Going Further on Cancer Waits: The Symptomatic Breast Two Week Wait Standard

A guide to support implementation

National Cancer Action TeamNHS Improvement

July 2009

Contents

Aim of Guide

Executive Summary

Background to the Symptomatic Breast 2ww Standard

The Symptomatic Breast 2ww Standard

Supporting Sustainable Delivery of Symptomatic Breast 2ww Standard

Information from units already delivering the Symptomatic Breast2ww Standard for all referrals

Conclusion

Further Information & Support

Annex A - Readiness to Implement (summary of Oct 08 questionnaireresponses)

Annex B - Implementing the Symptomatic Breast 2ww Standard(summary of Jan 09 workshop)

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Aim of Guide

This guide seeks to support cancer networks, trustsand breast units working to deliver thesymptomatic breast 2ww standard. It sets out:

• background to why this standard was introduced;

• technical information related to implementationof the standard;

• information to support sustainable delivery of thestandard including advice on how to ensure thereare effective breast pathways in place and skillmix considerations;

• information from breast units that are alreadyimplementing the standard including: how theyachieved it, challenges they faced andsuggestions for those getting started;

• where to go for further information and support.

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Executive Summary

1. The symptomatic breast 2ww standardgoes live (ie. is due to be implementedacross the NHS) from 1 January 2010.

2. Data on performance against thesymptomatic breast 2ww standard shouldhave been collected locally from 1 January2009 (in accordance with theDSCN20/2008 mandate) and should havebeen uploaded on to the Cancer WaitingTimes database (CWT-Db) from 30 April2009.

3. A small number of units are already seeingall patients with breast symptoms on a2ww pathway but evidence from areadiness questionnaire in October 08 plusdata already submitted to the CWT-Dbsuggests that many units may still havesome way to go if they are to achieve thisstandard by 1 January 2010.

4. Key to implementing the symptomaticbreast 2ww standard are:

• good data capture systems – theseshould ensure that all relevant data arecaptured and available (preferablyelectronically and linked to othersystems such as PAS) and that progresscan be tracked with minimal manualintervention;

• effective pathways – these shouldensure that good clinical care (asoutlined in relevant NICE guidance) isprovided through a robust system thatoffers quality, timely, equitable and“value for money” services;

• good prospective patient managementand navigation systems – these shouldensure that you know where patientsare in the system and allow you tonavigate them through the pathway sothat they are in the right place at theright time receiving the right care.

5. In addition, implementation of the 4 HighImpact Changes identified by NHS

Improvement for cancer service pathwayswhen the original CWT standards wereimplemented have been shown to reducewaiting times, improve performance andhave a direct impact on the quality of thepatient experience. These are:

• one route into the system;

• straight to test approach;

• timely decision making;

• appropriate follow-up.

6. Achieving this standard will ensure that allpatients with breast symptoms benefit fromfaster care pathways (2ww and 62 days).This should improve their experience of theservice and could also, potentially, improvetheir outcome.

7. There is no one size fits all approach tohow the symptomatic breast 2ww standardcan be implemented. In some units, extracapacity has been created by providingtraining to support the development ofadvanced practitioner roles. In other unitsextra clinics have been created, and insome, separate clinics have been set up tomanage different patient cohorts such asthe under 35s.

8. Sharing practice and learning from differentunits should help other breast units withthe challenge of delivering this standard by1 January 2010.

9. Sustainability is unlikely to be guaranteedwhere pathways are designed to fit themaximum waiting time ie. 2 weeks. Truststhat generally achieve consistent deliveryand sustained performance of cancer waitsstandards have pathways that deliverwithin the standard timescales.

10. Further information is available atwww.improvement.nhs.uk/cancer. CancerNetwork and Trust Service ImprovementLeads are also a source of support.

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1. Background to the SymptomaticBreast 2ww Standard

1.1. The NHS Cancer Plan (published inSeptember 2000) summarised a number ofservice standards relating to waiting times.This included a 2 week standard (2ww)from urgent GP referral for suspectedcancer to first hospital assessment.

1.2. The Cancer Reform Strategy (published inDecember 2007) noted that the currentcancer waits service standards did not applyto all cancer patients or treatments andthey would therefore be expanded toextend the range of patients who couldbenefit.

1.3. As part of this expansion the existing 2wwstandard was expanded so that any patientreferred with breast symptoms would beseen within 2 weeks, whether cancer wassuspected or not. This standard goes livefrom 1 January 2010 although Trustsshould already be collecting data for thisstandard (in accordance with theDSCN20/2008 mandate) and uploading itonto the National Cancer Waiting TimesDatabase (CWT-Db).

1.4. A key reason for introducing this standardwas that only about half of diagnosedbreast cancers were coming through theurgent 2ww route. For example, in Q3(Oct-Dec) 2008/09 there were 4581patients diagnosed with breast cancerfollowing an urgent 2ww referral comparedto 4539 patients diagnosed with breast

cancer following other types of referral(including from the screening service). As aresult there were a significant proportion ofpatients that were not benefiting from thefaster pathways (2ww and 62 days) thatcould improve, not only their experience ofthe service, but also, potentially, theiroutcome. The new standard aims toaddress this.

1.5. In October 2008 the National CancerAction Team (NCAT) issued a questionnaireto assess readiness in England toimplement this standard. Completion wasvoluntary. Results from 76 of around 170breast units were received and indicatedthat there was still some way to go if thisstandard was to be fully implementedacross the country from 1 January 2010.The position over the last 9 months is likelyto have moved on but the results of thequestionnaire are available, for information,at Annex A.

1.6. In January 2009 a small workshop wasorganised by NCAT to consider the resultsof the questionnaire and to seek viewsfrom delegates on issues such as how tomanage backlogs, how to overcomebottlenecks and how to increase capacityincluding the potential role of advancedpractitioners. A summary of the discussionsat the workshop are set out at Annex B.

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2. The Symptomatic Breast 2wwStandard

2.1. The symptomatic breast 2ww standardshould ensure that all patients (men andwomen) with breast symptoms (wherecancer is not suspected) are seen by aspecialist within 2 weeks of a referral beingreceived from their GP or other relevanthealth professional.

2.2. The standard covers breast symptoms notcovered by the NICE referral guidelines forsuspected cancer but that a healthcareprofessional believes still need to be seenby a specialist.

2.3. There are two types of breast referral thatare excluded from the symptomatic breast2ww standard. These are referrals:

• from family history clinics (unless apatient is symptomatic);

• for cosmetic breast surgery (such asenlargement or reduction).

