August 2018

NHS Wales plan to introduce a Single Cancer Pathway (SCP)

The latest National Oesophago-Gastric Cancer Annual Audit report shows that 50% of patients are waiting over 60 days from referral to radiotherapy and chemotherapy and over 90 days for surgery. About 7 years ago the Upper Gastro Intestinal (UGI) clinical community in Wales noticed that despite what seemed a long and complicated diagnostic and cancer staging pathway for patients with oesophago-gastric cancers, the system was reporting near 100% compliance with the Not Urgent Suspected Cancer (nUSC) Cancer Waiting Time (CWT) target.

The overall majority of cancer patients (55-65%) are diagnosed via the n-USC route, as patients typically present to emergency departments or their diagnosis is picked up following a test that was not requested via the USC route.

More worryingly is the high proportion of patients presenting with UGI malignancy (up to 70 to 80% in some Health Boards) present via this nUSC pathway. For these patients even when the tumour is seen at endoscopy and the patient had waits for CT scan, CT-PET scans, endoscopic ultrasounds and MDT decisions, the CWT clock only starts when the patient accepts the treatment plan, usually just before start of treatment.

At the then Welsh Health Minster’s request the clinical community was asked via the National Specialist Advisory Group (NSAG) to consider what the best measure of cancer waiting times would be. Their response was that waiting times were important (delays adversely affect patient outcomes and experience), and that 62 days should be the longest time any patient should wait for treatment. Patient focus groups said they wanted information on how long they would be expected to wait and they wanted assurance that they would not come to harm through waiting.

Due to these concerns Welsh Government (WG) then indicated they would consider what a single CWT target for all would look like. This single suspected cancer pathway (SCP) would record and report all patients from the point of suspicion (PoS) of cancer be that through primary care suspected cancer referral or other routes to diagnosis (e.g. radiology, endoscopy, A&E, secondary care inpatients/outpatients).

It was clear therefore that the system is:

  • Not reporting the actual patient experience
  • Not reporting the pressures in the diagnostic system.
  • Not driving improved performance through improving the causes of delays

Single Suspected Cancer Pathway (SCP): A single suspected cancer pathway would measure CWT from the point of suspicion of cancer.

  • For current USC referrals there is little change except the clock starts at the date the GP referred the patient rather than receipt of referral by secondary care.
  • For current nUSC routes to diagnosis the time the clock would start is from clinical point of suspicion, when a clinician refers and/or requests a test thinking cancer, with as a minimum the point being the same as NG12 NICE Guidance on Suspected Cancer.

CWT pathways and performance, and diagnostic workforce/infrastructure issues are similar in England and Wales as evidenced by respective Government statistical reports, National Clinical Audits and the International Cancer Benchmarking Partnership (ICBP). Whilst Wales is the first home nation to pilot the SCP, England is considering adopting the Faster Diagnosis Standard (FDS). The learning derived from this change to the SCP and from the FDS will support efforts across the UK to improve cancer outcomes.