Cancer Diagnostic Demand & Capacity Workshop SPH Workshop Presentation

Transcription

1 Cancer Diagnostic Demand & Capacity Workshop SPH Workshop Presentation 10 th March 2016

2 Aims of Project Identify areas of improvement required across the cancer pathway focussing on cancer diagnostics Review current diagnostics capacity and infrastructure of 5 cancer specialties Review demand for diagnostics from patients entering the cancer pathway via the urgent 2WW route, compared with other routes Develop a model to predict future referrals and tests (to 2021) taking account of demographics and new NICE urgent referral guidance Run a workshop to share the project findings and explore the significance of the results 2

3 Project scope Elements: 12 CCGs you know who you are. 6 Trusts - OUH, BHT, RBH, GWH, MKH, FN 5 specialties - Gynaecology, Colorectal, Upper GI, Lung, Urology 11 cancers - ovarian, cervical, vulval, endometrial, oesophageal, pancreas, stomach, bladder, kidney prostate, lung NICE guidance 3 scenarios plus baseline 3

4 4

5 High level plan Summary of guidance desk top exercise Gather current data from national sources Gather Trust qualitative data Gather Trust quantitative data 5

6 Data gathering - Guidance Achieving world-class cancer outcomes: A strategy for England Suspected cancer: recognition and referral NICE Suspected cancer urgent referral guidance Horizon scanning: An evaluation of imaging capacity across the NHS in England Delivery for Cancer Research UK Scoping the future: An evaluation of endoscopy capacity across the NHS in England. Cancer Research UK Improving outcomes: A strategy for cancer fourth annual report. DH, PHE, NHSE. Delivering cancer waiting times A good practice guide. NHS Interim Management and Support Intensive Support Team Elective Care Guide 6

7 Data gathering - National Data NHS England Cancer Waiting Times Statistics o CCG and Trust performance against 2WW, 31 day and 62 day targets NCIN Cancer Commissioning Toolkit o 2WW referrals by CCG and Trust over time o 2WW referrals by CCG and Trust diagnosed with cancer over time o Non-2WW referrals diagnosed with cancer and treated within 31 days over time o Routes to Diagnosis data for certain common cancers o Proportion of cancers diagnosed early (stage 1 or 2) vs late (stage 3 or 4) for Thames Valley CCGs 7

8 Data gathering - National data continued Southern Bowel Cancer Screening Hub o Referrals from bowel cancer screening to Thames Valley providers Health and Social Care Information Centre o Referrals from cervical cancer screening to Thames Valley Trusts and number of referrals from cervical cancer screening services for Thames Valley CCGs TVSCN o Incidence data for Thames Valley CCGs/PCTs from 2009 to 2013 o Average decision to treat date for Thames Valley providers in 2015 PHE o Proportion of emergency cancer presentations for Thames Valley CCGs 8

9 Data gathering - Questionnaires Questionnaire developed for each cancer specialty Information requested on: o Outsourcing of tests o Number of referrals in 2014/15 o How many clinics, how often these ran, how many slots per clinic o Equipment used in clinics o Pathology and radiology turnaround times o Staffing Questionnaires were circulated to providers in early November and return was originally requested by end of November, then by Christmas. The latest return was late February. 9

10 Data gathering - Quantitative data from Trusts We sent a data request to Trusts asking for an anonymised dataset showing the tests performed for each suspected cancer referral in 2014/15 o This was to inform our modelling of the future demand for diagnostic tests o Our fantasy was.patient level data of each event along the pathway blood test, biopsy, outpatient appointment, CT scan etc 10

11 Data gathering - Qualitative Data from Trusts Cancer managers face to face interviews Telephone interviews with radiology and pathology managers Collated emerging themes from questionnaires and interviews Information presented in a mini-report for each Thames Valley Trust along with projected referrals and tests for that Trust 11

12 Data returns from Trusts Returned Questionnaires from Trusts with some information Gynae Lower GI Lung Upper GI Urology Bucks GW HWPH MK OUH RBH Completed interviews with Cancer, Pathology, Radiology Managers Cancer Manager Pathology Manager Radiology Manager Bucks GW HWPH MK OUH RBH Returned data requests and shared modelling work with some information Tests Data Request Previous Modelling Work Bucks GW HWPH MK OUH RBH 12

13 Outputs - Mini reports Way too much information for one report Purple = Guidance report Blue = National data report Green = Modelling report methodology plus projected referrals and tests by health economy Orange = Six Trust reports qualitative information plus projected referral and tests by specialty To follow.excel spreadsheet with all modelling includes approximately 2000 tables.. 13

14 Outputs: Guidance Summary Mini Report 14

15 NICE Guidance: Impact on Referrals Cancer Specialty Lower Estimate Upper Estimate Colorectal 5% 15% Upper GI -40% -80% Lung 10% 15% Urological 5% 10% 15

16 Upper GI NICE predicted 2ww Upper GI cancer 2WW cancer predicted referrals drop of -40% to -80% Assumed primary care will refer to direct access endoscopy so not technically cancer 2WW but urgent 2WW instead. Will identify patients unlikely to have cancer. A much smaller proportion of patients will therefore require a 2 week wait cancer referral to the hospital Trust. The overall number of referrals will not be impacted by this change only whether they are referred as a 2 week wait cancer pathway referral to the hospital Trust or an urgent 2 week wait direct access referral to an endoscopy service. The benefit is a significant reduction in the number of outpatient appointments required in the hospital Trust and associated costs. Issues around governance and pathway linkage with the independent endoscopy providers and associated pathology laboratories have been raised. 16

17 NICE Guidance Direct access Direct access X-ray Upper GI endoscopy CT Ultrasound Cystos copy CA125 PSA Urine test Colpos copy Lung X Oesophageal X Pancreatic X Stomach X Colorectal Ovarian X X Endometrial X Cervix (screened) Vulva Prostate X X Bladder X X Renal X X X 17

