These updates and reflections are written by Louise Paton, a co-researcher with Q Lab. Co-researchers work alongside the test team to support them to distil and communicate their learning and progress.

“I am Louise and I work as a Clinical Vascular Scientist, which means that I perform diagnostic ultrasound examinations to assess problems with circulation throughout the body. I have worked in a hospital as a healthcare scientist for over 12 years, first starting in London where I completed my training and now in Surrey at Frimley Park Hospital.

I decided to get involved with Q Lab as a co-researcher because I am keen to widen my experiences within healthcare, to broaden my understanding of different specialities and to hopefully help address the problem with delays in elective pathways. I hope that my clinical experience will help me to understand and relate to problems that the test team are having but that I will also be able to bring a fresh perspective and new ideas to discuss with the wider improvement community.”

Finishing the first phase of the Lab

May 2024

This marks the concluding report from the Aneurin Bevan team after the 9-month lab process, which has proven both productive and challenging. Despite the relatively short timeframe, the improvement project has gained momentum and yielded tangible results.

To recap

The primary aim of the project was to ensure that the pathway from the Point of Suspicion to the Decision to Treat adheres to the 28-day target. Analysed data from the past three years revealed that this target is rarely met, with an average duration of 55 days, effectively doubling the intended timeframe.

The significance of this goal is emphasised by a recent study published in the Annals of Surgical Oncology by Rygalski et al. (2020), which retrospectively examined 37,730 patients diagnosed with head and neck cancer. The study concluded that a delay of one month in receiving surgery correlates with a 4.6% increase in the risk of mortality. So, any delay in reaching the decision to treat directly impacts survival rates.

Early impact

Remarkably, the team has successfully trimmed the duration of the pathway by a month. Previously, patients waited up to 15 days for their initial clinic appointment. This has been reduced to 2-6 days. This achievement was facilitated by implementing a ‘straight to book’ system upon referral receipt, devised by two head and neck consultants. They compiled a list of keywords for patient identification and direct booking into consultant clinics, bypassing triage. This approach has expedited patient access to consultants, covering around 50-60% of referrals.

The most substantial improvement has been observed in access to ultrasound scans. Previously limited to three sessions per week, through upskilling existing staff and employing more specialists, there has been increased capacity to 11 sessions per week. Although not for the sole use of ear, nose and throat (ENT) referrals and at additional cost, this has had a significant impact on the pathway. Consequently, the wait time for scans has been reduced by 18 days, with there now being no significant waiting period.

Feedback from patients

The team has conducted a feedback survey among patients and analysed the results. Overall, the feedback was positive, with patients expressing satisfaction with appointment timeliness. However, the main negative aspect was the significant travel distance to appointments, which the team is taking into consideration.

Key learning

The Aneurin Bevan team worked hard to engage the right stakeholders. This fostered a collective sense of responsibility for the process, and they were driven by a shared passion for effecting substantial change.

What has the team leant from this experience? They’ve realised the potential for change and the importance of collaborative efforts in addressing challenges incrementally, which enhances their likelihood of success. Achieving their goals demanded commitment and perseverance in overcoming obstacles. Despite their current achievements, they remain driven to pursue further improvements.

Securing funding to hire a specialist to develop a mathematical model marks a significant step forward. This model aims to predict patients’ likelihood of missing appointments, facilitating a targeted intervention strategy. Patient information will be shared with Macmillan cancer nurses to actively engage patients and enhance their participation in the process.

Next steps

Efforts are underway to amend clinic check-in procedures. Confidentiality constraints currently impact on obtaining comprehensive patient information, including contact details, affecting the timeliness of follow-up scans and tests. Addressing this issue is crucial for improving access to much needed diagnostic tests.

The team is committed to addressing additional areas for improvement. They aim to reduce the frequency of hospital visits for patients, which can be financially and logistically challenging. Consolidating multiple scans into a single-day visit at a centralised location can alleviate this burden. Moreover, expanding service locations can minimize patient travel distances, thereby reducing instances of missed appointments. There is current work on securing funding for additional equipment, which will enable the effective utilisation of multiple hospital sites, offering patients greater flexibility over location.

