The panel had previously raised concerns in respect of Do Not Attend (DNA) rates for South Tees CCG patients for the Symptomatic Breast Service at North Tees and further information had been sought. Representatives from South Tees CCG, South Tees NHS Hospitals Foundation Trust (STHFT), North Tees and Hartlepool NHS Foundation Trust (NTHFT) were all in attendance to update the panel.
Members were advised that the CCG had further analysed data regarding DNAs and had carried out a full review of patients who did not attend their first outpatient appointment for the Symptomatic Breast Service. A report had been prepared for the panel, which reviewed DNA rates for South Tees patients; explained the rationale for providing the service from NT&HFT; explained work that was progressing with regards to establishing a Spoke service at South Tees Hospitals NHS Foundation Trust (STHFT); information on current national and local workforce issues and detailed what work was being undertaken to address DNA rates.
It was explained that the Symptomatic Breast Service was for patients who had experienced some changes to the breast and had been referred by their GP. Under NHS Standards all breast patients should be offered an appointment within two weeks whether the GP suspected cancer or not. South Tees CCG was responsible for the commissioning of the Breast Symptomatic Service for South Tees patients.
In the months leading up to October 2015, South Tees Hospitals NHS Foundation Trust (STHFT) had identified that due to recruitment problems and the inability to recruit Radiologists into the Breast Radiology Service, they would need to find an alternative option for patients in South Tees. NT&HFT were approached by South Tees CCG and it was agreed following a considerable amount of service redesign and negotiations that the triple assessment clinics would be delivered by NT&HFT. If cancer was detected the patient would be allocated an appointment with a consultant. The allocation and referrals into the clinics were organised such that South Tees patients would be seen by a South Tees consultant so that surgery, if required, could be carried out at STHFT where clinically appropriate.
In October 2015, STHFT announced temporary closure to the Breast Radiology Services at STHFT. There was an initial request from STHFT for North Tees radiology staff to attend the clinics at STHFT; however North Tees Radiology staffing capacity and physical infrastructure at STHFT would not allow.
In September 2016, NHS commissioners in Middlesbrough, Redcar and Cleveland, Hartlepool and Stockton raised workforce concerns in regard to breast services and requested the Cancer Alliance to carry out a regional breast service review of current practice and explore future models for the services. The aim of the report was to provide an overview of current breast services for Cumbria and the North East.
The review took place and the preferred model of a Hub and Spoke was recommended regionally and agreed as the preferred model by South Tees CCG. In the Hub and Spoke model, the Breast Screening Unit (BSU), currently provided at the University Hospital of North Tees, was the anchor site providing an integrated care model with spoke sites providing local services to a wider population utilising existing facilities and equipment where possible. The BSU was responsible for the whole service and the workforce within it. The Cancer Alliance recognised that this was an aspirational model due to a national shortage of Breast Radiologists. The Breast Units in the Northern region were not currently in a position to fully adopt this model but would continue to work towards it. In the interim, the hub model had been adopted by the Tees-wide Breast Service.
National Workforce Issues
The panel was advised that in a statement provided by Chair of the Cumbria and North East Imaging Group (Workforce Sub-group) on 2 July 2018, it was explained that England has a significant shortage of radiologists, sonographers and radiographers. For example, England had half the number of radiologists per head of population compared with the European average. In the North East and North Cumbria, there were currently 30 radiologist vacancies, a further 37 retiring in the next five years and a projected requirement for a further 25 over the same period to cope with growth in imaging demand. At the time of writing, there were approximately 120 radiographer vacancies across the North East and North Cumbria.
In part this had been driven by increased demand for imaging over the past twenty years, driven by an ageing population, increased rates of cancer, but better cancer treatments which lead to improved cancer survival. Cancer survivors were usually on imaging surveillance programs, which created another, albeit welcome, demand. This increase in demand had not been met with an increase in the imaging workforce, for which there were a variety of factors.
Since 2009, the North East and North Cumbria had invested in training more Radiologists, (the Northern School of Radiology has increased from 55 radiologists in training in 2009 to 70 in 2018), the Region lifting from 7th out of the 10 English regions in terms of whole time equivalent Radiologists per head of population, to 2nd in 2016, a reflection of the sustained investment.
The Region continued to invest in innovative models of working and innovative models of training to both grow and develop the workforce, recognising that there was no easy solutions to a complex Regional problem.
In the next two to three years there would only be two trainee registrar breast radiologists who would qualify in the whole North East and Cumbria area. It was explained that this further demonstrated the fragility of the service in the region. To support the fragile radiology workforce position, the Breast Screening National Radiographic Workforce Report 2016 identified a number of supporting roles to help deliver the required services. These included:-
Radiographic support staff
Consequently, Trusts were developing innovative staffing structures within breast services in order to sustain a safe service for patients. NT&HFT had embraced this change in skill mix and maximised the alternative practitioners to deliver the service.
