The purpose of this synopsis is to highlight keys issues as raised in the Nuffield advice document, and in doing so make specific observations and ask direct questions. Some of the sub-headings used are taken directly from the Nuffield document.
- Co-Location at UHW is the preferred option
- Time constraints that are being used to challenge this option lack definitive proof and are largely assumptions.
- The Transforming Cancer Services (TCS) Programme has been insular and inward looking, and as such has failed to properly engage key stakeholders.
- Recent proposals by TCS appear to be reactive to criticism rather than proactive.
- 6 years and £20 Million have not provided a blueprint to transform cancer services. The plan is simply to replicate current services.
- Failure to co-locate threatens research opportunities.
- Failure to co-locate threatens teaching programmes.
- Failure to co-locate threatens patient safety.
- The redevelopment of Velindre Cancer Centre is a once in a lifetime opportunity to transform cancer services for the whole of South East Wales, yet this opportunity may be missed.
- Transforming Cancer Services should never have been the responsibility of a single organisation that delivers only part of the pathway.
The Nuffield report raises significant key points with regard to the current provision of cancer services, and the predicted needs for the future.
There is no doubt that the Velindre site is no longer fit for purpose, and that a new development is needed.
Current plans for a new stand alone Velindre Cancer Centre have failed to acknowledge the crucial requirement of “Future Proofing” , which will, of necessity, include integrated care, accepting that some newer treatments will be more toxic, and likely to require anaesthetic/Medical/Surgical/ITU/HDU input to be readily accessible.
CO-LOCATION, THE NEW VCC AND FUTURE STRATEGIC OPPORTUNITIES:
The general consensus is that co-location of a new cancer centre within an acute hospital site would be the preferred option, when drawing on the collective experience of other institutions throughout the UK.
“We explored the potential for creating VCC at University Hospital Wales (UHW), but we have concluded that full co-location will not be an option for some considerable time”
It is far from clear how this conclusion was reached, as we aren’t given any further information as to how, exactly, they ‘explored the potential for creating VCC at UHW. Is this the result of in-depth discussions with CVUHB estates, with WG or with independent external experts in planning?
The logistics of co-location at UHW need to be openly and honestly discussed between the two health boards. The paradox here is that a new unit can apparently be built on a land-locked greenfield site in under four years yet developing on the readily accessible UHW site will take 10-15 years. Considerable time is vague and meaningless. It is a man-made construct which may represent incompletely evidenced opinion rather than clear and accurate advice. These time constraints can be overcome if the will exists.
“Given this and the urgent need at Velindre, the proposed solution of a network model supported by a cancer centre focussed on high-volume ambulatory care represents a reasonable way forward”
This statement is in itself very worrying. Looking for a solution that can only be described as “reasonable” needs to be fully explained. ‘Reasonable’ is hardly a ringing endorsement. Why not ‘ideal’ or ‘optimum’ or ‘best value-for-money’? Or, at least, ‘most feasible’?!
The people of South East Wales deserve the best, not simply a compromise consequent upon multifactorial missed opportunities.
“Cancer outcomes in the UK are behind those in other developed countriesand South East Wales has some of the worst in the UK and Europe for one-, five- and ten-year survival across all cancer types”
The people of South East Wales already have the worst outcomes in terms of cancer survival across the board. The project as envisaged will cost over £200 million, and for that the people of this area deserve the very best, not simply a compromise, rushed through at the end of a poorly executed engagement process which has failed to appreciate that cancer care involves many specialities outside chemotherapy and radiotherapy.
This is not “Transformational”, it seeks to continue the status quo as has been the case since the 1950s.
The report advises that Velindre should not admit patients who are at risk of needing escalated care, and that these patients should be managed in acute hospitals, with each LHB developing a strategy for acute oncological unscheduled care, including inpatient admission.
This will require multidisciplinary liaison within each LHB, and is fraught with practical difficulties. The very nature of cancer is such that it is often very difficult to know which patient will be suitable for care at a remote site, and which will need direct admission to an acute unit. The imprecise nature of telephone triage means that some very sick patients attend the current Velindre assessment unit, only to be transferred to an acute hospital. Co-Location would mitigate this very serious problem.