One section of the pathway that has not had much attention is regarding those patients who require a panendoscopy. This requires involvement of the theatre team and is the target of future improvement work.

Thank you for following the Aneurin Bevan team’s journey and I hope it has inspired you to take part in your own improvement project.

Update about the Aneurin Bevan test team: Engaging the stakeholders

January 2024

Following the last update on the Aneurin Bevan team, this post focuses on how the project has developed and the importance of stakeholder engagement.

Recognising and managing different priorities among stakeholders

The Aneurin Bevan team are focusing on reducing the length of the ‘Point of Suspicion to the Decision to Treat’ pathway for head and neck cancer patients. In addressing this issue, it was crucial to identify key individuals at an early stage. Initially, the team included head and neck consultants, the business manager, Macmillan nurses, the cancer services manager, and representatives from theatre and radiology. The consultants were aware of the substantial impact that streamlining the pathway could have on a patient’s outcome. Therefore, they demonstrated a willingness to invest time in exploring potential solutions to address this challenge.

Since the head and neck consultants were the driving force behind the project and lacked an in-depth understanding of how radiology services operated, it became challenging to identify crucial individuals. Understandably, for radiology staff this specific project was less of a priority, considering it was just one pathway among many, and they were unable to devote exclusive time to these improvement efforts. Similar constraints applied to the theatre staff, who faced numerous demands on their time and additional responsibilities. While the arrangement and access to theatre for panendoscopy procedures were crucial for the head and neck consultants, it represented just one portion of the duties managed by the theatre team.

General Practitioners (GPs) play a pivotal role in the patient journey and referral pathway. However, establishing successful and productive engagement with this widely dispersed group poses significant challenges. Meaningful interaction often takes place on an individual basis rather than through broader workforce initiatives.

Engaging patients

Another vital component in the success of the project is the involvement of the patients themselves. It had previously been discussed whether patients’ awareness of being on a cancer pathway would hinder compliance or not. Unfortunately, reaching out to this group has proven to be notably challenging, primarily stemming from a lack of inclination within the target demographic. This reluctance may be attributed to patients feeling intimidated by the circumstances. This is an area in which further work is being undertaken.

The current length of the pathway had been identified as a significant problem before the Q lab opportunity arising but there was a lack of sufficient funding available to enable any time to be spent focusing on it. When it became possible for the project to be funded externally, there was a large appetite for it to begin as the wider cancer network knew that targets were not being achieved. The Q lab has allowed the team to come together and at the same time provided a structured, well thought out approach to progress the work.

Next steps

Most of the staff involved in this project have shown eagerness to contribute, but the challenges lie in high clinical workloads, resulting in delayed responses to emails and difficulties in coordinating everyone’s availability. Consequently, information discussed in group sessions may need to be conveyed and reiterated multiple times to those unable to attend, impeding overall progress. The approach now involves working with the aspects under more immediate control and collaborating with those who are currently available. This necessitates breaking down the problem into smaller, manageable sections, allowing for a step-by-step approach to tackling the issues.

The team will now focus on two specific areas for prototyping and testing.

• Reducing patient wait times for initial consultant appointments by categorising referrals with keywords, allowing them to be ‘straight to book,’ and eliminating the need for consultant triage. This represents 50-60% of referrals.
• Introducing a ‘UCP’ (unconfirmed cancer patient) tag for patients awaiting clinical confirmation of cancer, streamlining bookings into a prearranged available daily time slot without the need for vetting.

We are waiting for the results of these two trials to see whether they can be adopted as permanent changes in procedure.

Update about the Aneurin Bevan test team: Research and discovery phase

October 2023

After having a few months to reflect on the problem, the Aneurin Bevan team have been working hard to gather research about their cancer pathway so they can identify the area(s) that are amenable to change in the next stage of the Lab process (“refine and define”). The team discussed some of their research at the first Lab workshop (read more about the workshop in this blog post).