18 Diagnostics National diagnostic capacity implementation fund Health Education England to focus on accessing and developing workforce - 60% increase in training positions - radiology Fund by activity not block contract Clear national evidence based protocols for follow up scanning/surveillance Better data coding PHE/NHSE to plan how to manage pressures from roll out of Bowel Scope 18

19 How to guide. Delivering cancer waiting times A good practice guide. NHS Interim Management and Support Intensive Support Team Elective Care Walk through guide of essential elements of cancer pathway for capacity planning Good practice Signposts to tools and practices to smooth pathway 19

20 Outputs: Trends in Cancer Data Mini Report 20

21 Outputs: Trends in Cancer Data Mini Report Two Week Wait Referrals Q1 & Q2 2013/14 Q1 & Q2 2014/15 Q1 & Q2 2015/16 % Change Q1 & Q2 2013/14 to Q1 & Q2 2014/15 % Change Q1 & Q2 2014/15 to Q1 & Q2 2015/16 % Change Q1 & Q2 2013/14 to Q1 & Q2 2015/16 Gynaecological 2,457 2,514 3,042 2% 21% 24% cancers Colorectal 4,562 5,021 5,702 10% 14% 25% cancers Upper GI cancers 2,376 2,912 3,735 23% 28% 57% Lung cancer ,096 11% 11% 23% Urological cancers Total Thames Valley 3,586 4,053 4,554 13% 12% 27% 13,872 15,488 18,129 12% 17% 31% Total England 330, , ,965 12% 12% 25% Number of 2WW referrals for selected cancers in TVSCN increased by 31% between 2013/14 and 2015/16 (Q1 & Q2). This was a greater increase than the England average of 25%. 21

22 Outputs: Trends in Cancer Data Mini Report Cervical Screening Referrals 2010/ / / / /15 % Change from 2010/11 Buckinghamshire ,599 1, % Healthcare Great Western Hospitals % NHS Foundation Trust Frimley North Hospital 1,424 1,569 1,604 1,675 1, % Milton Keynes Hospital % Oxford University 1,293 1,081 1, % Hospitals Royal Berkshire Hospital 946 1,039 1, % Thames Valley 5,953 5,799 6,787 9,252 9, % England 142, , , , , % Number of cervical screening referrals have increased from approx. 6,000 per annum to approx. 9,500 per annum in TVSCN. This is a 61% increase since 2010/11, compared to a 39% increase for England over the same period. 22

23 Outputs: Trends in Cancer Data Mini Report Bowel Screening Referrals Buckinghamshire Healthcare Great Western Hospital Frimley North Hospital Milton Keynes Hospital Oxford University Hospitals Royal Berkshire Hospital extrapolated Increasing trend in number of referrals from bowel screening programme to TV providers 23

24 Outputs: Trends in Cancer Data Mini Report Cancer Incidence Total Change between 2009 and 2013 % Change between 2009 and 2013 % Change in England between 2009 and 2013 (where data are available) Gynaecological , % 7% cancers Colorectal Cancer 1,433 1,494 1,501 1,567 1,575 7, % - Upper GI cancers , % 7% Lung Cancer , % 7% Urological cancers 2,284 2,240 2,320 2,301 2, % 13% Total 11 cancer sites 6,399 6,490 6,542 6,658 6,960 33, % - Incidence of selected cancers is increasing in TVSCN area, but at a lower rate than referrals 24

25 Screen detected Two Week Wait GP referral Other Outpatient Inpatient Elective Emergency presentation Death Certificate Only Unknown Outputs: Routes to Diagnosis 2006 to 2013 Thames Valley SCN Bladder 40% 19% 14% 7% 15% 0% 5% Bladder (in-situ) 32% 29% 18% 9% 4% 8% Cervix 28% 10% 34% 10% 3% 9% 0% 6% Cervix (in-situ) 1% 0% 64% 21% 6% 1% 7% Colorectal 6% 24% 22% 11% 8% 22% 1% 6% Kidney 22% 26% 20% 4% 22% 0% 6% Other and unspecified urinary 20% 30% 25% 7% 12% 5% Lung 24% 21% 14% 3% 34% 0% 3% Oesophagus 34% 17% 9% 14% 20% 0% 5% Ovary 26% 23% 14% 3% 27% 1% 7% Pancreas 13% 18% 15% 5% 44% 1% 5% Prostate 37% 34% 12% 3% 7% 0% 7% Stomach 22% 20% 10% 12% 31% 1% 4% Uterus 40% 33% 11% 2% 8% 0% 5% Vulva 33% 37% 15% 2% 6% 7% 2ww accounts for only 20% to 40% of cancer diagnoses. Emergency presentation accounted for 44% of pancreatic cancer diagnoses and 34% of lung cancer diagnoses 25

26 Screen detected Two Week Wait GP referral Other Outpatient Inpatient Elective Emergency presentation Death Certificate Only Unknown Outputs: Routes to Diagnosis 2006 to 2013 England Bladder 34% 28% 13% 3% 18% 0% 3% Bladder (in-situ) 23% 47% 16% 4% 7% 0% 3% Cervix 23% 18% 32% 10% 2% 11% 0% 4% Cervix (in-situ) 16% 0% 56% 19% 4% 1% 0% 4% Colorectal 7% 28% 25% 8% 4% 25% 0% 3% Kidney 22% 30% 18% 2% 25% 0% 3% Other and unspecified urinary 17% 37% 22% 3% 18% 0% 3% Lung 26% 21% 11% 2% 37% 1% 3% Oesophagus 38% 20% 8% 10% 21% 0% 3% Ovary 27% 26% 12% 2% 29% 1% 4% Pancreas 14% 21% 11% 3% 47% 1% 4% Prostate 33% 41% 11% 2% 9% 0% 4% Stomach 25% 22% 8% 9% 32% 0% 3% Uterus 45% 34% 8% 1% 8% 0% 4% Vulva 36% 40% 12% 1% 7% 0% 3% England similar to Thames Valley, 47% of Pancreas cancers diagnosed by emergency presentation and 37% of lung cancers 26