2.4. The starting point for this standard (ie day0 when the clock starts) is the receipt ofthe referral for an appointment in theappropriate breast clinic (recorded as theCANCER REFERRAL TO TREATMENT PERIODSTART DATE on the CWT-Db). The referralcan be received either:

• direct from the GP or other healthcareprofessionals who may see a patient

with breast symptoms (recorded asORIGINAL REFERRAL REQUESTRECEIVED DATE on the CWT-Db); or

• via Choose & Book, in which case theUBRN CONVERSION (the UniqueBooking Reference Number conversiondate for an appointment) would markthe start of the 2ww period.

2.5. The end point for the standard would bewhen the patient is seen for the first timeby a specialist or in a diagnostic clinicfollowing the referral receipt. This isrecorded as DATE FIRST SEEN.

2.6. If cancer is confirmed the patient continueson a 62 day pathway for treatment.

2.7. If cancer is excluded the patient continueson the 18 week pathway.

See diagram 1.

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Diagram 1 - the symptomatic breast 2ww pathway:

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Diagram 2 - pausing the clock for the symptomatic breast 2wwstandard

2.8. There is only one pause (clock stop)allowed for the symptomatic breast 2wwstandard. This is if a patient DNAs (DoesNot Attend) their initial outpatientappointment ie. does not turn up and givesno notice. This would allow the clock to

effectively be re-set from the receipt of thereferral (recorded as the CANCER REFERRALTO TREATMENT PERIOD START DATE) tothe date upon which the patient rebookstheir appointment. See diagram 2.

2.9. The difference between the two types ofbreast 2ww standard we now have (urgentand symptomatic) are that:

• the urgent breast 2ww standard iswhere the GP suspects cancer;

• the symptomatic breast 2ww standard iswhere the GP (or other relevant healthprofessional) is referring a patient forbreast symptoms but does not suspectcancer.

2.10. Patients coming through the newsymptomatic breast 2ww route need to bedistinguished from the suspected cancerbreast 2ww patients by the data item 'TWOWEEK WAIT CANCER OR SYMPTOMATICBREAST REFERRAL TYPE' where:

• code 01 is suspected breast cancer; and,

• code 16 is exhibited (non cancer ) breastsymptoms.

2.11. It is necessary to differentiate between thetwo for monitoring the separate Vital Signsrequirements. The differentiation mightalso help to monitor appropriateness ofreferrals and therefore identify anyeducation needed about signs andsymptoms of breast cancer amongstrelevant healthcare professionals.

2.12. Data on the symptomatic breast 2wwshould have been collected from 1 January2010 (in accordance with theDSCN20/2008 mandate) and should havebeen uploaded on to the CWT-Db from 30April 09 when the updated database cameon line.You do not need to upload 2wwand breast 2ww data separately. All datacan go in the single monthly csv file, aseparate upload is not required.

2.13. You should make sure that you know thenext deadline for uploading data – a list ofupload deadlines is available fromhttp://nww.connectingforhealth.nhs.uk/nhais/cancerwaiting/prop_report

2.14. It is strongly advised that you do not waituntil the last available day to upload data

to the CWT-Db. You should leave time tovalidate data and some contingency to gothrough the CWT-Db’s three distinct phasesof validation. These are:

• Initial: where the format of the file ischecked, and the system confirms theNHS Number is valid;

• Cross-Field Phase 1: where the systemruns the logic tests (detailed within the.csv specification) that can be discretelyrun within a two week wait or 31-dayrecord. All records in a file must pass forthe file to be placed in the uploadqueue; and

• Cross-Field Phase 2: where the systemidentifies potential matched records thatare already in existence within the CWT-Db and then runs validation within 62-day records. All validations passed atPhase 1 are rechecked on the matchedrecords. Records that pass are savedindividually, failures are reported to theprovider and not saved.

2.14. Because of this phased validation process auser should not assume that any recordthat is accepted into the upload queue willbe saved on the CWT-Db. Users should login and check the following day, then makeany necessary corrections.

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3. Supporting Sustainable Delivery ofSymptomatic Breast 2ww Standard

3.1. When considering how best to implementthe symptomatic breast 2ww standardlocally there should be two over-ridingprinciples:

• patients’ needs should be at the centreof improvement work;

• the focus should be on deliveringeffective pathways, rather thandelivering performance standards.

3.2. There are three questions that you need tobe able to respond to positively if you areto ensure that you can deliver thesymptomatic breast 2ww (and the othercancer waits standards) in a sustainableway:

• do you have a good data capturesystem in place ie. to ensure that allrelevant data are captured and available(preferably electronically with links toother systems such as PAS) and thatprogress can be tracked with minimalmanual intervention;

• are effective breast care pathways inplace ie. to ensure that good clinicalcare is provided through a robust systemthat offers quality, timely, equitable and“value for money” services;

• does the team have goodprospective patient managementand navigation systems in place ie. toensure that you know where patientsare in the system and allow you tonavigate them through the pathway sothat they are in the right place at theright time receiving the right care.

Your Cancer Network or Trust Service ImprovementLeads should be able to offer you advice about howto take this work forward. In terms of ensuringeffective pathways are in place the following mighthelp:

Effective pathways3.3. The key action to take (if it has not already

happened) is to map and investigate therelevant patient pathways for symptomaticbreast patients (see diagram 1). As patientsthat go on to be diagnosed with breastcancer will continue on a 62 day pathway itis important to consider the whole patientpathway rather than just up to DATE FIRSTSEEN which ends the 2ww period.

3.4. Mapping the pathway(s) in your local areawill ensure that you can:

• define and understand the currentpatient process;

• identify delays, bottlenecks (ie. the stagein the patient journey which causespatients to wait), duplication and whereto begin measuring capacity anddemand;

• identify what/where are the specificconstraints (eg. lack of a specific skill orpiece of equipment);

• identify opportunities for improvementand key issues in service delivery;

• avoid reliance on one perspective ie. notjust focus on one part of the patientjourney;

• understand, capture and incorporate thepatients’ and carers’ viewpoints.

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3.5. If you put an effective pathway in place youwill ensure that:

• quality and timely care is delivered topatients throughout their breast carejourney;

• services are equitable and offer value formoney;

• cancer waiting times standards aredelivered in a sustainable way;

• minimum intervention and support isneeded in terms of tracking andnavigation as the pathways should‘automatically’ pull patients throughtheir journeys.

3.6. A Pathway Mapping Event with clearobjectives and scope, supported by keystakeholders, and attended by the relevantclinical, managerial and service leaders plusstaff involved in the relevant stages ofpatient care can be a useful first step. Atsuch an event it is suggested that each stepis mapped using “post it” notes ie: who(person), does what (action), where (place),when, to whom and with what (ie.equipment). Then each step is workedthrough focusing on what happens 80% ofthe time.

