinical oncologist opinion at the colorectal MDT and any oncologist
opinion at the urology and Skin MDT’s weakens the MDT discussion. Whilst involvement of
a medical oncologist in the colorectal MDT is valued, he can only contribute to chemotherapy
treatment discussions. The fact that an oncologist specialising in urology work is present at
the JPUHFT on the same day as the urology MDT, but doesn’t attend, is surprising. (refer to
section 5.15.4)

6.25 Any case for a 2nd breast MDT needs to be driven by the Lead Clinician for Breast at the
JPUHFT. Even if the principle is accepted there will be practical difficulties in releasing time
for all specialties to attend. Interestingly, the NNUHFT has 1 x Breast MDT / week, serving a
population twice that served by JPUHFT.

7 Recommendations
7.1 For planning purposes, the Oncology Notes System with JCCO conversion and with 8% uplift
for rising cancer incidence, is used. This means that the JPUHFT should be planning on a New
Patient demand of 930 patients and a Follow Up demand of 4765 patients / year.

7.2 Current clinic templates are replaced with templates that provide capacity for the anticipated
demand of New and Follow Up Patients. The actual slots required are:

7.2.1 For Team A – 260 New Patient slots and 1405 Follow Up slots / year – appropriately
aligned to the relative caseloads of Dr Dernedde and Dr Martin. There is scope for Dr
Dernedde to provide OP consultation alongside Dr Martin on Friday pm using the existing
Op nursing / admin support.

7.2.2 For Team B – 310 New Patient Slots and 1555 Follow Up slots / year

7.2.3 For Team C – 360 New patient Slots and 1805 Follow Up slots

7.3 The time allocated for New and Follow Up slots is standardised at 30 mins / New patient and 15
mins / Follow Up patient. (This would then be consistent with the standard at the NNUHFT)

7.3.1 This means that the OP time required for the teams is:

Team New Follow Up Total OP New Patient Follow Up

Patient hrs Patient hrs hrs required slots (30 mins) slots (15 mins)
required required required required
A 3.1 8.4 11.5 6 34
Dr Martin
Dr Dernedde
B 3.7 9.25 12.95 7 37
Dr Harnett
C 4.3 10.75 15.05 9 43
Dr Wade
Dr Epurescu

7.3.2 Limit the total time for OP clinics to 6 to 6.5 hours / day – allowing 1 to 1.5 hours / day for
associated administrative work.

7.4 Accommodate these OP hours required by:

7.4.1 Maintaining the current number of clinic days for team A, re-aligning OP slots appropriately
to the caseload of Dr Dernedde and Dr Martin – and review capacity in 6 months

7.4.2 Providing an additional full days clinic / week (additional 2 x Clinics) for team B

7.4.3 Providing an additional full days clinic / week (additional 2 x clinics) for team C

7.4.4 Uplifting the visiting JPUHFT oncology establishment by 20% to ensure that OP clinics are
always covered during annual and study leave absences and that the New Patient target of
being seen within 7 days is maintained.

7.5 Whilst there may be benefits of using Tuesdays or Thursdays for these additional clinics, any
days where clinic resources are available can theoretically be used.
7.6 Scope for Nurse / Radiographer led Breast Follow Up should be investigated alongside the
proposed expansion of Team B clinics (7.4.2). In the long term, the Nurse / Radiographer can
then provide cover for Breast Follow up. (Until the case for radiotherapy at JPUHFT is
approved, this cover should be provided by Nursing)

7.7 Scope for Nurse led follow up for Urology should also be investigated alongside the proposed
expansion of Team C clinics (7.4.3).

7.8 Nursing and Administrative support to the additional clinics needs to be reviewed and increased
if required.

7.9 The demands on Oncologist time associated with in-patient care are unlikely to change in the
short term. No additional resource associated with in-patient care is proposed at this time.

