Anaesthesia for head and neck surgery

230 Pages·2016·10.01 MB·English

00222151_130-S2_00222151_130-S2 06/05/16 12:05 PM Page 1
The Journal of
Laryngology & Otology
VOLUME 130 MAY 2016 VOLUME 130 | NUMBER S2 | MAY 2016 ISSN: 0022-2151
Foreword S1
T
Guidelines h The Journal of
e
Introduction to the United Kingdom National Multidisciplinary Guidelines for Head and Neck Cancer: V Paleri, N Roland S3 J
Organisation and provision of head and neck cancer surgical services in the United Kingdom: United Kingdom National Multidisciplinary Guidelines: o
u
F Stafford, K Ah-See, M Fardy, K Fell S5 r Laryngology
n
Aetiology and risk factors for head and neck cancer: United Kingdom National Multidisciplinary Guidelines: R Shaw, N Beasley S9 a
Pre-treatment clinical assessment in head and neck cancer: United Kingdom National Multidisciplinary Guidelines: A Robson, J Sturman, l o
f
P Williamson, P Conboy, S Penney, H Wood S13 L
Anaesthesia for head and neck surgery: United Kingdom National Multidisciplinary Guidelines: P Charters, I Ahmad, A Patel, S Russell S23 a
r
y
Imaging in head and neck cancer: United Kingdom National Multidisciplinary Guidelines: H Lewis-Jones, S Colley, D Gibson S28 n
g
Nutritional management in head and neck cancer: United Kingdom National Multidisciplinary Guidelines: B Talwar, R Donnelly, R Skelly, M Donaldson S32 o
Restorative dentistry and oral rehabilitation: United Kingdom National Multidisciplinary Guidelines: C Butterworth, L McCaul, C Barclay S41 lo & Otology
g
Psychological management for head and neck cancer patients: United Kingdom National Multidisciplinary Guidelines: G Humphris S45 y
&
Quality of life considerations in head and neck cancer: United Kingdom National Multidisciplinary Guidelines: SN Rogers, C Semple, M Babb, G Humphris S49
O
Tumour assessment and staging: United Kingdom National Multidisciplinary Guidelines: N Roland, G Porter, B Fish, Z Makura S53
to
Pathological aspects of the assessment of head and neck cancers: United Kingdom National Multidisciplinary Guidelines: TR Helliwell, TE Giles S59 lo
Radiotherapy in head and neck cancer management: United Kingdom National Multidisciplinary Guidelines: C Nutting S66 g
y
Surgery in head and neck cancer: United Kingdom National Multidisciplinary Guidelines: JJ Homer S68
Chemotherapy: United Kingdom National Multidisciplinary Guidelines: CG Kelly S71
Laryngeal cancer: United Kingdom National Multidisciplinary guidelines: TM Jones, M De, B Foran, K Harrington, S Mortimore S75
Oral cavity and lip cancer: United Kingdom National Multidisciplinary Guidelines: C Kerawala, T Roques, J-P Jeannon, B Bisase S83
Head and Neck Cancer:
Oropharyngeal cancer: United Kingdom National Multidisciplinary Guidelines: H Mehanna, M Evans, M Beasley, S Chatterjee, M Dilkes, J Homer,
J O’hara, M Robinson, R Shaw, P Sloan S90 United Kingdom National Multidisciplinary Guidelines
Nasopharyngeal carcinoma: United Kingdom National Multidisciplinary Guidelines: R Simo, M Robinson, M Lei, A Sibtain, S Hickey S97
Edited by Vinidh Paleri and Nick Roland
Hypopharyngeal cancer: United Kingdom National Multidisciplinary Guidelines: P Pracy, S Loughran, J Good, S Parmar, R Goranova S104
Nose and paranasal sinus tumours: United Kingdom National Multidisciplinary Guidelines: VJ Lund, PM Clarke, AC Swift, GW McGarry,
C Kerawala, D Carnell S111
Management of lateral skull base cancer: United Kingdom National Multidisciplinary Guidelines: JJ Homer, T Lesser, D Moffat, N Slevin,
R Price, T Blackburn S119
Non-melanoma skin cancer: United Kingdom National Multidisciplinary Guidelines: C Newlands, R Currie, A Memon, S Whitaker, T Woolford S125
Head and neck melanoma (excluding ocular melanoma): United Kingdom National Multidisciplinary Guidelines: OA Ahmed, C Kelly S133 ENDORSED BY:
V
Management of Salivary Gland Tumours: United Kingdom National Multidisciplinary Guidelines: S Sood, M McGurk, F Vaz S142 O
Management of thyroid cancer: United Kingdom National Multidisciplinary Guidelines: AL Mitchell, A Gandhi, D Scott-Coombes, P Perros S150 L
U British Association of Endocrine and
Management of neck metastases in head and neck cancer: United Kingdom National Multidisciplinary Guidelines: V Paleri, TG Urbano, H Mehanna, M
C Repanos, J Lancaster, T Roques, M Patel, M Sen S161 E Thyroid Surgeons (BAETS)
Investigation and management of the unknown primary with metastatic neck disease: United Kingdom National Multidisciplinary Guidelines: K Mackenzie, 1
M Watson, P Jankowska, S Bhide, R Simo S170 3
Speech and swallow rehabilitation in head and neck cancer: United Kingdom National Multidisciplinary Guidelines: P Clarke, K Radford, M Coffey, 0 British Association of Head and Neck
M Stewart S176 | N Oncologists (BAHNO)
Recurrent head and neck cancer: United Kingdom National Multidisciplinary Guidelines: H Mehanna, A Kong, SK Ahmed S181 U
Reconstructive considerations in head and neck surgical oncology: United Kingdom National Multidisciplinary Guidelines: M Ragbir, JS Brown, H Mehanna S191 M
Palliative and supportive care in head and neck cancer: United Kingdom National Multidisciplinary Guidelines: H Cocks, K Ah–See, M Capel, P Taylor S198 B British Association of Oral and