3.7. For each step it is suggested that you ask:

• can it be eliminated?

• can it be done in another way eg.separate clinics for follow up patients,family history patients etc?

• can it be done in a different order?

• clinics in the community?

• can it be done by someone else eg. by aspecially trained nurse instead of adoctor?

• can it be done in parallel eg. one-stopclinics for ultrasound, fine needleaspiration and clinical examination;

• can any “bottlenecks” be removed?

• does it add value for the patient?

• would patients find it an acceptableoption?

3.8. If you identify any potential changes it issuggested that they are tackled using theImprovement Model Approach ie. Plan - Do- Study - Act (PDSA) cycles. Your CancerNetwork or Trust Service ImprovementLeads should be able to advise on this.

3.9. Useful markers for whether you have aneffective pathway are that it:

• is agreed and understood by allproviders/stakeholders across thepathway and supported by protocolsand guidelines;

• has clear timings for each step withidentified escalation points andallocation of responsibility;

• is achievable well within the standardtime;

• includes the Cancer High ImpactChanges ie:

- one route into system;

- straight to test approach eg. onestop triple assessment clinics;

- timely decision making;

- appropriate follow up.

• has strong teamwork and a wellfunctioning MDT with clarity of role inpathway coordination;

• it is the sort of pathway we would wantfor ourselves and our families.

Skill Mix3.10. It is likely to be necessary to create

additional capacity to implement thesymptomatic breast 2ww standard. Use ofskill mix to enable different models of caresuch as nurse led assessment are optionsworthy of local consideration.

3.11. At the workshop held in January 2009 toconsider implementation of this standardthere was general agreement that therewas a need to focus on skills not peopleand that units should consider if it wasappropriate locally for certain healthprofessionals (such as nurses, radiographers

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and radiologists) to extend their roles intoareas such as:

• clinical breast examination;

• breast ultrasound;

• fine needle aspiration (FNA);

• punch biopsies;

• seroma care;

• supporting patients discharged withdrains.

3.12. It was suggested that the introduction ofan advanced breast practitioner role wouldenable different models of care to beconsidered locally to expand capacity suchas: nurse practitioner led clinics for followup patient and radiographers carrying outimage guided biopsies.

3.13. There was general agreement that anational training programme is notneeded.There are a range of existingcourses around the country suitable fortraining advanced practitioners. Localitiesneed to consider if this is a route they wish

to pursue and, if so, consider who to trainand in what. For example, a breast centrecould choose to train all their nursing staffto a certain level of breast care or certainindividuals to take on certain tasks.

3.14. It was suggested at the workshop thatnational criteria should be developed tosupport locally developed training and thata directory of training programmesapplying the national criteria should thenbe established. NCAT, the DH and NHSImprovement are taking this work forward.Further details of the workshop discussionsare at Annex B.

Conclusion3.15. Whatever the outcome of pathway

planning, skill mix considerations etc, it isrecommended that units/trusts/networksdevelop a delivery plan with clearmilestones and responsibilities forimplementation of the symptomatic breast2ww standard.

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4. Information from units alreadydelivering the Symptomatic Breast2ww Standard for all referrals

4.1. This section includes examples from breastunits that advise that they are delivering atwo-week wait for all breast referrals(urgent & symptomatic).

4.2. The approaches taken by the units aredifferent and the examples demonstratethat there isn’t a one-size fits all approachto how the symptomatic breast 2wwstandard can be implemented.

4.3. In some units, extra capacity has beencreated by providing training to support thedevelopment of clinical nurse specialistroles, in others, extra clinics have beencreated and, in some cases, this has

involved separating out clinics for newpatients from follow-up clinics ordeveloping clinics for specific patientcohorts such as the under 35s.

4.4. It is hoped that by sharing practice fromdifferent units and the learning from thosesites all breast units will be able to meet thenew national minimum standard by 1January 2010.

4.5. Practice from 7 breast units that report thatthey see all breast referrals within twoweeks is set out in this section along withkey messages that can be drawn from theinformation provided.

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Key messages from units seeing all referrals in two-weeks:• Strong leadership within the unit

• Culture in the unit is open to change and service improvement

• Buy-in and support from frontline staff in the unit

• Desire to implement a two-week wait for all breast referrals

• A ‘Can do’ attitude

• Communication between staff in the unit and other departments

• Developing skills within team to increase capacity

• Process monitoring and having a clear idea of demand and capacity

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Barriers identified by units achieving the 2ww standard:• Clearing any backlog and maintaining the standard

• Staff willing to support running extra clinics

• Managing increasing numbers of referrals and blips month to month

• Utilising Choose and Book efficiently for breast referrals

• New cancer waiting time rules and a lack of ability to make adjustments

• Don’t have enough clinics but have enough capacity

Best practice in achieving the 2ww standard:• Secure extra capacity, without impacting on other services

• Review the entire patient pathway to ensure efficiency, starting with referrals made by the GP

• Ensure access to clean and reliable data on demand and capacity in order to ensure processmonitoring

• Involve patients and staff in decisions about changes to pathways and processes

Patient involvement4.6. While meeting the symptomatic breast

2ww standard is unlikely to requiresignificant service re-alignment, breastunits, like Frenchay Hospital, havebenefited from consulting with patients ontheir experience to support achieving thestandard, including developing primary careservices. Results of past patients surveys,peer review or feedback gained fromparticipating in Breakthrough BreastCancer’s Service Pledge can be used toensure changes to services to achieve thestandard align with patient views.

Sharing best practice4.7. The examples that follow highlight seven

units that report that they are delivering atwo-week wait for all breast referrals. Weare aware that there are other units alsodelivering such a service and wouldencourage them to share their experienceeither with the National Cancer ActionTeam or with Breakthrough Breast Cancerso that we can promote best practice/different service models already underway.

Countess of Chester Hospital NHS

Foundation TrustUrsula Keyes Breast Care Unit

How is the breast unit achieving a two-week wait for all breast referrals?The unit increased capacity by starting clinics aquarter of an hour earlier, split new and reviewclinics and used evening clinics to clear existingbacklog. The unit has trained a clinical nursespecialist to see patients and created an extra cliniceach week for patients under 35.

Were additional resources needed?Training the clinical nurse specialist required someextra resource, but an existing session with theconsultant was used for the under 35s clinic.