Conversely, without an on-the-spot oncologist, management of some patients at the DGH may bring its own risks. There are some things (e.g. cardiac surgery, transplantation) that have been proven to be delivered most safely in regional centres, rather than in every hospital. This is why cancer services are delivered on a regional basis right now. We believe that there should be one regional oncology centre, colocated with an acute hospital, so that cancer patients can benefit from expert, on-site care for every aspect of their condition.
Transforming Cancer Services was a programme established in 2014, and at the time of the Nuffield advice it had spent around £20 million.
The Nuffield report states:
“The planning approach for cancer services in South East Wales needs to be reviewed and improved. In particular, the coordination of strategy, the use of a common dataset and the leadership of the process all need to be strengthened”
This would appear to directly call in to question exactly what TCS have achieved over the 6 years, the suggestion being that there is an urgent need to transform most areas of the current planning strategy. Why this is not already underway is a question which needs to be answered. Transforming Cancer Services should never have been the responsibility of a single organisation that delivers only part of the pathway.
NUFFIELD REVIEW, THE PROCESS:
The Nuffield review in itself was constrained by significantly rigid terms of reference.
They were asked to comment on the proposed model, rather than perform a clinical review of what was actually needed. Advice was sought on how best to mitigate the risks associated with the plans for a new stand-alone centre, and not specifically whether a new stand-alone centre was clinically safe or appropriate.
“First, this is not and has never claimed to be a wholescale independent review of the project”
“It is very important to stress that this advice is being given on the proposed model and is not an option appraisal of all the different permutations for siting or distributing services across South East Wales”
The report highlights the fact that Velindre cancer centre predominantly delivers radiotherapy, chemotherapy and palliative care.
“Surgery, high-risk therapy such as immunotherapy, some SACT (Systemic Anti-Cancer Therapy), specialist investigations such as endoscopy, interventional radiology and specialist care for the side effects of treatment are provided in other hospitals across the network”
RESEARCH DEVELOPMENT AND INNOVATION:
Nuffield observe that Velindre NHS Trust “Considers that it has established an excellent national and international reputation in research”
This needs to be reviewed perhaps in the light of current CRUK funding streams and where Cardiff/Velindre currently sit in terms of international research. It may be that Velindre is using itself as a benchmark, rather than comparing their research achievements against those of its international peers.
Consultants working within the Velindre trust raised the following concerns in a letter to senior management in July 2020
“our ability to continue delivering world-leading clinical research involving increasing numbers of emerging state-of-the-art treatments will be significantly limited if we are not collocated with appropriate facilities. Systemic therapies, and innovative drug- radiotherapy, vaccine and early phase clinical research, now routinely mandate immediate access to high dependency and intensive care input.”
Of significant concern is the comment in the Nuffield report:
“The VCC Research & Development (R&D) Task and Finish group was established in September 2020 and is working on refreshing its R&D strategy for publication in early 2021.”
Transforming Cancer Services has been in existence for 6 years, and only now in late 2020 have they addressed the future needs for their clinical research. This is a very disturbing development, and clearly demands an explanation.
The importance of co-location at a site such as UHW is clearly stated in regard to future research needs:
“The acute unit recommended for UHW should also form a hub for research activity and include collaboration with haemato-oncology research as part of the networked model”
MEDICAL EDUCATION AND TRAINING:
The current level of medical education and training is addressed by the Nuffield report. The proposed changes to the training curriculum for 2021 places an emphasis on acute oncology, and as such the proposed new Velindre Cancer Centre will be significantly restricted in its ability to train the oncologists of the future.
In discussing the training arrangements currently in place, the report highlighted the fact that at night the only resident doctor on site may be an ST1 level junior, only having just completed their foundation year programme. This again speaks to the safety concerns highlighted elsewhere in the report.
