World class service in radiotherapy

Radiotherapy is on the edge of a great opportunity to deliver a world class service. The National Radiotherapy Advisory Group (NRAG) report along with the Cancer Reform Strategy (CRS) have clearly set a framework for correcting the under provision of radiotherapy across the country.

The present financial climate, along with the current political landscape suggest, some real uncertainty over longer term plans for service development and expansion. No-one doubts the difficult challenges ahead. During these times, it’s essential that patient care is not compromised and that an efficient health service is maintained.

Radiotherapy is just one aspect of care, but is an area that is relatively low profile, both in the public and healthcare fields, compared to other cancer treatments such as chemotherapy.

It is our focus in the National Cancer Action Team to achieve goals set in the World Class Radiotherapy Programme and help raise the public profile of radiotherapy. This demands improvements in both quality and quantity. Building quality requires implementation of advanced technology to allow clinicians to deliver the best results, whereas capacity involves timely access and availability of treatment for all patients.

It is not sufficient just to quote the NRAG Report or the CRS to ensure engagement with commissioning plans; setting radiotherapy clearly within the QIPP framework allows both commissioners and service providers to understand the full service and economic benefits of the radiotherapy programme. Evidence based discussion is essential.

Overcoming the hurdles

Radiotherapy is involved in the treatment of approximately 40 per cent of cancer patients who are cured of their disease. It is an important and cost effective anti-cancer therapy. However, according to the NRAG report in 2007, the provision of radiotherapy is below what’s expected. It identified a large gap (63 per cent) between current activity levels and optimal treatment levels, if radiotherapy were to be given to all who might benefit from it.

NRAG estimates that there is a two and a half fold variation in the number of fractions (the attendances for radiotherapy a patient needs during treatment) that are provided per million population between cancer networks. This is regarded as an unacceptable variation, so networks and local commissioners in lower providing areas are being challenged to more accurately model their radiotherapy requirements, review their cancer pathways and commission more fractions for their populations.

By the end of December 2010, service standards will have been implemented to provide improved patient access to radiotherapy so no patient has to wait longer than 31 days for treatment. NRAG estimates that by 2016, the NHS will need to deliver around 2.9 million fractions across the country – this is around 54,000 fractions per million population, but is subject to local modelling depending on demographic and population needs.

Added to this, approximately 60 per cent of cancer sufferers are over 65 and with improving health technology and increasing life expectancy, there is likely to be a greater demand for cancer care and therefore radiotherapy across the country.

So, how do you treat more patients within the same resources, reduce waiting times and improve outcomes?

Optimisation is key

To meet these NRAG standards, it’s important for health services to map out and understand existing provisions before diving into major re-structuring processes – you wouldn’t order new drugs without first checking what’s already in stock, and the planning process for radiotherapy shouldn’t be any different. It’s therefore vital to make the best use of available resources and demonstrate value for money.

Having accurate data on areas such as existing performance across healthcare organisations (e.g. through the National Radiotherapy Dataset), identifying areas of high achievement and those in need of improvement, helps justify areas of spend and allocate time, money and resources to those who need it most and where it will achieve the biggest impact.

With budget cuts looming, any proposals for change will need to be backed up with evidence and a strong business case to gain financial support from commissioners. And it is technology that can help ease this burden.

Tackling targets with technology

The National Radiotherapy Capacity Planning Tool (R-PORT) is a web-based tool which has been developed in partnership with Concentra and widely used by radiotherapy units across the UK over the past year. It is currently operating in 25 of 28 cancer networks, aimed at all 49 radiotherapy services on 54 hospital sites.

The tool helps provide radiotherapy service improvement by allowing healthcare providers and commissioners to assess current service analysis, undertake scenario modelling, financial analysis and reporting of the impact of any change. It takes into account all resources, from personnel and equipment, to patient demand and seasonality. Results can then be compared at a local or national benchmark level. It is often the case that issues vary in each area of the country, so there is no ‘one size fits all’ solution.

The main benefits of using R-PORT can be summarised below:

1)     Transparency – PCTs need to show they are looking at effective local commissioning. R-PORT can give an accurate setting of any service in the NHS

2)     Improve operational efficiency – it’s important to be able to make strong fact based business cases for change, where necessary supported by analysis and evidence.

Focusing on people power

With workforce planning being a major factor for healthcare professionals to consider, this technology gives them easy access to performance levels across the UK.

R-PORT is based on competencies within the workforce, from clinical oncologists and physicists to radiographers, identifying the best placed person to do specific tasks. This capacity management is a fundamental way of resourcing radiotherapy departments – it’s no longer about job titles, it’s about the patient pathway and skill sets of the individuals.

For example, a trust based in the south east recently looked at its staffing resources and levels available. After carrying out a cost and performance analysis, it found that a certain number of staff gave the best performance or throughput, but found that actually adding more staff to the process, through the principle of diminishing returns would detract from the efficiency of the overall service provided.

The future of radiotherapy treatment

Developments in radiotherapy, over the next few years, to progress the quality of service are already being rolled out. Intensely Modulated Radiation Therapy (IMRT) shapes radiation beams to closely follow both the shape and profile of the tumour, allowing the potential for an increased dose of radiation. Benefits include, improved quality of life, potentially reducing side effects and so saving medication and ongoing care costs but also improving cancer control rates.

The second, Image-Guided Radiation Therapy (IGRT), involves conformal radiation treatment guided by specialised imaging. This is done in the treatment room just before and during the daily radiotherapy treatment to improve accuracy.

It is these creative and exciting developments emerging, combined with accurate radiotherapy data sets, which will help radiotherapy reach its world-class vision and hit the quality standards. Delivering world-class radiotherapy is about improving quality as well as quantity.

Traditionally it has been a challenge to invest in radiotherapy as it has a high initial cost outlay and is often therefore (inaccurately) seen as a high cost service. However, we’ve seen it’s possible to provide a strong case for improving efficiencies in radiotherapy care, using technology to prove the value that can be added from making changes.

World-class anything is a goal that constantly moves; just when you think you’re there, you find the gold standard has moved on. So, to truly achieve world-class radiotherapy we must reach for what is not yet in sight, and effective planning for the future will help achieve this.

Top tips to help achieve improved radiotherapy care:

• Delivering world-class radiotherapy requires engagement of the whole health economy – we are all part of the solution and need to work together through whole system tools.
• It’s important to provide strong reasoning and evidence for changes to the radiotherapy system, and technology can help with this.
• Nationally developed tools and systems will require local application and adjustment, as the issues are often different in each area of the country.
• Developing a workforce plan requires a system based on competencies, rather than job titles.