What were some of the challenges inmeeting the standard?Putting on clinics in the evening and finding staff towork the extra clinics has been a challenge. It iswidely acknowledged within the unit thatconsultants are already being stretched as is theextra capacity from the evening clinics. However,overall, clinicians are happy to be involved and theprocess has gone very smoothly.

Suggestions for those just getting started?The advice from the unit is that you need to clearthe backlog. You need to make sure everyone inthe unit is engaged in the process and get supportto add additional capacity where needed, ie anextra clinic each week. Finally, ensure a consistentadministrative support is responsible for the unit’sappointments system.

Who has been the driving force behindachieving a two-week wait for all breastreferrals?The lead consultant surgeon in the unit has beenthe driving force.

For further information, please contact FionaCurtis, Cancer Manager atfiona.curtis@coch.nhs.uk

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King’s College Hospital NHSFoundation Trust

How is the breast unit achieving a two-week wait for all breast referrals?The unit has been meeting a two-week wait for allbreast referrals since 1999, based on their workshowing half of cancers were in the non-urgent group. All patients are seen by a consultantand while there are a set number of new patientclinics each week, additional clinics are added asneeded on alternate days in order to achieve a two-week wait for all referrals and thus match capacityto demand.

Were additional resources needed?No additional resources have been needed. Whathas been needed is flexibility in clinic schedulingand investment into the clinical and informationsystems within the organisation.

What were some of the challenges inmeeting the standard?Keeping the process monitoring going andconstantly looking for new ways to do things betterin the unit.

Suggestions for those just getting started?Start by making small changes (PDSA’s, learning bysmall successes and small failures) and build oneach them. Once you start achieving the wait,make sure you keep it up. Make sure you have yourprocess monitoring in place to identify upcomingissues.

Key principles at the unit are:

• Pull work in not push work away, so work hard tobring down waits, shorten the administrative timeand distance from referral to seeing a patient.

• Work hard at getting information back topatients eg. fax bookings within 10 minutes toGPs or to patients at work so they can get timeoff from their supervisor more quickly.

• Plan holidays, public holidays, conferences andplanned downtime well ahead of time. Smallplanned adjustments (extra clinics) work betterthan virtuoso efforts and don’t have clinicsoverrun.

• No named consultant booking or consultantupgrades.

• Flat service model, there is one kind ofappointment, behind that is the complexity.

• Emphasise providing service focussed on patientsnot targets.

• Clearly identifying process through protocoldriven information systems, which use workflowdocuments and not requests.

• Add value for every attendance a patient makeson coming to the unit.

• Allow all levels to provide their own solutions.

• Map out work to be done against who is bestable to provide it, rather than demarcating workto one professional group.

• Every episode of patient contact is important andpeople handling each one need access to theinformation and resource to meet patients’ needs.

• Aim for 10 days rather than 2 weeks - yourworking life will be that much better.

• Shorten cycle time between seeing, diagnosingand treating patients.

• Aim to see more new patients than follow-uppatients, aim to do all but reconstructive surgeryin day surgery.

• Strive for co-location for symptomatic clinics,

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King’s College Hospital NHSFoundation Trust...continued

breast imaging, oncology services, plasticsservices and gynae-endocrine support.

Remember:

“Do today’s work today” – Mark Murray IHI

“What are we doing next Tuesday?”

And finally make sure you feedback to everyone inthe unit on your progress. The number of patientsseen and current waiting times appear on all thecomputers in the unit to ensure all staff are awareof their progress – the benefits of hard work arevisible to all.

Who has been the driving force behindachieving a two-week wait for all breastreferrals?Achieving the wait has been a team effort but hasbeen led by one of the consultant surgeons.

For further information, please contact JonathanRoberts, Consultant Surgeonjonathan.roberts1@nhs.uk

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North Bristol NHS Trust Frenchay Hospital

How is the breast unit achieving a two-week wait for all breast referrals?An additional number of routine referral slots wereagreed and added to all clinics (clinics are not everyday). One of the clinical nurse specialists hasundertaken training in ultrasound and breastpalpation and is now responsible for the hormonaltherapy clinic. This has resulted in an additionalclinic for routine referrals by releasing theconsultant from the aforementioned clinic. The unitis currently piloting the use of a nurse practitionerbased in the community to enable additionalroutine referrals to be seen. Approaches toachieving a two-week wait and progress areconsulted on and monitored with patients.

Were additional resources needed?The unit has achieved the wait without anyadditional investment. The appointment timetablewas re-organised in order to fit in the extra clinicsand funding for training nurses was organisedthrough a joint pilot project with the University ofthe West of England and NHS Improvement.

What were some of the challenges inmeeting the standard?The unit would like to have facilities to offer allpatients, regardless of referral route, a full one stopclinic/diagnostic service. Currently only three clinicsper week are dedicated one stop clinics. Pathologyand radiology provide services for the whole trustbut can offer an informal one stop diagnosticservice outside of the designated clinics.

There are issues around year on year increases inreferral rates and how to keep up with demand.

Another challenge has been using Choose andBook and getting the appointments filled. When apatient rings the national central appointmentsoffice they might have been offered anappointment a month later when there were freeslots available prior to the date given. The unit hasonly just recently learnt that they can block thenational office from having access to appointmentsbeyond two weeks to encourage the administrationteam to look within all clinics for availability. This isworking. If all clinics are full, the Breast Care Centreis contacted and can overbook certain clinics toensure all referrals are seen in two weeks.

Suggestions for those just getting started?Units needs to have an up-to-date knowledge oftheir referral numbers and a better understandingof how to work with central appointments toachieve a two-week wait for all referrals. Clinicsand appointment slots need to be co-ordinated sothe unit isn’t constantly fighting fire.

Who has been the driving force behindachieving a two-week wait for all breastreferrals?It’s been a team effort, but one of the consultantsurgeons and a breast care nurse have encouragedthe unit to continuously provide a better service.

For further information, please contact Jane Barker,Breast Care Nurse at jane.barker@nbt.nhs.uk

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Doncaster and Bassetlaw Hospitals

NHS Foundation TrustJasmine Centre, Doncaster Royal Infirmary

How is the breast unit achieving a two-week wait for all breast referrals?The unit has always tried to maintain a two-weekwait for all breast referrals since 1997. They arecurrently striving for a 7 day wait. The unitincreased capacity by adding one extra clinic andthrough employing a nurse practitioner.

Were additional resources needed?The extra clinic was self-funding as a result ofpayment by results.

What were some of the challenges inmeeting the standard?Coordinating referrals between the two breastunits in the trust has been a challenge, as well aschanges to cancer waiting times and no longer

being able to make adjustments when one unitreceives a larger number of referrals than the other.