7.10 Responsibility for the oncology teams’ workload should lie with the team rather than
individual consultants. The recommendation is that secretaries will continue to be book patients into
a specific consultant slots but that unused clinic capacity is at least offered to another consultant
within the team to use where possible.

7.11 If an oncology team is unable to use any of its teams’ unused capacity then this capacity
should at least be offered to the other oncology teams. It is acknowledged that it will only rarely be
possible for a consultant from another team to use this capacity to see other cancer types.

7.12 The Trust monitors utilisation of clinic slots for each consultant to ensure that slots are used
efficiently and that templates are appropriate.

7.13 The Trust continues to collect data on waiting time performance (particularly for New
Patients) and analysis is carried out as required. A target of <7 days between referral and New
Patient appointment should be maintained in line with performance at the NNUHFT.

7.14 Clinical leadership of the Oncology service across both Trusts should lie with the NNUHFT
Oncology Clinical Director. The Clinical Director should be allocated 1 PA for his/ her
JPUHFT contribution and this should be reflected in his / her job plan.

7.15 The Oncology Clinical Director should work closely with the Medical Oncologist at the
JPUHFT but should take overall responsibility for:

7.15.1 Distribution of relevant cancer work to the NNUHFT, making provision at the NNUHFT for
the additional 130 New Patients and their corresponding Follow Up appointments.

NB – the distribution of cancer work between the two Trusts should be formally agreed by the
appropriate Trust Executives.

7.15.2 Integration of a plan for Acute Oncology Services across the two Trusts. Potential resource
requirements are likely to be known soon.

7.15.3 Assisting in developing the relationships between the service and other specialties within the
JPUHFT

7.16 Team A continues to take responsibility for Follow up of the Head & Neck cancer patients to
be seen at the JPUHFT (estimated at 110 patients / year)
7.17 Team B takes responsibility for the Skin (BCC and SCC) and Haematology cancers to be
seen at the JPUHFT

7.18 The Trust does not wait until the outcome of the business case for radiotherapy is known
before taking action on Oncology capacity. The shortfall can be addressed now and then the
oncology establishment reviewed again in line with the requirements for radiotherapy.

7.19 Follow up of Breast cancer patients on chemotherapy is maintained according to protocol

within the additional Follow Up capacity proposed.

7.20 No outreach services to Beccles are provided unless the numbers increase significantly, in
which case the situation should be reviewed.

7.21 Support the wish of oncologists to run oncology clinics alongside surgical oncology clinics if
it is practical to do so and out patient capacity is not lost as a result.

7.22 Input to JPUHFT MDT meetings is accommodated within the new schedules proposed in 7.4

7.23 A number of shortfalls associated with MDT’s need to be addressed as follows:

7.23.1 A clinical oncologist from Team C should provide input to the Lower GI MDT. If the
additional 1 day clinic for team C took place on a Monday then it is possible that a clinical
oncologist could attend. If this is not possible then attendance through video link from
NNUHFT is a realistic compromise.

7.23.2 A second oncologist involved in the additional Breast clinic for Team B should link into the
existing Breast MDT and possibly a second Breast MDT if that was to be developed. This
could either be by direct attendance or through video link.

7.23.3 An oncologist from Team C to attend the JPUHFT Urology MDT on Wednesday.

7.23.4 If there is a need for a separate Skin MDT on Friday, (rather than a common Skin MDT
across the Trusts) then an oncologist from Team B should participate.

7.24 The full cost implications of these recommendations should be considered by the JPUHFT
Medical Division / Finance team. In summary they are:

7.24.1 2 x additional days of Oncology clinics (4 x clinics) – with associated oncologist, nursing
and administrative costs (potentially including secretarial costs within that) – based on
NNUHFT Job Plans, 4 additional clinics equates to 6 PA’s.

7.24.2 Cover for the equivalent of 20% of clinics (based on 10 / 52 weeks / year absence) = 2 PA’s

7.24.3 Nursing costs to support 400 Breast Cancer Follow Up slots / year – approximately 1 clinic /
week. Potentially Urology Cancer Follow Up could also be included.