Specialists at Velindre made the following observation in another letter sent to senior management:
“Co-location of acute cancer care would also afford a significant enhancement of training and education opportunities for all members of the multidisciplinary team. Training in Acute Oncology is part of the core curriculum and a cancer centre aligned with the University and a major teaching hospital would provide a clear opportunity to make Wales a leading centre within Europe for Cancer care”
TRANSFORMING CANCER SERVICES:
The report discusses the role of the Transforming Cancer Services programme, outlining what was envisaged when set up in 2014. Having listed in bullet point form the objectives of TCS, it observes that some 6 years later
“The detailed components of some of this have not been developed”
Why after 6 years had these components not been finalised?
Whilst not fully developed “This planning process culminated in the approval in 2017–18 by all LHBs of an outline business case for a new VCC to be built on the Northern Meadows”
One must question whether the approval of a business case formulated on the basis of incomplete evidence and information is acceptable?
PLANNING ACUTE ONCOLOGY SERVICES ACROSS SOUTH EAST WALES/LOOKING FORWARD-THE CANCER SYSTEM IN SOUTH EAST WALES
Planning for the future of acute oncology is a major area of concern, and an ever-changing clinical landscape. This requires flexibility and the ability to engage, as opposed to intransigence and a refusal to listen.
Nuffield feel that there is broad agreement that local delivery of acute care by each LHB is the preferred route, as part of an integrated Acute Oncology Service, but to date there has been a failure to fully explore the practical issues surrounding this proposal.For example- what would be required in each site? Would there be on-site oncologists? And if so, would these specialists be additional to the current Velindre establishment, or would we see the same number of specialist oncology staff spread thinly across every unit in the region? t is clear that a significant amount of co-ordinated work is still required. Full engagement of all stakeholder Local Health Boards is clearly a necessity.
There is agreement that an integrated network of cancer care, with Local Acute Oncology Service (AOS) units determining the need for local intervention, or admission to the Velindre Cancer centre. This will require robust data analysis on a local level, and there is no mention in the Nuffield report as to whether any of this data currently exists. At this point in time the concept of local acute oncology service provision is largely an evidence free zone. Only now is this work in progress, having been undertaken by TCS.
Nuffield make the following observation:
“With planning, we can move from a variable, poorly planned service to a high quality, sustainable service to deliver care without the need for as many patients to travel to the main Cancer Centre in Whitchurch”
One might ask what progress has been made on these issues in the last 6 years, since the inception of TCS, for Nuffield to describe the current situation as “Variable and poorly planned”
The overall consensus was that a more comprehensive AOS footprint at UHW would be the preferred option, allowing full integration with services already established there.
“Solutions to the immediate issues facing cancer services across the region, and at the VCC in particular, are required now, rather than at an indeterminate point in the future”
It should not be an indeterminate time, after six years of engagement with TCS.
A clear understanding of what was needed would have required engagement with all stakeholders. This could then have resulted in more meticulous planning to allow a realistic timescale to be proposed. “Indeterminate” and some “point in the future” are nebulous terms that further reflect the abject failings of TCS.
Nuffield did however observe:
“In particular, we recommend the development of an oncology footprint at UHW to provide a focus for cancer care and the provision of inpatient beds and an assessment service. This would have the added functionality of providing ‘hot’ elective activity such as early-phase trials, working with the haemato-oncology specialists in areas such as CAR-T, caring for those with immunotherapy toxicity, protected access to interventional radiology procedures and so on”
The size of that footprint, the exact configuration and the timescale is something that can be determined now without delay. Obstacles to this progress are not insurmountable and should be addressed on the clear understanding that co-location is the ideal clinical preference.
The concerns regarding acute inpatient services revealed that VCC had become aware of issues surrounding the escalation of care and transfer of deteriorating patients from the VCC to acute care. Working parties had been set up to examine this issue in the few months prior to the Nuffield’s appointment. Why TCS and VCC had only acknowledged these issues at such a late stage needs to be further explored.
The transfer figures described in the Nuffield report contrast markedly with the figures repeatedly quoted by VCC, (and tally with those provided to Colocate Velindre by WAST) and this disparity needs to be challenged.
Of significant concern is the statement:
“During the course of our work, the trust proposed a new set of admissions criteria that would further reduce the risks associated with sick patients out of hours”
- Why only now during the course of the Nuffield’s work did they elect to do this?