Suggestions for those just getting started?Speak with the local primary care trust and worktowards a solution which includes the local healthneeds, ie exploring the role of nurse practitioners inthe community. It is also important to be aware ofwhat type of service patients want.

Who has been the driving force behindachieving a two-week wait for all breastreferrals?It’s been a team effort.

For further information, please contact JackieSimpkin, Cancer Manager at

Jackie.Simpkin@dbh.nhs.uk

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Cambridge University Hospitals

NHS Foundation TrustAddenbrooke’s

How is the breast unit achieving a two-week wait for all breast referrals?The unit struggles at times to maintain a two-weekwait for all referrals. Additional clinics and using avarying number of slots throughout the week tokeep up with referrals, along with the use of nursepractitioners, has helped the unit continue to seeall referrals within two weeks.

Were additional resources needed?Resources have been needed for training the nursepractitioners and the team are at times carrying outextra clinics in their free time, due to limitedresources. Another consideration is that any extraclinic requires additional support and resourcesfrom pathology and radiology and admin staff.There are knock on effects and costs which areoften forgotten and therefore not planned orbudgeted for.

What were some of the challenges inmeeting the standard?Keeping capacity aligned to referrals can bedifficult, particularly if there is a blip in referrals. Itcan be difficult to plan when month to monthaverages vary by more than 100 patients. The unitalso has difficulty with Choose and Book ending upwith vacant slots which if they were allowed toclose earlier, they would be able to fill withpatients.

Suggestions for those just getting started?Ensure you have the agreement for extra resourcesin place before you start organising extra clinics,otherwise it will be difficult to gain the additionalresources.

Who has been the driving force behindachieving a two-week wait for all breastreferrals?Achieving the standard has been led by the leadconsultant surgeon at the unit, but the NurseConsultant has played an equally important role intraining and developing a nationally accreditedprogramme for nurse practitioners.

For further information, please contact DawnChapman, Nurse Consultant atdawn.chapman@addenbrookes.nhs.uk

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Princess Royal Hospital NHS Trust

How is the breast unit achieving a two-week wait for all breast referrals?The unit has been achieving the standard for manyyears. The key is not to have fixed clinic capacitybut to be able to expand capacity by the provisionof an overflow clinic. Also, the use of cytologywithin clinic reporting, alongside core biopsy, allowsfor fewer second clinic visits.

Were additional resources needed?No additional resources have been needed but alack of staffing has, at times, had a significantimpact on the unit’s ability to achieve the wait. Atone stage, the unit needed to insist that they wereno longer able to achieve the standard as a resultof breast care nurse and data manager posts notbeing replaced following retirement. Managementare aware of the problem and these posts havenow been recruited.

What were some of the challenges inmeeting the standard?Maintaining the standard with varying levels ofstaffing has been the biggest challenge. There havealso been ongoing problems with Choose andBook, as a result of patients being able to chooseto wait longer than two-weeks. Finally,incorporating over-flow clinics has been achallenge. The Wednesday clinic is scheduled to rununtil 18.00 but it sometimes runs over till 20.30(the unit chose this model rather than a separatelyscheduled overflow clinic).

Suggestions for those just getting started?Review and challenge poor models of working.Mammogram capacity is an issue so we havedeveloped an approach where only women whohave symptoms suggestive of breast cancer, or areat increased risk, are offered a mammogram. Anoverflow clinic is essential to cope with peaks indemand.

Who has been the driving force behindachieving a two-week wait for all breastreferrals?Achieving the standard has been clinically led. Forfurther information, please contact ChristopherHinton, Breast Consultant atchristopherhinton@tiscali.co.uk

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Guy's and St Thomas' NHSFoundation Trust

How is the breast unit achieving a two-week wait for all breast referrals?In 2005, the unit developed a Model of Care whichincluded an aspiration to see all breast referralswithin 2 weeks and a further aim to reduce this to48 hours from referral, regardless of being urgentor routine. The 48 hour wait to be seen at thebreast clinic was developed because the unitrecognised that two thirds of ‘routine’ referralsresulted in a breast cancer diagnosis.

Were additional resources needed?Implementing the wait has required advancednurse practitioners to support diagnostics clinics,along with two additional staff in radiology tosupport the provision of one-stop-clinics forpatients.

What were some of the challenges inmeeting the standard?Securing clinical and nursing support, funding,organisation, culture and sustainability.

Suggestions for those just getting started?Ensure you have engaged and gained the supportof all the key stakeholders, especially surgery,radiology and pathology right from the beginning.Having them on board and sharing the vision willmake achieving the standard and providing one-stop-clinics possible.

Who has been the driving force behindachieving a two-week wait for all breastreferrals?Achieving the standard has been led by the MDTlead and Director for the Integrated Cancer Centre.This has been with the complete support ofmembers of the breast unit.

For further information, please contact MaireadGriffin, Lead Cancer Nurse atmairead.griffin@gstt.nhs.uk

5. Conclusion

5.1. The symptomatic breast 2ww standardgoes live from 1 January 2010 and all Trustsare expected to be implementing thestandard from this date.

5.2. All Trusts should already be uploading dataon to the CWT-Db for this system (as perDSCN20/2008 mandate) so should be ableto see how they are progressing towardsthis standard and any shortfall they need tomake up in the next few months

5.3. Key to implementing the symptomaticbreast 2ww standard (alongside the othercancer waits standards) are:

• good data capture systems;

• effective pathways;

• good prospective patient managementand navigation;

• implementation of the 4 High ImpactChanges:

- one route into the system; - straight to test approach; - timely decision making; and - appropriate follow-up.

5.4. There is no one size fits all approach tohow the symptomatic breast 2ww standardcan be implemented but examples set outin this document show that sustainableimplementation is achievable.

5.5. Service Improvement Leads should becontacted for advice if needed.

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6. Further Information & Support

Information6.1. Further information to support

implementation of cancer waiting timesstandards can be found at:www.improvement.nhs.uk/cancer. Thisincludes:

• A Guide to Delivering & Sustaining theGoing Further on Cancer WaitsStandards Through Effective PathwayManagement, 2009;

• ‘The Challenge of ImplementingSustainable Improvement in CancerWaiting Times’ June 06;

• ‘How to Guide –Achieving CancerWaiting Times’, 2005;

• The Cancer High Impact Changes.

6.2. In addition:

• the Connecting for Health website at:http://nww.connectingforhealth.nhs.uk/nhais/cancerwaiting/documentationincludes some useful documentationsuch as the GFOCW Guide v6.5.