7.24.4 1 x PA for clinical leadership

7.24.5 Costs associated with JPUHFT element of the integrated plan for Acute Oncology Service –
as yet unknown (potentially this could include additional medical / nurse specialist resource)
7.24.6 Costs associated with any referral of the 130 New cancer patients (Head and Neck, Skin,
Brain, Sarcoma, Sarcoid and other rare cancers) to NNNUHFT

7.24.7 1 x MDT session for Clinical Oncologist input to Lower GI MDT

7.24.8 Possibly 1 x MDT session for Clinical Oncologist input to Skin MDT

Coaching and Management

Solutions

Garry Shayes
Mobile: 07979 770365 Office: 01362 861109
Email: garryshayes@coachingandmanagementsolutions.co.uk
Web: www.coachingandmanagementsolutions.co.uk
 Appendix A
JPUH – Oncology patient numbers according to clinic statistics
(based on IPM data December 08 – May 09)

Upper gastro-intestinal cancer (Monday morning clinic, U Dernedde)

Seen in last Extrapolated figures for Patient numbers per
6 months 1 year clinic
New patients 43 86 1.6
Follow up pat. 205 410 7.8
(Follow-up in this (173 + 32)
clinic + follow-up in
nurse-led clinic)
Ratio New/FU 1 : 4.7

Lower gastro-intestinal and ovarian cancer (Monday afternoon clinic, D Epurescu)

Seen in last Extrapolated figures for Patient numbers per
6 months 1 year clinic
New patients 54 108 2.0
Follow up pat. 166 332 6.3
Ratio New/FU 1 : 3.2

Breast cancer (Wednesday all day, A Harnett)

Seen in last Extrapolated figures for Patient numbers per
6 months 1 year clinic
New patients 114 228 4.3
Follow up pat. 340 680 13

Ratio New/FU 1 : 2.9

Urology and gynaecology. cancer (Wednesday all day, R Wade)

Seen in last Extrapolated figures for Patient numbers per
6 months 1 year clinic
New patients 85 170 3.2
Follow up pat. 384 778 14.9
Ratio New/FU 1 : 4.5

Lung clinic (Friday all day, C Martin / U Dernedde)

Seen in last Extrapolated figures for Patient numbers per
6 months 1 year clinic
New patients 138* 138 2.6
Follow up pat. 730* 774 14.8
Ratio New/FU 1 : 5.2
(* corrected IPM figures, because some patients were seen as new patients by one consultant are booked as new patients twice when referred for
radiotherapy)

Total number of new cancer patients seen in oncology clinics: 730 per yeari
 Appendix B

Estimate of activity in oncology for 1/1/08-31/12/08

1. Oncology Notes Registrations 1/1/08-31/12/08

3201 NPs registered

52 never seen (very brief MDT notes etc – all excluded)
3149 seen (or major annotation on Notes)

Coding

Approx 60% had ICD-10 code on Notes – assumed correct

Approx 25% had diagnosis on Notes – retrospectively coded without reference to main Notes entry
TWR May09
Approx 15% had no diagnosis – Notes reviewed and retrospectively coded TWR May 09

Possible errors

Over-estimates – other brief MDT notes, registrations from phone calls and ward referrals not seen
in oncology
Under-estimates – recurrences, 2nd primaries seen as NPs?
Either – incorrect data entry

Summary

TWRf WMCM MRDf ANH HMS RJWg ASB GKh MJOi UD EDE Total

H&Na 97 77 174
Lung 121 229 42 1 1 52 446
Upper GI 42 53 34 56 22 65 2 274
Brain 67 2 2 1 1 3 76

