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Cancer care put through its paces

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VOL: 98, ISSUE: 12, PAGE NO: 32

Jo Luthert, MSc, RGN, HDipHV, OncCert, is coordinator, London Cancer Services Peer Review

How good are your trust's cancer services? How would you find out? You have probably used a variety of measures until now, but you will not have seen the whole picture.

How good are your trust's cancer services? How would you find out? You have probably used a variety of measures until now, but you will not have seen the whole picture.

Last year every trust providing cancer services in England was assessed against about 300 measurable, objective standards designed to provide baseline information about the quality of care provided.

Cancer care has had a high priority since the publication of the Calman-Hine report (Department of Health, 1995), followed by the appointment of the national cancer director in 1999, and The NHS Cancer Plan (DoH, 2000).

In December 2000, the DoH published the Manual of Cancer Services Standards. This draws on the Calman-Hine report and the evidence-based Improving Outcomes guidance (DoH, 1996-2001) for the four major cancers - breast, colorectal, lung and gynaecological - to establish national standards for cancer care.

These focus on the infrastructure for providing care, rather than on clinical outcomes, and cover: teamwork; core members of multidisciplinary teams; service policies and procedures; patient information; and communication with primary care. They are designed to reflect local and national issues that affect the delivery of cancer services, including equity of access, consistency of care and workforce issues, all key to achieving the targets in The NHS Cancer Plan.

At the beginning of last year, each trust assessed its performance against the standards, and this was followed by a peer review visit to validate the self-assessment.

This process identified whether standards were being met, and encouraged a supportive environment in which good practice and solutions could be shared to overcome any difficulties.

The manual and peer review process
The Manual of Cancer Services Standards contains 10 topics, each contributing to the patient pathway and the organisation of cancer services (Box 1). They follow the same format: the topic title; the objectives (one or more broad objectives to be met for each topic); and the standards (between two and 60 standards per topic) that need to be met.

The standards are split into three levels: Level 1*, then Level 1 and Level 2. Achievement of Level 2 is identified as good practice. Some standards represent a 'direction of travel', starting with achievement of Level 1*, progressing to Level 1, and on to Level 2. Each standard is clearly defined, together with the evidence required to show it is being met. The minimum standard of good practice is Level 1*, which has the highest priority.

Box 2 lists members of the core multidisciplinary team for breast cancer. This is a Level 1* standard, so it is a priority. The evidence required to show it has been achieved is a signed document recording the members of the core team, with a description of their role. It must show clearly that the members have agreed to being in the core team.

The peer review teams looked for this documented evidence, and proof that the core team meets regularly, that everyone attends these meetings, and that they discuss the best course of treatment for all patients with breast cancer.

The second example in Box 2 relates to the facilities required for administering inpatient chemotherapy. This is another a Level 1* standard with priority status. To identify that the standard has been achieved, the peer review teams visited units to assess the environment. They wanted to see documents identifying the name or location of the ward(s) used to administer chemotherapy, and a formal agreement that this was the acknowledged purpose of the area.

The peer review teams
This article uses the London region as an example of the peer review process. Other regions used slightly different methods but the outcome - to assess every cancer unit and centre against the standards - was the same.

The London peer review teams each had eight members (Box 3), supported by a peer review coordinator from the regional office. The teams were drawn from clearly defined professional groups, together with patient representatives, and were nominated by their cancer network with the agreement of their employers.

Ten teams were needed to visit 29 trusts in the London region, each undertaking no more than three visits lasting two days.

Wherever practical, the teams visited trusts within one cancer network to enable them to build up a picture of how this operated, and how the relationship between the network's cancer centre and cancer units worked in practice (Box 4). The teams did not visit trusts in their own network.

Each peer review team member attended a training day which aimed to:

- Put the peer review process in the context of The NHS Cancer Plan;

- Familiarise team members with the paperwork associated with the process, such as the Manual of Cancer Services Standards, completed self-assessments, and peer review visit reports;

- Identify how to collect and review the evidence to support meeting the standards;

- Rehearse how to approach interviews with trust staff and gain experience of working as a team;

- Provide an opportunity to meet a manager from a trust that had had a peer review, a previous team leader and a team member, to find out what it was like and how the trust felt about being scrutinised.

Peer review visits
A two-day programme was agreed with each trust in advance. Every topic completed in the self-assessment was reviewed, using documentary evidence and interviews with staff. The trust lead cancer nurse and clinical nurse specialists were interviewed, and ward-based nurses met members of the team as they visited areas in the hospital.

The visits started with a meeting between the peer review team and trust staff. This was to understand how the trust worked within the network, and how the patient population was served by the trust. Topics were then reviewed in turn, with team members completing a written report for each, and preparing a verbal report for the trust at the end of the second day.

Reporting structure
A reporting structure was developed to show clearly whether the peer review team agreed with the trust's self-assessment. This identified where a trust had not complied with Level 1* and Level 1 standards (the priority areas) and where it had met Level 2 standards (good practice).

The team's report provided detailed explanations of any shortfalls in services, what the trust might wish to consider or review to rectify them, and any other factors that might help to achieve the standards. The trust was then asked to work with its cancer network and health authority to identify a timetabled action plan to achieve any outstanding Level 1* and Level 1 standards.

Each regional office established a quality monitoring group to oversee the peer review process, the trust action plans, and whether trusts achieved the standards.

If the peer review team identified serious concerns regarding an aspect of a service (where it was considered that patient safety might be at risk), this was reported to the quality monitoring group.

The monitoring group's ultimate sanction would be to stop a trust providing cancer care if it continued to fail to achieve Level 1* and Level 1 standards, or failed to take the agreed action to remedy a patient safety issue. So far this has not happened in the London region.

Visit outcomes
It is easy to dismiss peer review as a labour-intensive, bureaucratic procedure with little benefit for patient care. But the process has a number of immediate benefits and is intended to improve services in the long term.

Trusts that approached the initiative with a positive outlook took the opportunity to review their services and work to meet the standards. It gave them a period of reflection within a safe environment - assessed by their peers against transparent standards.

The initiative provided the opportunity to identify areas of good practice in every trust, which were then published on a region-wide website (

This encourages professionals to see the process as supportive and to work within and across networks. It also gives trusts with shortfalls in some areas the chance to liaise with colleagues who may be able to offer ideas for solutions and support.

For peer review team members, the process provided valuable opportunities for professional development as they were learning from, and sharing expertise with, colleagues in other trusts and other disciplines.

The process was not without problems. It was time-consuming and this is likely to increase as more guidance documents are added to the process. There were often feelings of anticlimax at the end, particularly for trust staff, and there was a tendency for them to hear only the criticisms, not the good practice found in every trust.

This is a challenge for those involved in the next stages of the process. One lesson to be learnt is that trust staff need as much training and preparation for the process as the peer review team.

Implications for other services
The peer review process will take place again next year. Until then, monitoring progress against action plans will continue at regional and network levels. Some trusts will be revisited to assess their performances in areas of concern. Some standards will be revised in advance of the next review.

Although this process has been established for cancer and palliative care services in acute trusts, it may well be applied in other services, particularly as other national service frameworks are published.

The initiative aims to tackle inequalities in cancer care and to put the patient at the centre of care - values that should be the same for any NHS service.

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