• the NICE website at:http://www.nice.org.uk/guidance/index.jsp includes referral and treatmentguidelines relevant to breast cancer

• Choose and Book have producedguidance notes (December 2008) onUrgent Referrals for Suspected CancerTwo-Week Waits: Implementationwithin Choose and Book. This isavailable at:http://www.chooseandbook.nhs.uk/staff/implement/guides/2ww_guide

Local Support6.3. Cancer network service improvement

teams should be able to provide serviceimprovement advice and support to enableyou to deliver the symptomatic breast 2wwstandard.

Acknowledgements6.4. Thank you to the NHS organisations that

provided case studies and to all those whohave had an input into this document.

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Annex AReadiness to Implement 2ww for all Symptomatic Breast Referrals:

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Summary Of Questionnaire Results(position in October 2008)76 of approximately 170 breast units responded toall or part of the questionnaire either directly or viatheir cancer network. As cancer networksresponded in some cases it has not been possible toprovide a definitive list of the 76 units. However,those that it was possible to identify from theresponses are listed at Appendix 1.

A summary of the survey results follow. However itshould be noted that this sets out the position inOctober 2008 ie. 9 months ago.

Number of breast units currently seeing allbreast referrals within two weeks ofreceipt of referral. • 12% of the units that responded (9 out of 76)confirmed that they were already seeing all breastreferrals within 2 weeks;

• 88% of the units that responded (67 out of 76)were not yet seeing all breast referrals within 2weeks (although a small number confirmed thatthis was achieved on occasion but notconsistently).

Estimated performance of those units notyet meeting 2ww for all patients.Of 32 units that responded to this question:

The gap to address therefore ranges from 10 –100% ie. 10-100% of symptomatic referrals notyet seen within two weeks in some breast units inOctober 08.

% of all symptomaticreferrals (non urgent)currently seen within 2weeks

No of units achieving thislevel of performance

80-90% 10

51-79% 3

26-50% 6

0-25% 13

In autumn 08 a questionnaire was circulated (via cancer networks and via BASO - the British Associationof Surgical Oncology) to breast units to establish their ‘readiness’ to implement symptomatic breast 2wwstandards. This section summarises the results of the questionnaire.

Assessment of how capacity could be/isgoing to be expanded to meet 2ww. Of 38 units that responded to this question:

• 37 were already undertaking or had undertakenan assessment of how capacity could beexpanded;

• 1 planned to do so early in 2009.

Actions being taken (or considered) tosupport implementation of all breastreferrals in 2 weeks• increasing capacity by not having breast unit staffon-call;

• extended roles for breast care nurses;

• one stop clinics 4-5 days a week;

• book referrals directly into a clinic rather thenbeing triaged first;

• under 35 clinics;

• nurse led clinics;

• advanced practitioners doing screening sessionsso radiologists can focus on symptomatic services;

• staff completing ultrasound courses to enablethem to do u/s guided biopsies without having toinvolve radiologists;

• monitoring performance weekly and arrangingadditional clinics on an adhoc basis as needed.

How many of the units used the breastassessment competencies developed bySkills for Health to develop theirworkforce?Of 65 units that responded to this question:

• 65% (42 of 65 units) did not use thecompetencies;

• 35% (23 of 65 units) did use the competencies.

How many units have plans to developbreast assessment practitioners as aworkforce solution to expand capacity? Of 41 units that responded to this question:

• 54% (22 of 41 units) had plans to developpractitioners.

Of those units that had plans:

• the following staff groups/areas were likely to bedeveloped to fulfil this role:

- breast care nurses (13 units)

- radiographers (6 units)

- sonographers to do breast ultrasound work (2units)

- breast physician (1 unit)

• tasks being considered for the expanded rolesincluded:

- ultrasound (2 unit)

- clinical assessment (2 units)

- mammogram reading (2 units)

- managing follow up clinics

Concerns about expanding practitionerrole.The following concerns were expressed:

• patients seeing an “assessment practitioner”would be more expensive in the long run aspatients would often need to return to see aconsultant anyway – better for consultant breastsurgeon to assess patients on their first visit;

• medico legal aspect of a breast care nursecarrying out this role, despite them being fullytrained;

• using trained non medical staff in new patientassessment or cancer follow up to free upmedical staff is not the way to go;

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• If non-medical staff are to be used more widelythen a national training scheme with a recognisedqualification available in all regions is necessary –otherwise local support unlikely.

Have any units accessed either of thetraining courses available at AddenbrookesHospital or the University of the West ofEngland (Bristol) in developing breastassessment techniques? • 3 Units mentioned that staff (incl doctors andassociate specialists) had attended ultrasoundcourses at Bristol

• 2 Units mentioned that staff had completed orapplied for advanced practice for breast carenurse courses at Addenbrookes.

Are you aware of any other courses todevelop breast assessment practitioners –either locally or elsewhere in the country?The following were identified:

• Royal College of Surgeons intermediate andadvanced courses for breast disease

• Masters level education for nurses eg. advancedassessment skills course at KCL and RMH.

• Diploma in breast evaluation, Kingston

• Course in clinical breast examination - Jarvisbreast screening centre, Guildford.

• NHSBSP training courses

• Courses for GPs on the management of breastdisease which includes breast examination andassessment of patients prior to referral – run byGreater Manchester and Cheshire Network

• Medical Ultrasound: extending your roles andclinical examination & diagnostics course - JohnMoores University, Liverpool

Any units planning on developing a localcourse to increase the number of breastassessment practitioners or planning tosend staff on existing courses?Of 52 units that responded to this question:

• 71% (37 of 52 units) have no plans to developlocal courses

• 21% (11 of 52 units) are developing local courses

• 8% (4 of 52 units) are considering developing alocal course

National Cancer Action Team

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Appendix 1 - Responses to the October 2008 Symptomatic Breast2ww Readiness Questionnaire

Units responding direct:• Doncaster

• Sheffield

• Barnsley

• Hereford

• Cheltenham

• Gloucester

• Worcester

• Royal Berkshire Hospital

• Countess of Chester Hospital

• Kings

• Guy's and St Thomas’ Hospital

• University Hospital Lewisham

• QMH

• Torbay

• Bromley North Cumbria Uni Hospitals

• Frenchay

• Taunton

• Wigan

• University Hospital of Coventry and Warwickshire

• Tunbridge Wells

• Doncaster and Bassetlaw

• Rotherham

• East Sussex Hospital Trust

Units responding via networks:• Mount Vernon (incl responses from 4 unnamedunits)

• South West London (incl responses from 4 units -Mayday NHS Trust, Royal Marsden, St George's,Kingston Hospital)

• Sussex(incl responses from 3 unnamed units)

• Manchester and Cheshire (incl responses from 11unnamed units)

• Surrey, West Sussex and Hampshire (inclresponses from 7 unnamed units)

• Anglia (incl responses from 9 unnamed units)

• South Central (incl responses from 6 unnamedunits)

• Merseyside and Cheshire (incl responses from 8unnamed units)

• 3 counties (incl responses from 4 unnamed units)

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This annex summarises views and ideas expressedat a small workshop held in January 2009 todiscuss implementation of the breast 2wwstandard.

