Advice on the proposed model for non-surgical tertiary oncology services in South East Wales

The Nuffield Trust was commissioned by Velindre University NHS Trust to provide independent advice on the clinical model underpinning its planned changes to Velindre’s cancer services contained in its Transforming Cancer Services programme.

The planned model includes delivering more care within patients’ homes; development of a number of Velindre@ facilities on Local Health Board sites across South East Wales, providing chemotherapy, outpatient and support services; a radiotherapy satellite centre in Nevill Hall Hospital, Abergavenny; and the redevelopment of the Velindre Cancer Centre on a new site at Northern Meadows in North Cardiff.   

The work assesses the proposals for the planned changes to non-surgical tertiary cancer services across South East Wales and clinical concerns raised about plans to build the new Velindre Cancer Centre on the proposed site.  

Other report resources:  Appendix 3 (Bed days and admissions of patients with a cancer diagnosis across South West Wales, by health board); and a list of interviewees.

Also, read the Nuffield Trust's press notice on the report publication.

Key findings

Need for action

• Action is needed to improve cancer services across South East Wales: a high proportion of accommodation at the existing Velindre Cancer Centre (VCC) is non-compliant with statutory requirements and creates challenges in maintaining high levels of patient safety and experience.
• Furthermore, the existing centre does not have the future-proofing needed to deal with a growing cancer population with increasingly complex health needs.
• Solutions to the immediate issues facing cancer services across the region, and at VCC in particular, are required now, rather than at an indeterminate point in the future.

Co-location, the new VCC and future strategic opportunities

• Our experts and a number of interviewees pointed out the trend for single specialty hospitals, and other focussed institutions such as cancer hospitals, to be co-located on acute sites, often at a teaching hospital.
• 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.
• Importantly, there are future strategic development opportunities provided by the development of a flexible new VCC and proposed developments in Cardiff and the wider region. Working together over a 15- or 20-year window, the health system should look to exploit these development opportunities.
• Therefore, a flexible design for the new building will be required to accommodate these opportunities and future developments such as new haemato-oncology, endoscopy and other diagnostics capacity. The design should also ensure that the full potential of digital technology is exploited.
• 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. With a number of service changes detailed below, this can offer a safe and high-quality service that provides a good patient experience.

Inpatient care

• The VCC model should not admit patients to VCC who are at risk of major escalation. Changes in the admission criteria and overnight cover are currently being developed. Admissions and transfers to acute care should be kept under regular review and refined. This may reduce the requirement for inpatient beds but would create other opportunities for VCC to offer ambulatory care and diagnostic services.
• Each local health board (LHB) needs to develop a plan for oncology support for unscheduled cancer patient admissions and acute oncology assessment of known cancer patients, with inpatient admission as an option. This approach will mitigate the risks for inpatients across the network.
• Alongside UHW provision of acute oncology care, an enhanced research hub should also be developed as part of the research network model. This will allow many of the benefits of a co-located model to be achieved.
• The pathways to support inter-specialty referral need to be improved across all sites. This needs to include interventional radiology which will need to be expanded over time.

Ambulatory care

• While a lot of focus has been on the risks of inpatient care, the majority of patients using VCC are outpatients and day cases and they greatly value the environment and culture of Velindre and convenience in terms of travel and parking.
• The satellite radiotherapy and proposals to further develop a more rational distribution of ambulatory care across the region is a sensible direction of travel that will improve equity of provision and access.
• Ambulatory care at VCC should be expanded to include systemic anti-cancer therapy and other ambulatory services for haemato-oncology patients and more multidisciplinary joint clinics. Consideration should be given to expanding a range of other diagnostic services, including endoscopy at the new VCC.

Building the network

• The network solution being developed offers a number of benefits, including care provided closer to home for patients, a much better environment for patients cared for at Velindre, improved oncology support for emergency care in the district general hospitals, more opportunities for multidisciplinary research, and greater equity and coordination of care across the system.
• The development of acute oncology services in each LHB is a priority and will help support reductions in acute admissions across the network. A common dataset is required to support the planning of these services.
• Each LHB needs to ensure that there is a plan for providing oncology advice and support for patients admitted via A&E, and for acute oncology assessment of known cancer patients presenting with symptoms/toxicities, with inpatient admission provided as an option on a district general hospital site if needed. The assessment service model should provide for multi-disciplinary input, in particular from palliative care, specialist nursing and allied health professionals.
• The Velindre@ model should complement acute oncology services in the LHBs and should aim to bring solid tumour and haemato-oncology ambulatory services together. Further work is required to describe capacity and operational requirements, the interface with acute services, and the wider pattern of ambulatory care.
• Developing and operating a network is not easy and there are workforce and organisational development implications that require urgent attention. This should include the development of a workforce strategy.

