Health Service Circular

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Health
Series number: Issue date: Review Status: date: Category:

Service
HSC 1998/242 22 December 22 December Performance Action
sets out a specific

Circular
Executive
1998 1999 Management
action on the part of the recipient with a deadline where appropriate

BREAST CANCER WAITING TIMES ACHIEVING THE TWO WEEK TARGET

For action by:
Health Authorities (England) - Chief Executive Primary Care Group Leads NHS Trusts - Chief Executives Regional Directors Regional Directors of Performance Management Regional Directors of Public Health Regional Cancer Co-ordinators

For information by Health Authorities (England) - Chair

NHS Trusts - Chair Community Health Councils Local Medical Committees

Further details from:

Lisa Westall 306 Wellington House 135-155 Waterloo Road London SE1 8UG 0171-972-4817

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Health Service Circular Additional copies of this document can be obtained from:
Department of Health PO Box 410 Wetherby LS23 7LN Fax 0990 210 266 It is also available on the Department http://www.open.gov.uk/doh/coinh.htm Crown copyright 1998 of Health website at

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Health Service Circular

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BREAST CANCER WAITING TIMES ACHIEVING THE TWO WEEK TARGET

Summary In December 1997 The new NHS set out the action necessary to deliver a modern and dependable health service providing prompt access to specialist services with hospitals linked to local surgeries and health centres to enable speedy and seamless access to treatment and care. It is guaranteed that from April 1999, (for all other cases of suspected cancer by 2000) everyone with suspected breast cancer will be able to see a specialist within two weeks of their GP deciding they need to be seen urgently and requesting an appointment. Action This guidance sets out the necessary action to achieve The new NHS breast cancer waiting times target and the steps required in the short term for the roll out of the target from April. The definitions of the key words of the cancer target are given in Annex A with the projected timeframe in Annex B.

1. This circular provides information on defining the target and the specific steps necessary to develop referral pathways and agree criteria for urgent referral. Achievement of the target will require action across primary and secondary care. GPs will be responsible for ensuring that referrals are prompt and appropriate. NHS Trusts will have the responsibility to arrange Monitoring and performance appointments within two weeks for urgent referrals. management of the target will be by Health Authority working with Primary Care Groups and will cover both GPs and NHS Trusts. 2. The cancer waiting times audit earlier this year covered waiting times for all cancer sites for the month of October 1997. Preliminary analysis of this pre-new NHS data shows that over 70% of patients referred urgently and diagnosed with breast cancer had been seen within the two week timescale. NHS Trusts will receive an analysis of their own data shortly. In addition, the 10 million made available recurrently in 1997 to improve breast cancer services has enabled substantial progress to be made in reducing waiting times and improving quality of care. Reports submitted in September 1998 by each health authority and NHS Trust show that over the past year NHS Trusts have used the money to invest in workforce, training and equipment, to develop rapid diagnosis clinics and to improve waiting times. Regional summaries indicate that the majority of NHS Trusts now have an average wait for urgent suspected breast cancer appointments of less than two weeks.

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The Process - An Overview 3. The responsibility for meeting the two week target is shared between GPs and NHS Trusts. If a GP decides that a patient with suspected breast cancer needs to be seen urgently, they should reflect that urgency by ensuring that the NHS Trust receives the referral within 24 hours of making that decision, by using telephone, fax or other electronic media. This is consistent with the Information for Health strategy which, as part of the overall agenda for modernizing the NHS, encourages same day direct booking systems by GPs. 4. Every referral made under the two week target must be clearly identified as urgent and include the decision to refer data. This will mean that Chief Executives of NHS Trusts will be responsible for ensuring that robust systems are in place to receive and record the urgent referrals and to identify quickly those being made on the fast track. GPs must also be absolutely clear about the route into Trusts for these urgent referrals and the way in which they should be made. NHS Trusts performance will be monitored on the basis of these correctly made referrals. Good communication between all players is one of the keys to the achievement of the target. 5. Achievement of the target is a priority within the National Priorities Guidance and a new monitoring system will be operational from April 1999. It is important that potential problems are identified early and resolved to ensure that all patients referred within the criteria are seen within two weeks by April 1999. This will require a systematic review of the way local services are organised, local agreement between GPs and consultants on the criteria for urgent referral and an assessment of the state of readiness for each NHS Trust. This process should complement the wider work which NHS Trusts undertake on the development of local clinical governance arrangements. 6. To enable problems in achieving the target to be identified at an early stage, regional offices will survey all NHS Trusts in January and agree with the Health Authority and NHS Trust where additional work is required. In addition, from 1 February 1999 to 30 June 1999, NHS Trusts will monitor urgent suspected breast cancer referrals on a monthly basis. This will test out the new reporting instructions and provide an updated monthly return on progress to health authorities. More detailed guidance will be issued on this in January. Formal quarterly monitoring of achievement of the target will start from 1 April. Referral Pathways from Primary Care 7. GPs and NHS Trusts must establish clear referral pathways and criteria so that those patients being referred urgently under the two week target can be identified and fasttracked. In many cases these will be extensions of well developed referral pathways and agreed criteria which are already in operation. Others will need to review their referral procedures to ensure that patients are referred to the most appropriate team for the initial investigation within the two weeks. 8. There is some evidence that referrals to clinics are increasing. Good communication channels between providers and primary care are essential to minimise problems of overloading of rapid referral clinics. National guidance already exists to help local cancer networks agree criteria for urgent referrals. Guidelines for Referral of Patients with Breast Problems, published in 1996 by the NHS Breast Screening Programme and Cancer Research Campaign, helps GPs differentiate between benign and malignant disease. They are currently being updated to incorporate the two week rule and will be sent to GPs, health authorities NHS Trusts should give regular feedback to and NHS Trusts early in the new year.