The views set out in this annex are notnecessarily those of the National Cancer ActionTeam, NHS Improvement or BreakthroughBreast Cancer.

General issues raised during the morningdiscussion included:• if a woman has breast symptoms they wouldusually want to be seen as quickly as possible ie.speed would usually be their priority over choice

• with only 9% of the units that responded to thesurvey indicating that they are already deliveringthe breast 2ww standard, there is a challenge ie.how do we clear the backlog and fill this gap.

• if average waits are 3-4 weeks (possibly more)how can we reduce this to 2 weeks – is there asolution that can be applied across the wholecountry?

• is it possible to deliver the breast 2ww standard ina cost neutral environment - what is the incentivefor units to try and meet the standard withoutrequesting more resources ie. where is theincentive not to spend? General view thatimplementation is not cost neutral, therefore

funding needs to be a local consideration.

• quality matters ie. what patients actually want –general consensus is that patients want to haveall their tests (and preferably the results too) onthe same day ie. one stop clinics for tests shouldbe the gold standard and are deliverable.However, if core biopsies are used for diagnosis,same day results may not yet be feasible – resultsrange from 2-3 days in some areas and a week inothers although work from NHS Improvementindicates that core biopsy results could be backwithin 2-4 hours.

• it is important to consider the quality of theservice for the 90%+ of women who will nothave cancer. For example, they will needinformation on breast pain, cysts, nodularity etcand if this is provided well it can reduce anxietyand depression.

• patients diagnosed with benign disease may notneed to come back to the main clinic to discusstheir diagnosis. Other models may be possible eg.satellite clinics in the community to reduce thenumber of patients coming into hospital clinics.

• it would be useful to be able to stratify risk forcertain patient groups eg. the risk of notbiopsying a fibroadenoma in the under 25s, riskof cancer in under 35s etc as a means tomanaging patients more effectively.

• three key areas for action are commissioning,training and raising quality.

Annex BNotes from Workshop on Implementing Symptomatic Breast 2wwStandard (20 January 2009)

Managing BacklogsSuggestions on how to reduce backlogs included:

• see if consultants have any spare capacity ie. toput on extra clinics

• don’t cancel clinics for bank holidays – if youusually have a Monday clinic, plan ahead ie.reschedule to Tues/Wed etc well in advance – getcolleagues on board to do this (perhaps write it into job plans ie. an extra 2-3 days per annum)

• reduce follow-up or change where follow-uptakes place eg. possibly discharge patients to alocal service (would be useful if we could stratifyrisk rather than do a blanket ‘ban’ on follow-upafter 5 years ie. base the decision on a person’srisk – develop a risk stratification tool)

• keep ‘follow up’ and ‘new’ patients in separateclinics so that services can be better directed. Ifseparate clinics not feasible then split a clinic iefirst half new patients (receiving results etc) andsecond half follow-up patients

• possibly do Saturday clinics – would need topersuade staff of benefit in terms of a successfulbreast service etc

• 1 stop clinics for tests (and if have good cytologyfor results too)

It was also noted that:

• managing a backlog was not just about thenumber of patients and clinics but also about thetime needed and the level of service that neededto be provided;

• if a backlog is reduced without an increase infuture capacity then a queue will just come backat some point in the future.

How to overcome bottlenecks & increasecapacityPotential bottlenecks/issues raised included:

• Waiting list initiatives linked to delivering 18weeks ie. some consultants are pulled to differentdisciplines to clear lists eg. dedicated knee lists etcwhich can cause problems elsewhere in system –cancer patients are a sub group of the 18 weekgroup and managers need to be educated of theimpact of wider 18 week initiatives on cancerpatients

• Surgeons – it was noted that surgeons oftenwork on multiple sites and have to fit in privatepractice so they may not have much timeflexibility to provide additional capacity and, withthe pivotal role they currently play, this couldresult in a bottleneck. As a result somesuggestions were made:

- if you do need to rely on surgeons toincrease capacity then consideration neededto be given to incentivising them to changetheir practise ie. how can existing job plansdrive flexibility in the system. For example itwas estimated that about 80% of breastsurgeons are no longer on call which makesa difference to available capacity. Anincentive for the remainder could be to dropon-call duties if 2ww is met for all breastpatients;

- some surgeons don’t see enough patientsand contracts need to be clear re. number ofpatients they are expected to see and/orclinics they are expected to run – the onuscould then be put on the surgeon to identifyhow they could deliver that includinginnovative management techniques. There is

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precedent in orthopaedics where thesurgeons were given a ‘target’ and it was leftto them how they delivered it eg. they couldtake additional leave if standard deliveredetc;

- surgeons need referrals or they have nowork – could referrals be controlled with afee per service like GPs have;

- re-look at teams so don’t have to rely onsurgeons ie go back to commissioners andchange care pathways to introduce, forexample, advanced practitioner roles.

• pathology – appointing posts is difficult due tonational shortage – this can impact onturnaround of core biopsies (eg. can be 4 days)and also HER2 results. It would be hard to expandothers’ roles into pathology.

• shortages of radiologists/imaging capacity – couldameliorate this by expanding roles of other staffto take on some of these duties.

• impact on traditional nursing roles ie. if nursestake on expanded roles who then fulfils theirimportant psychosocial role. If it is to remain aspart of the advanced practitioners role than morepractitioners will be needed as they will only beable to deal with a smaller number of patients. Ifthey are no longer to have this psychosocial rolethen back fill is needed to undertake the formerroles plus others such as chaperoning, passing thebiopsy gun etc.

• possible inundation with inappropriate low riskreferrals such as men with bilateralgynaecomastia who are anabolic steroid users oroverweight, known marijuana smokers or womenwith cyclical breast pain etc. It was suggested thatsuch patients should be excluded from the

standard. However, it was also noted that themore exclusions that are introduced the morelikely it was that a 2 tier system would beintroduced and cancer missed which this standardwas aiming to remove.