Research

• 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.
• Finalising the refreshed research strategy supplemented by external peer review is a priority, and further work is required to fully take advantage of the networked model.
• The importance of multidisciplinary research and ensuring the involvement of all locations will be very important.

Planning

• There are significant opportunities from planning all cancer services in a more integrated way rather than the silos that currently exist. 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.

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What was within the scope of this work?

This project sought to provide advice to Velindre on the following questions:

1. What are the benefits of the planned regionally integrated network clinical model for non- surgical tertiary cancer services?
2. What are the risks inherent in the planned regionally integrated network clinical model, including the location of the main non-surgical tertiary cancer centre on the Northern Meadows?
3. Are the strategies proposed to manage these risks satisfactory and what else might be considered with regard to:
   1. additional opportunities to strengthen planned arrangements
   2. prioritising/accelerating any specific areas of planned work
4. What are the risks and benefits of the planned regionally integrated network clinical model with regard to research, development and innovation?
   1. How does the network model support high quality research and development and promote innovation?
   2. How might any risks be mitigated?
5. How could the benefits/opportunities be further optimised with learning from other health care systems? Are there any broader development opportunities related to cancer/related healthcare that could be considered to maximise the opportunity?

What was not within the scope of this work?

This project focused on providing independent advice to Velindre but was not a wholescale independent review of the project. The scope of this piece of advice is tightly defined and relates specifically to the clinical management of the planned regionally integrated network model for non-surgical tertiary cancer services and the location of the new Cancer Centre at Northern Meadows.

It did not seek to offer a definitive verdict on any broader plans to reconfigure cancer services in South East Wales and will offer no view on other important issues such as environmental concerns, inequalities impact or financial or cost considerations.

Who carried out this work?

The work will be carried out by a small team from the Nuffield Trust and assessed by a panel of clinical experts. The Nuffield Trust team will be led by Chief Executive Nigel Edwards and the project work will be delivered by Hilary Wilderspin, with input from Dr Louella Vaughan.

Nigel Edwards is Chief Executive of the Nuffield Trust.  His career has been spent in health service management and health policy, focusing particularly on innovation and change in the delivery of health services in the UK and internationally. Nigel’s work and interests are wide ranging, from the development and implementation of new models of service delivery at the front line to wider health care policy in the UK and internationally. 

Hilary Wilderspin is a Senior Associate at the Nuffield Trust. She is an experienced health service manager who has worked at all organisational tiers of the NHS and in the private sector. Hilary’s core skills are in strategy and business case development, option appraisal, project management and problem solving. She has led strategy review and development work across a broad range of subjects, including cardiac, cancer, neonatal and community services, and waiting list/time management.

Hilary worked in the acute provider sector for the first 10 years of her career both managing direct clinical services and undertaking service reconfiguration and business case development work and has an excellent understanding of the components and dependencies of a wide range of clinical services. Since 2000 Hilary has enjoyed a successful career as both a freelance and retained consultant working with clients such as the London Cancer Alliance, the Integrated Cancer Centre, South East London (Guy’s and St Thomas’ and Kings College Hospitals), South East London Cancer Network, the Department of Health, South Central SHA and the Government Office, East of England.

Internal peer review and clinical advice

Louella Vaughan is an Acute Physician and clinical academic who has extensive experience in research in networked care and care in remote locations. Louella works at the Royal London Hospital and for the Northwest London CLAHRC. She is the Research Group Lead and a Council Member of the Society for Acute Medicine, is a member of the NICE Clinical Guideline Development Group on Sepsis, an External Clinical Advisor for the Ombudsman and has sat on a number of Working Parties of the Royal College of Physicians, including the Future Hospital Commission.

How was the project carried out?

This work was carried out in three phases:

Phase 1 

Information gathering:  reviewing existing literature and evidence from healthcare systems around the world, together with clinical/operational information.

Phase 2

Engagement: The Nuffield Trust team interviewed clinicians and healthcare professionals within the Velindre Trust and with partner organisations, as well as patient representatives to gather further views and evidence on the model.

Phase 3

Analysis and findings: The information and evidence gathered was examined and analysed by a panel of eminent cancer experts, drawing out the key findings and any recommendations for Velindre University NHS Trust and the wider regional system.