In terms of DNA figures it was advised that the data provided previously to the Health Scrutiny, had shown that postcodes TS1, TS3 and TS10 had the highest not attended rates. However, since providing the initial report a deep dive of the data, including a review of the coding, had identified that the actual numbers of DNAs for South Tees patients for 2017/18 was 0.07% (2 patients) as a whole.
The data provided previously had been un-coded and included patients who had cancelled and re-arranged their appointments. What was clear however was that patients in TS1 and TS3 were deciding to re-arrange appointments and this could be outside of the recommended two week referral timeframe. This was an area of concern and something that required investigating. The CCG expressed the view that it was important to note that for patients who did truly DNA the Trust offered the patient a second appointment and a third if clinically considered necessary and if they failed to attend again the patient was referred back to their GP for clinical review and a letter was sent to the patient and their GP advising of this.
The CCG was aware that TS1 and TS3 had high levels of deprivation and a transient population which were typically known to be difficult to engage. The CCG was aware from discussions with GP practices and Public Health that engagement with the NHS in these postcode areas was significantly lower for a number of services including Cervical and Bowel Screening. Public Health were focusing a number of projects on this population to address this issue. These projects include Reduce your Risk and Screening Saves lives. The CCG were working with public health to deliver the Public Health Tackling Cancer Together Action Plan throughout 2018.
National Breast Screening Service
Whilst the report focused on the Breast Symptomatic services, the CCG had also provided information on theuptake for the National Breast Screening Service.
The actual true DNA rates were very low for South Tees patients.
NT&HFT performance standards were met and there had been no issues raised regarding performance by the Northern Cancer Alliance.
Patient satisfaction survey demonstrated good patient satisfaction with the service.
There were national, regional and local workforce issues for Radiology Services.
NT&HFT had embraced the workforce skill mix and maximised alternative practitioners to deliver the service and had the highest skill mix in the northern region.
NT&HFT had a number of staff planning to retire in the near future adding to the fragility of the service.
NT&HFT did not currently have the required staffing levels to deliver the Hub and Spoke model.
Future service delivery of a hub and spoke model was dependent on a sustainable workforce.
The CCG was working closely with the Cancer Alliance and Health Education North East to stabilise the future workforce in order to deliver the preferred model for breast services.
During discussion the following points were raised:-
The panel expressed real concerns about the potential impact that the current operating model would have on JCUH's ability to attract breast radiologists and breast surgeons in the future. Members queried the longer term impact / consequences for JCUH, as a result of building in this structural deficit.
Breast cancer was a population health issue and Members described the current arrangements as a sticking plaster, the question was posed as to what consideration was being given to service provision over the next 10 years? What were the implications for South Tees patients in respect of these plans.
The panel queried how the current provision was impacting on outcomes for our patients, particularly in the TS3, TS1 and TS10 postcodes?
The question was posed as to whether working at acceptable national levels was really good enough. It was also queried as to how high a priority establishing a hub and spoke model was for the CCG.
The CCG advised that a period of engagement was required with people who used the service to establish the reasons and experiences of the patients to date and the reasons for DNAs. Panel Members agreed that they would be willing to partake in any engagement activity. It was accepted that a period of 6 months would be afforded to the CCG to report back on their findings.
If was emphasised by North Tees NHS FT that it was not trying to hold onto patients and this message would be reiterated to staff at North Tees.
The panel formally requested data on the patients returning to JCUH for treatment in figures and percentages.
The South Tees Trusts representatives expressed the view that from their perspective the desire and intent to develop a hub and spoke model was not apparent in the CCGs cancer action plan. Members advised that they were keen seen to further work undertaken on the CCG's action plan.
The CCG advised that work was being undertaken on encouraging eligible patients to claim back travel expenses.
Reference was made to the need for further collaborative working, as well as the work successfully undertaken by South Tees with colleagues at York in the provision of radiology support to the Friarage. It was queried as to whether North Tees could offer their staff any additional incentives?
The panel emphasised that it was keen to see the Breast Symptomatic Service back at JCUH.
i) The all representatives in attendance at today's meeting would be invited to a meeting of the Health Scrutiny Panel on Tuesday 8th January 2019 to provide an update on the progress made, further service user engagement undertaken and to respond to the queries posed.
ii) A special meeting of the Health Scrutiny Panel would be held to consider the breast screening statistics, as it was acknowledged that the take up rates in some wards were extremely poor.