Design for living

Amid all the political debate around targets, national cancer director Professor Mike Richards sits quietly and makes an important point. It is, he says of the 62-day, urgent referral-to-start-of-treatment target for cancer services, a matter of life and death.

But he claims not to be too bothered that the figures for the last quarter of 2005-06, due to be released by the Department of Health this week, will probably show the NHS has narrowly missed the 95 per cent target.

But interviewed by HSJ just eight months ago about progress on the key targets, Professor Richards said 'there is a long way to go, but we know it can and must be achieved'.

Now Professor Richards, who took up the additional role of chair of the National Cancer Research Institute at the end of April, is much more concerned with the rapid progress made in the last five months leading up to D-Day at the end of March 2006 by when the targets had to have been met.

'This is not just about achieving a target,' he says. 'It is about benefits for patients. This work has made us look again at the pathways and redesign them for the benefit of patients. That has given much greater certainty and clarity so we can now give them the promise that we will treat them in a reasonable timescale. For some, that may mean the difference between life and death.'

According to his own tracking, by the end of March 2006 a substantial number of trusts regularly hit or exceeded the target to start treating 95 per cent of urgent cancer referrals within 62 days. Overall, 91 per cent of patients started their treatment within two months of urgent referral. Just 30 trusts required intensive support from Professor Richards' small team to help them get up to speed. This is in stark contrast to the situation last summer. 'It had been flatlining at 70-80 per cent for a long while. But if you look at the last five months [to the end of March 2006] it has been getting better at a rate of 2 per cent a month,' he says. 'That's pretty remarkable.'

It is more remarkable if you take out the breast cancer figures, which have been around 97-98 per cent for several years. Top up the figures, says Professor Richards, and the improvement rate was 3 per cent per month for five months.

'Finally,' he adds with a flourish, 'if you look at the tumour group that has presented the greatest problems - colorectal cancer - the improvement rate is going up by 4 per cent per month'.

In the way of a good team worker - and hitting these targets is very much a team effort - he praises the 'hundreds, perhaps thousands of people who have made this possible'.

'The NHS has done fantastically well to deliver this,' he adds.

He shuns complacency, admitting that there is some way to go. 'But the direction is now very clear,' he says. 'We can say that the 95 per cent target is achievable because a very substantial number of trusts are achieving it. I am confident that we will achieve the target relatively soon.'

If he is right, it will be an achievement made against all predictions. And when the figures for the 31-day target between diagnosis and treatment are announced, Professor Richards is confident that trusts will have met or exceeded the 99 per cent objective.

In March, Monitor warned in its nine-month report that missing the 62-day target was a significant risk for over a third of foundation trusts and that a very similar picture prevailed elsewhere in the NHS. How has it been done? 'It's a combination of factors,' says Professor Richards. Certainly improved IT and the increased diagnostic capacity have played a part.

But Professor Richards cites neither as his top factor: 'The first and most important is senior clinical and managerial engagement, or what I would call grip and leadership. That is absolutely critical.'

Janet Williamson, national director of the Cancer Services Collaborative, agrees. 'You have to have senior executive leadership and the clinical directors engaged, as well as good team-working at all levels,' she says.

Since March 2005, the collaborative has sponsored 28 demonstration sites for all three cancer targets (two-week wait from referral to seeing a specialist, 31-day wait from referral to decision to treat and the 62-day target).

The most successful trusts have an attitude of wanting to make a difference for cancer patients rather than setting a goal. 'There's a subtle difference,' says Ms Williamson.

She and Professor Richards both cite good data as key: knowing not only who patients are but also where they are at any time so hospitals can steer patients through the care pathways, dealing with blockages as they arise. 'Many of the successful trusts have introduced pro-active pathway management with real-time patient tracking,' adds Ms Williamson. 'They can take action or escalation if a patient gets stuck.'

Next comes managing these pathways, says Professor Richards: 'It's about being completely clear about what your pathway should be and, if necessary, redesigning it with the patient in mind.'

For example, patients with suspected colorectal cancer have historically been referred to a surgeon, who then decides an endoscopy is needed, so they join a queue. The results go back to the surgeon who decides a CT scan is needed and the patient joins another queue. It takes time.

The pathway can be redesigned, says Professor Richards. Some places now have a straight-to-test policy where the GP referral triggers an endoscopy clinic booking. Others have a 'one-stop shop' where the flexible sigmoidoscopy clinic appointment is held at the same time as the outpatient appointment with the surgeon.

Ms Williamson draws out another lesson. Each pathway for each tumour site needs individual attention from its own multidisciplinary team.

'Inevitably, several changes are required to any given pathway,' she adds. 'It may appear that diagnostics is the problem, but if you cannot move patients from diagnostics to a decision to treat a new bottleneck will appear.'

In general, the best-performing trusts have adopted the collaborative's high-impact changes for cancer, published last February. In essence, it advocates a single route in to services; patients going straight to test; pooled referrals rather than separate lists for each consultant; and treatment decisions made by the multidisciplinary team.

Will improvements continue? 'The challenge over the next year is going to be sustainability,' says Professor Richards. 'Trusts fall into three groups,' he says. The first has redesigned pathways in a sustainable way. The second is still struggling. The third has achieved the target in a relatively unsustainable way - for example, by seeing patients at 50 days and reorganising services to start treatment inside the target.

Ms Williamson reckons around one in four trusts has made sustainable change, which she defines as meeting the target for six months.

The single best indicator of whether a trust is nearing sustainability is a short time between referral and decision to treat. 'If your interval is more than 50 days, it is putting a lot of pressure on your treatment services.'

Professor Richards has another trick up his sleeve to keep people on their toes: 'If we go back a couple of years, we had patients waiting months and months for cancer treatment. It's radically different today but we still have further to go. We are committed in the election manifesto to do just that and we are now turning our attention to it.'

In other words, expect a new target soon. Will it be a 62-day wait for all cancer patients, not just those referred urgently? Professor Richards won't say. 'We are still working on what a target might look like, but the commitment is there.'

The urgent referral 62-day wait is the first end-to-end target, so has lessons for the 18-week referral to treatment target for all patients by 2008. Professor Richards cites three key points.

'The first is about the need for combined clinical and managerial leadership, nationally and locally,' he says.

The second is measurement. 'We have to know who these patients are and measure where they are on the pathway. It is useful to be able to measure individual elements such as elective waiting times and endoscopy waiting times, but we also have to measure the whole pathway.'

Finally, achieving the target will require a 'whole pathway' approach. 'We need to look at care pathways not just by disease but also by how patients present,' says Professor Richards. 'For example, a pathway for back pain.'

Given that there are scores if not hundreds of pathways, Professor Richards' final word might seem obvious: 'We need to start now.'