27 100% Outputs: Trends in Cancer Data Mini Report Stage at Diagnosis 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 21% 31% 48% Thames Valley 13% 30% 57% England Not Recorded Stage 3 & 4 Stage 1 & 2 More not recorded data for TV than England but % ovarian/uterine cancers diagnosed at stages 3 and 4 is slightly higher than for England in % of lung cancer cases diagnosed at stages 1 and 2 in TV, similar to 20% for England in % 90% 80% 70% 60% 50% 40% 30% 20% 10% 17% 14% 62% 66% 21% 20% Not Recorded Stage 3 & 4 Stage 1 & 2 0% Thames Valley England 27

28 Outputs: Trends in Cancer Data Mini Report 2ww for CCGs 2013/ / / / / / / / / /16 CCG Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 NHS Bracknell and Ascot CCG 94.7% 94.2% 96.2% 96.7% 93.2% 93.6% 95.9% 94.5% 94.0% 94.2% NHS Slough CCG 94.7% 95.5% 97.7% 96.7% 94.4% 96.1% 95.1% 94.8% 94.1% 94.1% NHS Windsor, Ascot and Maidenhead CCG 94.7% 95.5% 97.2% 96.1% 92.9% 94.7% 95.3% 95.3% 95.1% 94.3% NHS Newbury and District CCG 93.2% 93.4% 95.4% 94.3% 90.9% 88.5% 91.2% 93.8% 89.3% 75.9% NHS North & West Reading CCG 92.6% 94.1% 95.1% 93.9% 90.9% 88.0% 91.8% 92.9% 88.2% 71.6% NHS South Reading CCG 93.7% 94.6% 94.6% 93.8% 90.4% 90.1% 91.5% 94.8% 88.3% 72.4% NHS Wokingham CCG 93.8% 94.3% 94.2% 93.4% 91.0% 90.2% 93.4% 94.5% 88.8% 71.5% NHS Aylesbury Vale CCG 99.1% 98.8% 98.5% 96.7% 94.0% 94.3% 94.4% 96.2% 95.1% 95.9% NHS Chiltern CCG 98.6% 97.8% 97.6% 96.0% 91.8% 93.9% 93.9% 94.4% 94.0% 94.6% NHS Milton Keynes CCG 98.6% 96.9% 96.8% 96.5% 94.7% 93.9% 96.0% 95.1% 95.8% 94.8% NHS Oxfordshire CCG 95.4% 93.6% 95.6% 96.5% 93.0% 93.1% 94.1% 97.1% 94.1% 93.1% NHS Swindon CCG 94.6% 94.1% 95.6% 93.5% 94.2% 93.8% 94.1% 95.1% 94.8% 95.1% Operational Standard 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% England 95.5% 95.2% 95.6% 95.0% 93.5% 93.6% 94.7% 94.7% 93.6% 93.5% 2ww operational standard being met by TV CCGs apart from West Berks in Q1 & Q2 2015/16 28

29 Outputs: Trends in Cancer Data Mini Report 2ww for CCGs 100% 95% 90% 85% 80% 75% 70% Q1 2013/14 Q2 2013/14 Q3 2013/14 Q4 2013/14 Q1 2014/15 Q2 2014/15 Q3 2014/15 Q4 2014/15 Q1 2015/16 Q2 2015/16 Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Frimley Healthcare NHS Foundation Trust (Frimley North only) Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Foundation Trust Royal Berkshire NHS Foundation Trust Operational Standard 2ww operational standard being met by TV providers apart from RBH in 2015/16 29

30 Outputs: Average Decision to Treat Date 2015 Q1 Q2 Q3 Q4 Gynaecological Buckinghamshire Healthcare NHS Trust Frimley North Hospital Oxford University Hospitals NHS Foundation Trust Royal Berkshire NHS Foundation Trust Colorectal Buckinghamshire Healthcare NHS Trust Frimley North Hospital Oxford University Hospitals NHS Foundation Trust Royal Berkshire NHS Foundation Trust Lung Buckinghamshire Healthcare NHS Trust Frimley North Hospital Oxford University Hospitals NHS Foundation Trust Royal Berkshire NHS Foundation Trust Upper GI Buckinghamshire Healthcare NHS Trust Frimley North Hospital Oxford University Hospitals NHS Foundation Trust Royal Berkshire NHS Foundation Trust Urological Buckinghamshire Healthcare NHS Trust Frimley North Hospital Oxford University Hospitals NHS Foundation Trust Royal Berkshire NHS Foundation Trust

31 Outputs: Modelling Future Demand for Cancer Diagnostics Mini Report 31

32 Modelling Methodology Data Sources Populations (Aged 20+) CCG populations o Current and past years we used ONS mid year estimates o Future years we used ONS 2012-based sub national population projections for CCGs o CCG populations grouped into health economies for modelling e.g. East Berks Trust catchment populations o Published APHO/PHE Trust catchment populations for 2011, 2012, 2013 o Estimated forwards and backwards using year on year increase in CCG population from ONS projections using CCG in which Trust is sited e.g. for Milton Keynes Hospital applied % change from MK CCG 32

33 Modelling Methodology: Data Sources NICE Guidance estimates of changes in numbers of referrals Baseline Scenario Scenario 1 Scenario 2 Scenario 3 Cancer Specialty No Impact Lower Estimate Mid-Point Estimate Upper Estimate Colorectal 0% 5% 7.5% 15% Upper GI 0% -40% -60% -80% Lung 0% 10% 12.5% 15% Urological 0% 5% 7.5% 10% 33

34 Modelling Methodology Data Sources 2ww Referrals NCIN Cancer Commissioning Toolkit Pre-2013 PCT data calculated for CCGs using ONS percentages Non-2ww Referrals NCIN Cancer Commissioning Toolkit Number of cancers diagnosed and treated within 31 days from routes other than 2WW 34