The “research and discovery” phase has allowed the team to analyse the different stages of the pathway and identify how long each step typically takes. Initially, they are interested in looking at the pathway from the Point of Suspicion to the Decision to Treat, which should meet the 28-day target. Data gathered from the past three years shows this target is very rarely met, with the average taking 55 days, which is effectively twice as long. Given that each day wasted could ultimately impact patient care and patient outcomes, the team wanted to understand where days were lost and what could be done to minimise this.

How Aneurin Bevan’s team understand the problem

• The pathway that the Aneurin Bevan team are focusing on typically includes the following steps, with delays occurring at different stages:
  A patient with possible cancer symptoms is referred by their GP, an emergency department, or another hospital department.
• When the referrals are received, the information is transferred to the hospital system for the medical team to triage and then go back to the administration team for booking into a clinic. This process of transferring information can take time, which means there are delays from the outset for patients to be seen in the 1st outpatient clinic.
• After being assessed in the clinic, diagnostic tests may be required to determine if it is indeed cancer, which can include an ultrasound scan of the affected area. The information collected by the Aneurin Bevan team showed that patients could be waiting excessive amounts of time for these scans, which then affects how quickly they can progress to have a panendoscopy and biopsy taken because the scan needs to happen first. In an average week, 66 patients will be referred to the team with a possible cancer. Of these, 15-20 patients will require an ultrasound scan. The capacity of the radiology department to carry out these scans has been assessed to be 30 scans per week, but despite the demand not exceeding the capacity, scans do not happen at the speed they should.
• Any samples then need to go to pathology for assessment before a diagnosis can be given, causing further delays.

One final area that has been identified as causing potential delays is the patients themselves not placing attendance to medical appointments at a high level of importance. This could be because they are unaware of the potential seriousness of the situation and that they are being tested for cancer. That leads us to ask two key questions:

• If more patients realise that undergoing tests quickly is essential, would they prioritise attending appointments over other life commitments?
• What effect does either knowing or not knowing that they are on a cancer pathway have on a patient’s compliance?

The team seek to gain a better understanding of patients’ experiences and barriers to attending the necessary appointments by opening discussions with patients. The findings from these discussions can inform the pathway for action. The Aneurin Bevan team are motivated and committed to this improvement project and working hard to get full participation from those involved at each stage of the pathway, so we are hopeful that positive changes can happen.

Introducing Aneurin Bevan University Health Board

August 2023

Aneurin Bevan University Health Board, Wales, works across multiple sites and departments. The team is comprised of specialist nurses, doctors, and administrators all looking to improve the cancer pathway for people suspected of having head or neck cancer. There is currently variability in how long patients wait with the 62-day target often not met which ultimately impacts patient experience and potentially patient outcomes.

The team is keen to try to improve compliance with the target, understand how and why delays occur, and what can be done to minimise them. The focus of the work will be on the first 28 days, which is from the point of suspicion to receiving a decision to treat. This period and the stages involved are mapped out on a national optimal pathway which will be useful in identifying the problem areas.

The project will involve collaborative working, trialling of new methods, and working to gain a better understanding and insight into the journey a patient takes. This has already begun with ‘patient A’ sharing their experience of the cancer pathway and will hopefully be a start towards continuous improvement. Involving patients in the process is crucial as their views and perceptions are always important to consider. Overall, the team hopes to reduce the number of patients on the waiting list and make a tangible improvement in the pathway.

Conclusion

The project is ambitious but also very necessary as achieving the 62-day target should be a priority for all cancer services. If patients can receive timely treatment, they can maintain a better quality of life which I feel is an important measure of success.

I am hopeful that a combined effort will enable steps in the right direction and have a positive impact on patient outcomes which is ultimately what everyone wants to achieve. As my work is in diagnostic imaging it will be interesting to learn more about the process that occurs after a test is performed, to see the full patient journey.

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