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Conference Coverage

BTOG 2018: Session provides update on National Optimal Clinical Lung Cancer Pathway

Background

  • The National Optimal Lung Cancer Pathway (NOLCP) was created against a background of poor compliance with 62 day waiting targets, Independent Cancer Task Force recommendations to provide a definitive diagnosis by day 28 (50% by 2 weeks, 95% by 4 weeks), the National Multidisciplinary Team project that aimed to reduce multidisciplinary team (MDT) discussions, and the need to improve efficiency in a stretched NHS.
  • The NOLCP aims to achieve fewer emergency admissions due to rapid process at the front end of the pathway, better use of cancer clinics, achieve cancer waiting times, reduce variation in diagnosis, staging and treatment, result in fewer MDT discussions, improve survival, and achieve a better patient experience.

What’s new:

  • NOLCP was approved by NHS England in August 2017.
  • Implementation of the pathway has occurred at Liverpool Heart and Chest Hospital (who achieve Chest X-ray to CT in 3 days); Crawley CCG, Horsham and mid Sussex CCG, University hospitals of north midland have achieved marked improvements in time to outpatient appointments and MDT review; and the Manchester RAPID pathway has achieved time to outpatient appointment within 4 days with reported CT and 77% to MDT by day 21.
  • The pathway can highlight system problems, e.g. in Manchester the pathway revealed difficulties accessing PET CT, allowing clinicians to provide evidence of need to managers.
  • The need for greater efficiency was identified including matching imaging reporting with acquisition, following protocols, avoiding MOT discussion (instead use expert help within service/ network), improvement of pathology processing (onsite for all tests) and improving treatment planning and scheduling.
  • The need for more capacity was identified, including reviewing the role of staff, using admin to take away unnecessary paperwork, employing locums to relieve consultants of non-specialist work, outsourcing of non-speciality work, training nurses to manage pathways, more reporting radiographers and recognition proceduralists may not need to be doctors.
  • Metrics need to be measured to ensure pathways are not overused, including appropriateness of referrals, with feedback systems to flag up GP practices overusing the service. Improved primary care tools are needed to accurately assess cancer risk.
  • Recognition is needed that some patients (especially the frail elderly) may find the pathway diagnostic process too quick and require support from specialist nurses.

Key features of the pathway

  • Chest X-ray reporting within 24 hours.
  • CT within 72 hours of referral (emergency admissions should have CT within 24 hours).
  • Clinic within 5 days of referral.
  • Multiple tests but sequences (especially PET first).
  • Pathology turnaround – 3 days to subtype, 10 days to full analysis.
  • Treatment – 3 working days to clinic, 14 days to treatment from MDT decision to treat.
  • Specialist supportive care for all stage 4 patients.
  • Curative intent pathway.
  • Direct to biopsy can be used for patients with advanced disease (curative management requires PET scans).

References


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