35 Modelling Methodology Data Sources Screening Referrals Bowel screening data provided by the Southern Bowel Cancer Screening Hub Cervical Screening obtained from HSCIC by provider - commissioner figures estimated based on provider proportions 35

36 Modelling Methodology Data Sources Milton Keynes Test Data Milton Keynes provide detailed referral and test data for 2014/15 Used to derive a ratio of tests per referral, by type of test Applied to the referral numbers to estimate numbers of tests 36

37 Basis of Modelling Chart rates of referrals for each health economy, provider and speciality, separately for 2WW, non-2ww and screening Add a log trend for each organisation Forecast forward 7 years Apply co-efficients from log trend to derive projected rates Apply these rates to projected populations to get projected referral numbers Apply NICE estimated changes to 2WW referral numbers Apply the Milton Keynes ratios of referrals to test to these referral numbers to get projected test numbers 37

38 Basis of Modelling For example (2ww referrals, colorectal, Oxfordshire) Add log trend to historic referrals 38

39 Basis of Modelling For example (con td) Apply calculated forecast rate to projected population to get projected number of 2WW referrals 39

40 Basis of Modelling Then add NICE Guidance estimated changes to this Baseline, to create 3 scenarios, based on: Scenario 1 Minimum level estimated by NICE Scenario 2 - Mid-point between minimum and maximum level estimated by NICE Scenario 3 - Maximum level estimated by NICE 40

41 Basis of Modelling For example (con td) Add NICE Guidance estimated % changes to 2WW referrals, and add these adjusted 2WW figures to the non-2ww and screening (where appropriate) projections 41

42 Basis of Modelling Bear in mind that Upper GI is different. If the NICE Guidance limits are applied, the results look like this. However, the Guidance is likely to result in changes in referral paths and routes to testing, rather than changes in the numbers of referrals and tests. Therefore, only the Baseline is used in the SPH modelling. More details are given in the separate Modelling Data Excel file, and Modelling Report Note NICE changes are assumed to be implemented evenly over the 5 years

43 Break phew! Back in 10 mins please 43

44 Modelling Results The model calculates future numbers of referrals and tests for multiple combinations: Organisations (6 providers + TV total, 6 health economies + TV total) 14 Specialties 5 Scenarios (Baseline + Scenarios 1,2 and 3) 4 Referral types (2ww, non-2ww, screening and total) 4 x each for referrals and tests 2 x Total 2,240 Key results are included in your packs 44

45 Modelling Results: Main Drivers Population changes underlie all other changes 45

46 Modelling Results: Main Drivers Between 2009 and 2014, Referrals steadily increased 14,000 12,000 Health Economy View 10,000 Bucks 8,000 6,000 East Berks Milton Keynes Oxfordshire 4,000 2, Swindon West Berks 14,000 12,000 10,000 Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Provider View 8,000 6,000 4,000 2, Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust Royal Berkshire NHS Foundation Trust Wexham Park Hospital 46

47 Modelling Results: Colorectal, Baseline Referrals Number of Referrals - Baseline Actual Projected Trust Buckinghamshire Healthcare NHS Trust 1,343 1,712 2,090 1,896 1,850 2,253 2,063 2,077 2,126 2,178 2,224 2,268 2,308 Great Western Hospitals NHS Foundation Trust 950 1,133 1,344 1,587 1,557 1,879 1,889 1,928 1,991 2,048 2,101 2,152 2,199 Milton Keynes Hospital NHS Foundation Trust ,122 1,087 1,201 1,454 1,352 1,422 1,472 1,518 1,563 1,604 1,645 Oxford University Hospitals NHS Trust 1,510 2,080 2,674 3,398 3,032 3,341 3,551 3,670 3,791 3,900 4,000 4,096 4,183 Royal Berkshire NHS Foundation Trust 1,519 1,792 1,978 2,386 2,432 2,554 2,598 2,688 2,772 2,846 2,914 2,978 3,038 Wexham Park Hospital 1,202 1,410 1,712 2,090 1,962 2,233 2,241 2,342 2,418 2,490 2,561 2,626 2,690 Total 7,313 9,050 10,920 12,444 12,034 13,714 13,695 14,126 14,570 14,980 15,363 15,725 16,063 Change between 2014 and 2021: 17% 47

48 Modelling Results: Colorectal, Scenario 3 Referrals Number of Referrals - Scenario 3 Actual Projected Trust Buckinghamshire Healthcare NHS Trust 1,343 1,712 2,090 1,896 1,850 2,253 2,063 2,125 2,226 2,331 2,433 2,535 2,581 Great Western Hospitals NHS Foundation Trust 950 1,133 1,344 1,587 1,557 1,879 1,889 1,973 2,084 2,193 2,300 2,407 2,460 Milton Keynes Hospital NHS Foundation Trust ,122 1,087 1,201 1,454 1,352 1,456 1,544 1,629 1,715 1,800 1,847 Oxford University Hospitals NHS Trust 1,510 2,080 2,674 3,398 3,032 3,341 3,551 3,766 3,990 4,210 4,425 4,642 4,743 Royal Berkshire NHS Foundation Trust 1,519 1,792 1,978 2,386 2,432 2,554 2,598 2,750 2,900 3,044 3,186 3,326 3,393 Wexham Park Hospital 1,202 1,410 1,712 2,090 1,962 2,233 2,241 2,396 2,530 2,664 2,800 2,934 3,006 Total 7,313 9,050 10,920 12,444 12,034 13,714 13,695 14,466 15,274 16,070 16,859 17,645 18,031 5,000 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1, Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust Royal Berkshire NHS Foundation Trust Wexham Park Hospital Change between 2014 and 2021: 31% Total Change by Baseline to Scenario 3: 12% 48