• education of primary care eg. to manage thesurvivorship and/or follow up agenda. It was alsosuggested that nurses in primary care could betrained to do breast examination and reassuranceto reduce unnecessary referrals. It was noted thatsuch nurses would need to sit on MDTs insecondary care and go to one stop clinics atregular intervals to maintain skills etc. However,there was also concern expressed that practicenurses would not see enough patients for thismodel to work in practice and that outreachclinics from secondary care into the community ie.part of the Darzi polyclinic model would be betterie. rather than train a practice nurse it might bepossible to have a breast care nurse go out to acommunity breast clinic. In addition, advancedpractitioners could manage patients withmetastatic breast cancer once back in thecommunity or patient discharged/released fromfollow up could go to them if they had concerns/wanted to discuss anything.

• members of breast units need to meet to discussbottlenecks/barriers to implementing breast 2wwand cancer networks/SHAs need to mandateproduction of local action plans to addressbottlenecks/barriers including maximising use ofstaff.

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The role of commissioningIt was noted that:

• commissioners are generally only interested inwhen providers will deliver not about the qualityof what is delivered – they need to be educatedabout what a good quality service is and howmuch it will cost eg. arrange a visit to show thembefore they sign SLAs for services.

• the acute sector is not the only place to deliverbreast services – PCTs and the private sector canbe providers too, this could drive increases inquality.

• work with cancer networks to educate and drivecommissioning.

• commissioners are the key but they onlyunderstand money so need to show how a highquality service can save money in the longer term.

Workforce solutionsWhat staff groups could have extended roles?

• There was general agreement that there was aneed to focus on skills not people although thebaseline requirement was that the member ofstaff should be a healthcare professional. It wasgenerally agreed that any health professionalcould extend their role but it was thought thatnurses, radiographers and radiologists might bethe key target groups. There was a suggestionthat nurses might be best suited to the clinicalexamination and face to face communicationskills side and other staff such as radiographersperhaps better suited to ultrasonography. It wassuggested that 1 nurse practitioner couldpotentially do 5 follow up clinics and 3 newpatient clinics a week.

What roles could advanced practitionersundertake?

It was agreed that there were potentially lots ofroles that could be undertaken by different healthprofessionals. Examples included:

• Breast examination

• Breast ultrasound

• Fine needle aspiration (FNA)

• Punch biopsies

• Seroma care

• Wound checks

• Aspirating cysts

• Supporting patients discharged with drains

• Advanced communication skills

• Psychosocial support (but need to handover toothers for more supportive role too if they haveextra roles)

Training Advanced Practitioners

• A range of existing courses exist such as:

- University of the West of England whichoffers a ‘Specialist Practice Course in BreastUltrasound for Experienced Breast CareNurses’ plus options for self-directed studyfor those wishing to learn additional clinicalskills such as Breast Examination, Fine NeedleAspiration and/or seroma drainage.

- Addenbrookes – which trains nurses to dobreast examination and follow up. It is a 4day residential course and staff then go backand shadow etc and are locally assessed untilcompetent and feel they can taken on roleindependently.

- Guildford - observation before start 5 dayresidential course, case studies and

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assignment, portfolio of evidence (min of 50cases – variety cysts, adenos, carcinomas etc)and Objective Structured ClinicalExamination (OSCE).

• There was general agreement that a nationaltraining course was not needed ie. it is forlocalities to determine who to train and in whateg. a breast centre could choose to train all theirnursing staff to a certain level of breast care orcertain individuals to take on certain tasks.However, it was agreed that it would be useful tohave some national criteria that ‘training centres’should meet and national criteria to support whathappens when staff return to take on theadvanced role locally before taking on the roleindependently eg. criteria for pre and postqualifying as an advanced practitioner.Suggestions for what was needed included:

- standards and competencies

- ‘accreditation’ – no. of cases to observe,supervision of practice, OSCE etc – potentialrole for RCN?;

- mentors and designated educationalsupervisors ie. about an hour per week perjunior trainee

- audit

- annual review/appraisal

- on-going cpd etc

- a register of advanced breast clinicians (inthe long term)

Potential barriers to advanced breast practitionerroles

Potential barriers were identified as:

• how to assess competency in breast examination

• costs of training

• cost of backfill

• how to ensure nurses (or other healthprofessionals) feel confident to put new skills intopractice

• how to ensure advanced practitioners have theconfidence of doctors

• would RCN need to endorse approved courses

• organisational leadership needs to supportbackfill and equipment etc for when staff returnfrom training

• cost of supervising once staff return from initialtraining ie. in short term it could slow downdoctors so see fewer patients but would bringbenefits in the longer term

Other issued raised about advanced practitioners

Other issues raised included:

• accountability of advanced practitioners – trustindemnity needs to be considered;

• there is no standard way to teach breastexamination in medical schools in the UK;

• does tariff adequately cover breast one stopclinics;

• a disincentive for nurses expanding roles is theglass ceiling on their pay ie. sometimes they arenot paid if they are over the threshold;

• if surgeons and nurses each do a session and dothe same tasks should they be paid the same forthat session? If not, are nurses just a way to dothings on the cheap (ie. same thing to samestandard). If standard/quality is not the same whydo it;

• money, pay, recognition and title that goes with itare important ie. a nurse ‘consultant’ has morestrategic clout than being a nurse practitioner;

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• BASO offers breast cancer nurse membership atreduced offers;

• there are still some units that have generalistsrather than breast specialists – this needs tochange;

• consider incorporating standards in peer review;

• consider setting up an Association of AdvancedBreast Practitioners.

The views set out in this annex are notnecessarily those of the National Cancer ActionTeam, NHS Improvement or BreakthroughBreast Cancer.

National Cancer Action Team

February 2009

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This guide was produced in partnership by theNational Cancer Action Team, BreakthroughBreast Cancer and NHS Improvement.

• National Cancer Action Team supports cancernetworks and the NHS to deliver thecommitments in the Cancer Reform Strategy andthe wider cancer programme.

• Breakthrough Breast Cancer is a pioneeringcharity dedicated to the prevention, treatmentand ultimate eradication of breast cancer. It fightson three fronts: research, campaigning andeducation. Its aim is to bring together the bestminds and rally the support of all those whoselives have been, or may one day be, affected bythe disease. The result will save lives and changefutures – by removing the fear of breast cancerfor good.

• NHS Improvement works with clinical networksand NHS organisations across England to helptransform, deliver and build sustainableimprovements across the entire pathway of carein cancer, diagnostics, heart and stroke services.

Going Further on Cancer Waits: The Symptomatic Breast Two Week Wait Standard

A guide to support implementation

July 2009

National Cancer Action TeamNHS Improvement