- The trust previously had no data on the numbers transferred.
- There is no data held by the trust to define the problems requiring urgent transfer.
- Despite the lack of data, the trust has consistently underplayed and misrepresented this issue.
Reliance on a system that accepts emergency transfer of deteriorating patients as part of the risk would require an understanding of the numbers involved. VCC have stated that they do not collect or collate such data, this perhaps being reflected in the comments of the Nuffield trust.
“In general, it is clear that the inter-hospital/specialty pathway requires significant work to make this appropriate for the type of network model envisaged in the TCS strategy”
BUILDING ON RESEARCH EXCELLENCE:
Whilst Velindre consider itself to have an international reputation in research, many within the Trust feel this would be compromised by failing to co-locate. Evidence presented suggests that certain Phase 1 trials will need to take place elsewhere if co-location is not undertaken.
A research strategy is a priority, including research in in its widest definitions, including research led by disciplines other than medicine.
This would in reality require a Velindre footprint at UHW.
CANCER PLANNING IN SOUTH EAST WALES:
With regard to cancer planning in South East Wales, Nuffield suggested that there was a need for reorganisation and improvement, stating
“It cannot be the responsibility of a single organisation that is only delivering part of the cancer pathway”
Over the last 6 years the responsibility has been with TCS, and clarification of an appropriate pathway that serves the whole of South East Wales has not as yet been forthcoming. There is no evidence that cancer care in this area will be transformed, despite the passage of 6 years and the spending up to December 2020 of some £20 million. Without a brick being laid.
- Velindre Hospital needs to be redeveloped.
- Co-Location at UHW is preferred by many, and in line with trends elsewhere.
- Time constraints reportedly preclude colocation at UHW, in the timescale required for some of the changes required. However, we are not given the evidence underlying this conclusion.
- The benefits of colocation may possibly be realised within each LHB by establishing local acute and inpatient oncology care without travelling to Velindre. There still remains much work to be done on this model of care.
- A footprint at UHW will be required to maintain a credible research base for an important sub-set of cutting-edge clinical trials.
- Planning for cancer services in South East Wales has been woefully deficient and needs to improve. Lessons can be learned from successful models in England that have taken responsibility for planning, leadership and performance management.
It may be that the planning project needs to be completely transformed itself, and the last 6 years accepted as part of a very costly and painful learning process that has failed to deliver.
- Each LHB needs a co-ordinated plan to overcome the paradox of integrated care being devolved to each locality.
- The New VCC should not admit at risk inpatients, though quantifying the risk and identifying these patients is a significant clinical problem.
- Work needs to be undertaken to create a successful cancer network, and this work is long overdue.
- Flexibility of design for both the new VCC and new UHW is important, and equally so this is long overdue.
- UHW need to work closely over the next 15-20 years to maximise development opportunities, yet the opportunities exist here and now to begin this work without delay.
- Co-Location of the new VCC at UHW is the preferred option.
- The presumed time constraints are the main obstacles, yet these time constraints are poorly defined, unevidenced and can be overcome.
- TCS have failed to achieve much of what was actually required over the last 6 years, in terms of Transforming Cancer Service for South East Wales, despite huge expense. The apparent major focus has been on replicating the current, out-of-date Velindre model in a new building, thereby failing to seize a once-in-a-generation opportunity to undertake a process which is genuinely transformative.
- Developing a new Velindre Cancer Centre, knowing that it may only be used for 10-15 years may require further explanation. The Mutual Investment Model (MIM) will presumably be locked in for many years, and the financial implications of paying for an underused/redundant unit for an additional period of time needs to be taken into consideration.
- Looking to develop the new VCC on the current UHW campus may actually accelerate the development of both projects.
- Dismissing the possibility of a co-located model on the basis of ill-defined time constraints needs to be re-evaluated
- There exists a logistical disparity in the figures being quoted. Apparently the new VCC if built on the land locked inaccessible northern meadows can be completed in 4 years yet building on a brownfield site directly off the A48 will take 10-15 years.