49 Modelling Results: Colorectal, Baseline Tests Number of Tests - Baseline Estimated Projected Trust Buckinghamshire Healthcare NHS Trust 1,826 2,327 2,841 2,578 2,515 3,063 2,805 2,823 2,891 2,961 3,023 3,084 3,138 Great Western Hospitals NHS Foundation Trust 1,292 1,540 1,827 2,158 2,117 2,555 2,568 2,621 2,706 2,785 2,856 2,925 2,990 Milton Keynes Hospital NHS Foundation Trust 1,073 1,255 1,525 1,478 1,633 1,977 1,838 1,933 2,002 2,064 2,124 2,181 2,236 Oxford University Hospitals NHS Trust 2,053 2,828 3,635 4,620 4,122 4,542 4,828 4,989 5,154 5,302 5,438 5,569 5,687 Royal Berkshire NHS Foundation Trust 2,065 2,436 2,689 3,244 3,306 3,472 3,532 3,654 3,768 3,869 3,962 4,049 4,130 Wexham Park Hospital 1,634 1,917 2,327 2,841 2,667 3,036 3,047 3,184 3,288 3,386 3,482 3,570 3,657 Total 9,942 12,304 14,846 16,918 16,360 18,644 18,619 19,205 19,808 20,366 20,887 21,378 21,838 49

50 Modelling Results: Colorectal, Scenario 3 Tests Number of Tests - Scenario 3 Estimated Projected Trust Buckinghamshire Healthcare NHS Trust 1,826 2,327 2,841 2,578 2,515 3,063 2,805 2,889 3,026 3,169 3,307 3,447 3,509 Great Western Hospitals NHS Foundation Trust 1,292 1,540 1,827 2,158 2,117 2,555 2,568 2,682 2,833 2,981 3,127 3,272 3,345 Milton Keynes Hospital NHS Foundation Trust 1,073 1,255 1,525 1,478 1,633 1,977 1,838 1,980 2,099 2,214 2,332 2,447 2,510 Oxford University Hospitals NHS Trust 2,053 2,828 3,635 4,620 4,122 4,542 4,828 5,120 5,425 5,723 6,016 6,312 6,448 Royal Berkshire NHS Foundation Trust 2,065 2,436 2,689 3,244 3,306 3,472 3,532 3,739 3,943 4,139 4,332 4,522 4,613 Wexham Park Hospital 1,634 1,917 2,327 2,841 2,667 3,036 3,047 3,258 3,440 3,621 3,807 3,989 4,087 Total 9,942 12,304 14,846 16,918 16,360 18,644 18,619 19,667 20,765 21,848 22,921 23,989 24,513 7,000 6,000 5,000 4,000 3,000 2,000 1,000 - Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust Royal Berkshire NHS Foundation Trust Wexham Park Hospital 50

51 Modelling Results: Lung, Baseline Referrals Number of Referrals - Baseline Actual Projected Trust Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust Royal Berkshire NHS Foundation Trust Wexham Park Hospital Total 1,687 1,763 1,992 2,264 2,211 2,646 2,447 2,523 2,595 2,661 2,722 2,780 2,834 1,200 1, Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust Change between 2014 and 2021: 7% Royal Berkshire NHS Foundation Trust Wexham Park Hospital 51

52 Modelling Results: Lung, Scenario 3 Referrals Number of Referrals - Scenario 3 Actual Projected Trust Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust ,018 1,067 1,090 Royal Berkshire NHS Foundation Trust Wexham Park Hospital Total 1,687 1,763 1,992 2,264 2,211 2,646 2,447 2,590 2,732 2,873 3,012 3,153 3,215 1,200 1, Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust Royal Berkshire NHS Foundation Trust Wexham Park Hospital Change between 2014 and 2021: 22% Total Change by Baseline to Scenario 3: 13% 52

53 Modelling Results: Lung, Baseline Tests 53

54 Modelling Results: Lung, Scenario 3 Tests Number of Tests - Scenario 3 Estimated Projected Trust Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust , ,239 1,089 1,158 1,226 1,293 1,359 1,426 1,455 Royal Berkshire NHS Foundation Trust Wexham Park Hospital Total 2,253 2,355 2,661 3,024 2,953 3,534 3,268 3,459 3,649 3,837 4,023 4,211 4,294 54

55 Upper GI NICE predicted 2ww Upper GI cancer 2WW cancer predicted referrals drop of -40% to -80% Assumed primary care will refer to direct access endoscopy so not technically cancer 2 week wait but urgent 2 week wait instead. Will identify patients unlikely to have cancer. A much smaller proportion of patients will therefore require a 2 week wait cancer referral to the hospital Trust. The overall number of referrals will not be impacted by this change only whether they are referred as a 2 week wait cancer pathway referral to the hospital Trust or an urgent 2 week wait direct access referral to an endoscopy service. The benefit is a significant reduction in the number of outpatient appointments required in the hospital Trust and associated costs. Issues around governance and pathway linkage with the independent endoscopy providers and associated pathology laboratories have been raised. In this modelling, only the Baseline is calculated. Further details about this are available in associated the Modelling Data excel spreadsheet and Modelling Report. 55

56 Modelling Results: Upper GI, Baseline Referrals Number of Referrals - Baseline Actual Projected Trust Buckinghamshire Healthcare NHS Trust ,133 1,091 1,135 1,173 1,212 1,246 1,280 1,310 Great Western Hospitals NHS Foundation Trust ,033 1,002 1,039 1,073 1,104 1,132 1,159 1,185 Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust 1,172 1,169 1,022 1,334 1,388 1,754 1,544 1,581 1,615 1,647 1,675 1,703 1,728 Royal Berkshire NHS Foundation Trust ,028 1,282 1,225 1,278 1,330 1,376 1,418 1,458 1,494 Wexham Park Hospital ,001 1,027 1,053 1,077 1,100 Total 4,078 4,304 4,396 5,324 5,639 6,808 6,349 6,572 6,778 6,969 7,147 7,315 7,472 2,000 1,800 1,600 1,400 1,200 1, Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust Royal Berkshire NHS Foundation Trust Wexham Park Hospital Change between 2014 and 2021: 10% 56