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referring GPs on the specificity of their referrals. Action within NHS Trusts 9. It will be the responsibility of Chief Executives of NHS Trusts to ensure that GPs have clear information about the way in which these urgent referrals are made and that NHS Trust systems are sufficiently robust to ensure that all urgent referrals are fast tracked. Whichever referral method is used locally, it is essential that NHS Trusts are able to identify immediately those patients being referred within the target criteria. To ensure local consistency, GPs and NHS Trusts should develop their own standardised referral formats giving the date of decision to refer and outlining the clinical and other information they wish to have included. Each referral should be clearly annotated that the two week target applies. 10. From 1 February 1999 to 30 June, NHS Trusts will monitor urgent suspected breast cancer referrals on a monthly basis to test out the new reporting instructions and provide an updated monthly return to Health Authorities of their progress in meeting the target. This will identify those NHS Trusts with any remaining problems in meeting the target and ensure that action plans are strengthened as necessary. Detailed guidance will be issued on this in January. 11. Formal quarterly monitoring will start from 1 April. Most NHS Trust information systems are not currently able to collect the information required to monitor this target and initially will need to monitor it manually. The new NHS target will require NHS Trusts to capture data for all patients referred urgently with a suspicion of breast cancer rather than only those with a confirmed diagnosis. The monitoring requirements are being road tested with NHS Trusts and regional cancer groups during December. In January they will be submitted to the Committee for Regulating Information Requirements (CRIR) and then to A further Health Service Circular will be issued in February that will give Ministers. guidance on arrangements for quarterly monitoring. Action Within Health Authorities and PCGs

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12. The target must be achieved for all patients referred within the agreed criteria. Regional offices will work with all NHS Trusts in January to identify where additional urgent work is still needed. Firm action plans can then be developed and agreed with the health authority to ensure that the target is met by 1 April 1999.

This circular has been issued by:

Dr Graham Winyard Director of Health Services NHS Executive

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ANNEX A ACHIEVING THE NEW NHS CANCER WAITING TIMES TARGET: DEFINITIONS

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The new NHS guarantees that Everyone with suspected cancer will be able to see a specialist

within two weeks of their GP deciding they need to be seen urgently and requesting an appointment. By April 1999 for breast cancer and by 2000 for all other cancers
i. It is the GP who decides in the light of the new national guidelines whether a patient needs to be seen urgently and requires a specialist outpatient appointment within the two week period. Guidelines for Referral of Patients with Breast Problems published in 1996 by the NHS Breast Screening Programme and Cancer Research Campaign have been shown to enable GPs to differentiate between benign and malignant disease. They are currently being updated to incorporate the two week rule and will be disseminated early in the new year . They should form the basis of local agreement between NHS Trusts and GPs on the criteria to be used for an urgent referral. ii. Able permits a degree of patient autonomy. Patient views should be considered when applying the two week rule, and monitoring should be able to allow for personal preferences and patient delay, where social and personal factors may mean that an appointment within Such factors could include the need for another person to 14 days is inappropriate. accompany the patient, a wish to digest the initial information and holidays. iii. A specialist means that person or persons who are most able to progress the diagnosis and treatment in timely fashion or re-refer where necessary. The specialist will be working in or attached to a multi-disciplinary specialist team, and referral routes to such teams need to be agreed by Primary Care Groups, and widely disseminated within local cancer networks. iv. The GP seeing the patient with the current illness is their GP. The diagnosis of possible cancer requiring urgent referral should remain the responsibility of the individual GP seeing the patient. Before deciding to make an urgent referral the GP may use time and appropriate investigations in order to refine possibility into probability. This is good clinical practice which is unlikely to have a deleterious effect on clinical outcomes, whilst at the same time focusing cancer resources where most needed, and protecting patients without cancer from unnecessary anxiety or trauma. v. The two week waiting interval, measured in calendar days, will start from the date that the GP decides to refer - the decision to refer - date and will be subject to the GP making the referral and the NHS Trust receiving the referral within 24 hours of the decision to refer being made. This will either be the day the patient sees their GP or because the need for urgent referral may only become apparent on receipt of results of investigations ordered by the GP, the date the GP lets the patient know that they are going to be referred urgently. The Information for Health strategy encourages same day direct booking systems, either by electronic media, telephone or fax. Whichever referral method is used locally, it is essential that NHS Trusts are able to identify immediately those patients being referred within the target criteria. Everyone vi. This includes all patients referred with a suspected primary cancer and suspected cases of relapse. Women referred from the breast screening programme will continue to be

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monitored under existing NHS Breast Screening Programme standards.

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Failures to attend vii. Monitoring must allow for the fact that social and personal factors may mean that a patient might choose to delay their appointment beyond 14 days. In such cases, the 14 day period would start from the date the patient is offered (and refused) an appointment to the date the patient is actually seen. This is consistent with existing outpatient waiting time procedures. Further Clarification viii. Advice on data collection January and February.

and central returns will be given in specific guidance

in

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Annex B ACHIEVING THE NEW NHS BREAST CANCER WAITING Projected timescale of planned action 18 December December Issue Health Service Circular

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TIMES TARGET

Draft monitoring guidance field tested with regional cancer groups and information contacts at NHS Trusts. In early January, monitoring arrangements and guidance for approval submitted by correspondence to CRIR Specific guidance issued on state of readiness report requirements and definitions for monitoring from 1 February

January

end January

Regional cancer co-ordinators Trusts

report on state of readiness of NHS

Action plans developed between HAs and NHS Trusts for achieving target 1 February NHS Trusts begin manual monthly monitoring Health Service Circular monitoring requirements April February July - June Quarterly monitoring Monthly monitoring Quarter 1 monitoring issued to the NHS explaining the quarterly and giving guidance for its completion.

begins data received return

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