Breast 1 2 0 370 57 1 146 1 4 101 683

Skin 2 9 4 100 3 2 120
Sarcomab 2 33 1 1 1 38
Haemc inc eye 23 95 1 1 120

GU 1 82 1 275 1 103 25 1 489

Lower GI 1 140 86 1 1 122 351
Gynae 6 98 11 61 176
Carcinoid 8 8

Unknownd 10 2 5 5 10 1 8 10 3 11 6 71
Benigne 7 4 0 0 111 0 0 0 1 123
Total 348 326 100 489 449 377 296 267 65 138 294 3149

Notes:
a) H&N patients all seen in joint clinic NNUH – some registered only at MDT but this figure seem
right
b) Sarcoma all seen in joint clinic
c) Haem now all (myeloma?) seen in joint clinic w haem NNUH
d) these are true unknown primary cancers
e) Majority are benign soft tissue disease managed by HMS in sarcoma MDT
f) includes 20 patients registered under AB and HBJ (CNS tumours)
g) started May 08
h) started March 08
i) retired May 08. Figures seem low – what was happening to his JPUH patients?
 Appendix C
Breast cancer treatment figures obtained from the “Bookwise”
electronic booking system in the Sandra Chapman Unit
Search criteria: any patients under Dr.Harnett seen between 01.06.08 and 31.05.09

Results:
979 visits in total
823 visits for breast cancer specific treatment
(=chemotherapy / bisphosphonates / Herceptin)
123 patients (breast cancer patients only)

Number of treatments and number of necessary clinic appointments as per departmental protocols
(e.g. patients on adjuvant treatment to be seen after every third cycle etc.ii)

Treatment regime Number of treatments Ass. Number of clinic

appointment as per
departmental protocol
AC 38 19
Capecitabine 188 63
Carbo/Gemcitabine 27 14
CMF 57 18
Doxorubicin 8 4
Epirubicin 36 12
FEC 198 66
Herceptin 117 30
Taxanes 38 19
Taxol weekly 17 3
Vinorelbine 43 22
Zometa 56 19
∑ 289

Minimum amount of follow-up consultant-led clinics would be 289/year. In addition, patients with problems (disease
progression etc.) should be able to seen in a consultant-led clinic at the nearest available clinic slot (usually next
upcoming clinic). This is at least an extra ~ 30 patients/year. So the total number of clinic slots required for these
treatment patients is ~320/year.  Assuming there are 45 clinics per year, this would be 7 follow-up patients per week
(again: absolute minimum! In other UK hospitals, these patients are seen more frequently).
 Appendix D
FU Waiting Times Data

Days Wait for FU Op Appointme nt - Dr Harne tt

1
11
400 1
UCL=365.1

300
aysWait

200
_
X=148.7
D

100

LCL=-67.7

1 32 63 94 125 156 187 218 249 280 311

Observation

Days Wait for FU OP Appointme nt - Dr Epure s cu

UCL=317.9
300

200
ait

_
aysW

X=125.7
100
D

LCL=-66.4
-100
1 18 35 52 69 86 103 120 137 154
Observation

Days Wait for FU OP Appointme nt - Dr M artin

1 1
400 1
UCL=376.7

300

200
aysWait

_
X=128.1
100
D

-100
LCL=-120.6

1 36 71 106 141 176 211 246 281 316

Observation

Days Wait for FU Op Appointme nt - Dr Wade

400 1
1 11 1 1

UCL=322.9
300

200
aysWait

_
X=117.7
D

100

LCL=-87.5
-100
1 34 67 100 133 166 199 232 265 298
Observation
 Days wait for Follow Up Op Appointme nt - Dr De rne dde
200
1
1
1
150 1
1
1 1 11
1 11
1
1 1 1
11 1 111
1 1 11
ait

100 11 1 11
aysw

1 11
1
1 1 1
1
UCL=74.7
D

50
_
X=24.2

LCL=-26.4

1 32 63 94 125 156 187 218 249 280

Observation
i
Not included are approximately 10-20 new cancer patients seen in the monthly joint head and neck clinic of Craig
Martin
ii
Compared with other UK hospitals, these figures represent an absolute minimum of care!