57 Modelling Results: Upper GI, Baseline Tests Number of Tests - Baseline Estimated Projected Trust Buckinghamshire Healthcare NHS Trust 890 1,020 1,095 1,323 1,308 1,598 1,539 1,601 1,655 1,709 1,758 1,805 1,848 Great Western Hospitals NHS Foundation Trust ,027 1,236 1,315 1,457 1,414 1,466 1,513 1,557 1,597 1,635 1,672 Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust 1,653 1,649 1,442 1,882 1,958 2,475 2,179 2,230 2,279 2,323 2,363 2,403 2,438 Royal Berkshire NHS Foundation Trust ,071 1,304 1,450 1,809 1,728 1,803 1,876 1,941 2,001 2,057 2,108 Wexham Park Hospital ,088 1,136 1,199 1,409 1,330 1,374 1,413 1,449 1,486 1,519 1,552 Total 5,753 6,072 6,202 7,511 7,955 9,605 8,956 9,272 9,562 9,832 10,082 10,319 10,541 3,000 2,500 2,000 1,500 1, Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust Royal Berkshire NHS Foundation Trust Wexham Park Hospital 57

58 Modelling Results: Urology, Baseline Referrals Number of Referrals - Baseline Actual Projected Trust Buckinghamshire Healthcare NHS Trust 1,263 1,482 1,593 1,661 1,890 2,128 2,048 2,125 2,193 2,261 2,323 2,382 2,435 Great Western Hospitals NHS Foundation Trust ,044 1,278 1,321 1,325 1,374 1,420 1,461 1,500 1,536 1,571 Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust 1,345 1,437 1,762 2,173 2,365 2,566 2,535 2,636 2,730 2,815 2,893 2,967 3,035 Royal Berkshire NHS Foundation Trust 907 1,082 1,203 1,209 1,566 1,931 1,728 1,802 1,873 1,936 1,994 2,048 2,099 Wexham Park Hospital ,006 1,283 1,347 1,361 1,427 1,484 1,537 1,590 1,638 1,684 Total 5,666 6,234 7,029 7,760 9,121 10,147 9,789 10,177 10,532 10,861 11,167 11,456 11,725 3,500 3,000 2,500 2,000 1,500 1, Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust Royal Berkshire NHS Foundation Trust Wexham Park Hospital Change between 2014 and 2021: 16% 58

59 Modelling Results: Urology, Scenario 3 Referrals Number of Referrals - Scenario 3 Actual Projected Trust Buckinghamshire Healthcare NHS Trust 1,263 1,482 1,593 1,661 1,890 2,128 2,048 2,165 2,275 2,389 2,497 2,605 2,664 Great Western Hospitals NHS Foundation Trust ,044 1,278 1,321 1,325 1,399 1,470 1,540 1,607 1,674 1,712 Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust 1,345 1,437 1,762 2,173 2,365 2,566 2,535 2,682 2,825 2,963 3,095 3,227 3,301 Royal Berkshire NHS Foundation Trust 907 1,082 1,203 1,209 1,566 1,931 1,728 1,835 1,942 2,043 2,141 2,238 2,293 Wexham Park Hospital ,006 1,283 1,347 1,361 1,452 1,536 1,618 1,701 1,782 1,833 Total 5,666 6,234 7,029 7,760 9,121 10,147 9,789 10,361 10,913 11,452 11,978 12,496 12,791 3,500 3,000 2,500 2,000 1,500 1, Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust Royal Berkshire NHS Foundation Trust Wexham Park Hospital Change between 2014 and 2021: 26% Total Change by Baseline to Scenario 3: 9% 59

60 Modelling Results: Urology, Baseline Tests Number of Tests - Baseline Estimated Projected Trust Buckinghamshire Healthcare NHS Trust 1,725 2,025 2,176 2,269 2,582 2,907 2,798 2,904 2,997 3,090 3,173 3,254 3,326 Great Western Hospitals NHS Foundation Trust 1,031 1,164 1,208 1,426 1,746 1,805 1,810 1,878 1,940 1,997 2,049 2,099 2,146 Milton Keynes Hospital NHS Foundation Trust ,010 1,167 1,082 1,110 1,137 1,162 1,186 1,209 1,232 Oxford University Hospitals NHS Trust 1,837 1,963 2,407 2,969 3,231 3,506 3,463 3,601 3,730 3,846 3,952 4,053 4,146 Royal Berkshire NHS Foundation Trust 1,239 1,478 1,643 1,652 2,139 2,638 2,361 2,462 2,559 2,645 2,724 2,798 2,867 Wexham Park Hospital 963 1,055 1,228 1,374 1,753 1,840 1,859 1,949 2,027 2,100 2,172 2,237 2,301 Total 7,741 8,517 9,603 10,601 12,461 13,862 13,374 13,903 14,389 14,838 15,256 15,650 16,018 60

61 Modelling Results: Urology, Scenario 3 Tests Number of Tests - Scenario 3 Estimated Projected Trust Buckinghamshire Healthcare NHS Trust 1,725 2,025 2,176 2,269 2,582 2,907 2,798 2,958 3,109 3,263 3,411 3,559 3,639 Great Western Hospitals NHS Foundation Trust 1,031 1,164 1,208 1,426 1,746 1,805 1,810 1,911 2,009 2,104 2,196 2,287 2,339 Milton Keynes Hospital NHS Foundation Trust ,010 1,167 1,082 1,131 1,181 1,229 1,277 1,325 1,350 Oxford University Hospitals NHS Trust 1,837 1,963 2,407 2,969 3,231 3,506 3,463 3,664 3,860 4,047 4,229 4,409 4,510 Royal Berkshire NHS Foundation Trust 1,239 1,478 1,643 1,652 2,139 2,638 2,361 2,507 2,653 2,791 2,925 3,057 3,132 Wexham Park Hospital 963 1,055 1,228 1,374 1,753 1,840 1,859 1,983 2,098 2,211 2,324 2,434 2,504 Total 7,741 8,517 9,603 10,601 12,461 13,862 13,374 14,154 14,909 15,645 16,363 17,072 17,474 5,000 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1, Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust Royal Berkshire NHS Foundation Trust Wexham Park Hospital 61

62 Modelling Results: Gynae, Baseline Referrals Number of Referrals - Baseline Actual Projected Trust Buckinghamshire Healthcare NHS Trust 1,733 1,610 1,446 1,664 2,272 2,275 2,127 2,190 2,246 2,302 2,353 2,402 2,446 Great Western Hospitals NHS Foundation Trust 1,204 1,324 1,398 1,500 1,713 1,778 1,784 1,833 1,879 1,922 1,960 1,998 2,033 Milton Keynes Hospital NHS Foundation Trust 1,332 1,283 1,334 1,494 1,688 1,902 1,776 1,837 1,895 1,948 2,000 2,048 2,096 Oxford University Hospitals NHS Trust 2,344 2,286 2,120 2,658 4,262 3,730 3,688 3,820 3,943 4,054 4,155 4,253 4,341 Royal Berkshire NHS Foundation Trust 1,735 1,682 1,857 2,002 2,272 2,978 2,563 2,653 2,741 2,819 2,891 2,958 3,021 Wexham Park Hospital 2,066 1,971 2,182 2,303 2,446 2,693 2,618 2,689 2,748 2,806 2,864 2,917 2,970 Total 10,414 10,156 10,337 11,621 14,653 15,356 14,557 15,023 15,453 15,851 16,224 16,576 16,907 5,000 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1, Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust Royal Berkshire NHS Foundation Trust Wexham Park Hospital Change between 2014 and 2021: 10% 62

63 Modelling Results: Gynae, Scenario 3 Referrals Number of Referrals - Scenario 3 Actual Projected Trust Buckinghamshire Healthcare NHS Trust 1,733 1,610 1,446 1,664 2,272 2,275 2,127 2,190 2,246 2,302 2,353 2,402 2,446 Great Western Hospitals NHS Foundation Trust 1,204 1,324 1,398 1,500 1,713 1,778 1,784 1,833 1,879 1,922 1,960 1,998 2,033 Milton Keynes Hospital NHS Foundation Trust 1,332 1,283 1,334 1,494 1,688 1,902 1,776 1,837 1,895 1,948 2,000 2,048 2,096 Oxford University Hospitals NHS Trust 2,344 2,286 2,120 2,658 4,262 3,730 3,688 3,820 3,943 4,054 4,155 4,253 4,341 Royal Berkshire NHS Foundation Trust 1,735 1,682 1,857 2,002 2,272 2,978 2,563 2,653 2,741 2,819 2,891 2,958 3,021 Wexham Park Hospital 2,066 1,971 2,182 2,303 2,446 2,693 2,618 2,689 2,748 2,806 2,864 2,917 2,970 Total 10,414 10,156 10,337 11,621 14,653 15,356 14,557 15,023 15,453 15,851 16,224 16,576 16,907 5,000 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1, Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust Royal Berkshire NHS Foundation Trust Wexham Park Hospital Change between 2014 and 2021: 10% Total Change by Baseline to Scenario 3: 0% 63

64 Modelling Results: Gynae, Baseline Tests Number of Tests - Baseline Estimated Projected Trust Buckinghamshire Healthcare NHS Trust 2,636 2,448 2,199 2,531 3,455 3,460 3,235 3,331 3,415 3,501 3,579 3,653 3,720 Great Western Hospitals NHS Foundation Trust 1,831 2,014 2,126 2,281 2,605 2,704 2,713 2,788 2,858 2,922 2,981 3,038 3,092 Milton Keynes Hospital NHS Foundation Trust 2,026 1,951 2,029 2,272 2,567 2,893 2,701 2,794 2,882 2,963 3,042 3,115 3,188 Oxford University Hospitals NHS Trust 3,565 3,477 3,224 4,042 6,482 5,673 5,609 5,810 5,996 6,165 6,319 6,467 6,602 Royal Berkshire NHS Foundation Trust 2,639 2,558 2,824 3,045 3,455 4,529 3,898 4,035 4,169 4,287 4,397 4,499 4,594 Wexham Park Hospital 3,142 2,997 3,318 3,502 3,720 4,096 3,982 4,089 4,180 4,267 4,356 4,436 4,516 Total 15,838 15,445 15,720 17,673 22,284 23,353 22,138 22,847 23,501 24,106 24,673 25,209 25,712 7,000 6,000 5,000 4,000 3,000 2,000 1,000 - Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust Royal Berkshire NHS Foundation Trust Wexham Park Hospital 64

65 Modelling Results: Gynae, Scenario 3 Tests Number of Tests - Scenario 3 Estimated Projected Trust Buckinghamshire Healthcare NHS Trust 2,636 2,448 2,199 2,531 3,455 3,460 3,235 3,331 3,415 3,501 3,579 3,653 3,720 Great Western Hospitals NHS Foundation Trust 1,831 2,014 2,126 2,281 2,605 2,704 2,713 2,788 2,858 2,922 2,981 3,038 3,092 Milton Keynes Hospital NHS Foundation Trust 2,026 1,951 2,029 2,272 2,567 2,893 2,701 2,794 2,882 2,963 3,042 3,115 3,188 Oxford University Hospitals NHS Trust 3,565 3,477 3,224 4,042 6,482 5,673 5,609 5,810 5,996 6,165 6,319 6,467 6,602 Royal Berkshire NHS Foundation Trust 2,639 2,558 2,824 3,045 3,455 4,529 3,898 4,035 4,169 4,287 4,397 4,499 4,594 Wexham Park Hospital 3,142 2,997 3,318 3,502 3,720 4,096 3,982 4,089 4,180 4,267 4,356 4,436 4,516 Total 15,838 15,445 15,720 17,673 22,284 23,353 22,138 22,847 23,501 24,106 24,673 25,209 25,712 7,000 6,000 5,000 4,000 3,000 2,000 1,000 - Buckinghamshire Healthcare NHS Trust Great Western Hospitals NHS Foundation Trust Milton Keynes Hospital NHS Foundation Trust Oxford University Hospitals NHS Trust Royal Berkshire NHS Foundation Trust Wexham Park Hospital 65

66 Modelling Results: A view of tests - baseline Number of tests top 10 by volume (in 2021) Estimated and Projected Number of Tests: All 5 Specialties Baseline All Thames Valley Hysteroscopy 8,837 8,618 8,772 9,861 12,434 13,031 12,353 12,748 13,113 13,451 13,767 14,066 14,347 Colonoscopy 5,728 7,088 8,553 9,747 9,425 10,741 10,726 11,153 11,596 12,018 12,424 12,817 13,095 CT Scan 5,978 6,655 7,505 8,609 8,871 10,222 9,826 10,230 10,627 11,006 11,369 11,722 11,972 Cystoscopy 3,631 3,994 4,504 4,972 5,844 6,502 6,273 6,580 6,871 7,149 7,415 7,674 7,854 Ultrasound 4,464 4,452 4,623 5,184 6,433 6,831 6,497 6,727 6,942 7,142 7,331 7,510 7,666 Other 2,930 3,303 3,746 4,236 4,603 5,192 5,041 5,257 5,468 5,667 5,859 6,044 6,179 OGD 3,222 3,401 3,473 4,207 4,455 5,379 5,016 5,193 5,355 5,506 5,647 5,779 5,903 MRI Scan 2,777 2,989 3,282 3,703 4,228 4,703 4,519 4,707 4,887 5,057 5,219 5,376 5,494 Ultrasound - Transvaginal 1,421 1,386 1,410 1,586 1,999 2,095 1,986 2,050 2,108 2,163 2,214 2,262 2,307 Flexi-Sigmoidoscopy ,039 1,184 1,145 1,305 1,303 1,355 1,409 1,460 1,510 1,557 1,591 66

67 Modelling Results: A view of tests Scenario 3 Number of tests top 10 by volume (in 2021) Estimated and Projected Number of Tests: All 5 Specialties Scenario 3 All Thames Valley Hysteroscopy 8,837 8,618 8,772 9,861 12,434 13,031 12,353 12,748 13,113 13,451 13,767 14,066 14,347 Colonoscopy 5,728 7,088 8,553 9,747 9,425 10,741 10,726 11,330 11,963 12,587 13,205 13,820 14,122 CT Scan 5,978 6,655 7,505 8,609 8,871 10,222 9,826 10,323 10,820 11,304 11,779 12,248 12,510 Cystoscopy 3,631 3,994 4,504 4,972 5,844 6,502 6,273 6,639 6,993 7,338 7,675 8,007 8,196 Ultrasound 4,464 4,452 4,623 5,184 6,433 6,831 6,497 6,740 6,967 7,181 7,385 7,580 7,737 Other 2,930 3,303 3,746 4,236 4,603 5,192 5,041 5,308 5,573 5,831 6,083 6,332 6,474 OGD 3,222 3,401 3,473 4,207 4,455 5,379 5,016 5,193 5,355 5,506 5,647 5,779 5,903 MRI Scan 2,777 2,989 3,282 3,703 4,228 4,703 4,519 4,739 4,952 5,159 5,359 5,555 5,678 Ultrasound - Transvaginal 1,421 1,386 1,410 1,586 1,999 2,095 1,986 2,050 2,108 2,163 2,214 2,262 2,307 Flexi-Sigmoidoscopy ,039 1,184 1,145 1,305 1,303 1,377 1,454 1,529 1,604 1,679 1,716 67

68 Any Questions? 68

69 Lunch Yay! 69

70 Outputs: Individual Trust Data Mini Reports 70

71 Qualitative data: Cancer managers Quality of referrals from primary care Primary care carrying out all available direct access testing? Difficult to keep within targets if a tertiary centre involved Patient choice is a significant reason for breach Sequential diagnostics pathway rather than parallel 71

72 Qualitative Feedback: Pathology Pathology requests increasing year on year Trend of more complex drugs and tailored treatment which typically all need a new test Service not always included in planning Workforce recruitment and retention national issue Local solutions include outsourcing of routine samples, overtime, agency staff, incentivising posts, but no solution is sustainable 72

73 Qualitative Feedback: Radiology Increasing complexity of tests Recruitment and retention at all levels national issue Local solutions, outsourcing, agency staff, shift work, extending working day (7 days 8am-8pm) Capital equipment overdue for replacement localise Always playing catch up - unsustainable 73

74 Qualitative Feedback: Specialty Lung PET scans, direct access results from CT and chest x-ray from GP, complex work up and late stage presentation Gynae direct access hysteroscopy, CA125 result from GP, hysteroscopy capacity generally, staffing Colorectal Patients unprepared for procedure, lack of nurse endoscopists, single sex clinics Upper GI complex work up, tertiary centre involved and late stage presentation Urology Primary care don t always undertake baseline investigations, single sex clinics, thinking time for treatment options and complex range of tests. 74

75 Highlights. Thames Valley 14% increase in referrals between 2014 and 2021 Diagnostics are becoming more numerous, complex and time consuming per referral Currently no one meeting 28 day referral to confirmed diagnosis - range 0-60% Overall radiology and pathology services are unsustainable in the long term o workforce, o year on year cut to budgets, o diagnostics not included in service planning, o equipment falling over. 75

76 Essentially all models are wrong but some are useful. George Box 76

77 Using what we ve done Go through reports is there anything you don t know already? Use excel spreadsheet we will send to you to identify figures most important to your organisation Fine tune the model use our methodology and referral information in the report with your own diagnostic data Feedback comments if there is anything wrong or that you want to add to TVCDS@sph.nhs.uk Come and talk to us. 77