E
Follow-up after treatment for head and neck cancer: United Kingdom National Multidisciplinary Guidelines: R Simo, J Homer, P Clarke, K Mackenzie, R Maxillofacial Surgeons (BAOMS)
V Paleri, P Pracy, N Roland S208 S
The clinical nurse specialist’s role in head and neck cancer care: United Kingdom National Multidisciplinary Guidelines: L Dempsey, S Orr, S Lane, A Scott S212 2
British Association of
Clinical research, national studies and grant applications: United Kingdom National Multidisciplinary Guidelines: N Stafford S216 |
Education of trainees, training and fellowships for head and neck oncologic and surgical training in the UK: United Kingdom National M Otorhinolaryngology–Head and
Multidisciplinary Guidelines: R Simo, A Robson, B Woodwards, P Niblock, P Matteucci S218 A
Y Neck Surgery (ENT UK)
Future perspectives: United Kingdom National Multidisciplinary Guidelines: EV King, K Harrington S222 2
0
1
6
British Association of Plastic,
Reconstructive and Aesthetic Surgeons
(BAPRAS)
The Royal College of Pathologists
(RCPath)
The Royal College of Radiologists
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The Journal of
Laryngology & Otology
Volume 130, Number S2,March 2016
Head and Neck Cancer:
United Kingdom National Multidisciplinary Guidelines
Edited by:
VinidhPaleri
DepartmentofOtolaryngology-HeadandNeckSurgery,TheNewcastleUponTyneHospitals
NHSFoundationTrust,NorthernInstituteofCancerResearch,NewcastleUponTyne
Nick Roland
DepartmentofOtolaryngology-HeadandNeckSurgery,AintreeUniversityHospitals
NHSFoundationTrust,Liverpool,UK
Endorsed by:
Sponsored by:
JLO (1984) Ltd
Publication of this Supplement was supported by JLO(1984) Ltd.
These guidelines have been reviewed bythe Guest Editors and may becited.
The Journal of
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Senior Assistant Editors lain Swan (Glasgow)
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TheJournalofLaryngology&Otology(2016),130(Suppl.S2),S1–S2. FOREWORD
©JLO(1984)Limited,2016. ThisisanOpenAccessarticle,distributedunderthetermsoftheCreativeCommons
Attributionlicence(http://creativecommons.org/licenses/by/4.0/),whichpermitsunrestrictedre-use,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.
doi:10.1017/S0022215116001195
On behalf of the British The British Association of Head and Neck
Association of Endocrine and Oncologists represents the multidisciplinary head and
ThyroidSurgeons,itisapleasure neck community within the UK, so as President, I
to endorse this multidisciplinary offer once again the grateful thanks of our association
document. BAETS represents to both the editors and the many contributing authors
surgeons who have developed for their tireless efforts in compiling and publishing
particular expertise in thyroid this essential set of clinical guidelines.
surgery, regardless of the spe-
cialty in which they originally trained. The inclusion Michael Fardy FFDRCSI, FDSRCS, FRCS
ofthyroidcancerwithupperairwaycancersispragmat- President
icbecausetheysharesomecommonfeaturesclinically British Association of Head and Neck Oncologists
atpresentation,particularlythepresenceofa‘lump’in
the neck.Themost recent British ThyroidAssociation
guidelinesforthetreatmentofthyroidcancercoverthe
investigation and management of thyroid cancer in Guidelinesareanessentialpartof
depth.BAETSmaintainsahugedatabaseofoutcomes theprocessofensuringappropriate
aftersurgeryofthethyroid,bothbenignandmalignant. treatmentisavailableandprovided
This satisfies the requirement for surgeons to collect for patients unfortunate enough to
data in linewith the requirements of HQIP. be given a diagnosis of a head
and neck malignancy. There is a
Mark Lansdown BSc, MBBCh, MCh, FRCS needtomakesurethattheseguide-
President lines are regularly updated so that
BritishAssociationofEndocrineandThyroidSurgeons our interventions remain up to date and effective, and I
am pleased that this has already taken place. As a max-
illofacial head and neck surgeon I have seen many
changes and improvements, but teamwork, respect and
The United Kingdom is a major co-operation with colleagues to smooth the patient
player in clinical and basic journey are paramount and have greatly improved. The
science research into head and Liverpoolgroupwasluckyenoughtohavetheopportun-
neck cancer, but trying to ity to host the European Congress on Head and Neck
compare treatment methods is Oncology in 2014, and demonstrate the high level of
fraught with difficulty, and there- team-working in the clinical and research arena. The
fore evidence for one treatment average head and neck cancer patient has a rocky path
over another is scarce. Due to the to tread, and there is no doubt that such a publication
complexity and rarity of head and availabletoall willhelp themalong theway.
neck cancer, it has always been very difficult to decide
what the best treatment is asthere are multiple elements Professor James S Brown MD FRCS FDSRCS
tothemanagement. President
In 2011, two brave souls decided that the time was BritishAssociationofOralandMaxillofacialSurgeons
right to pull together the great and the good to
produce a UK Multidisciplinary Consensus Guideline
forHeadandNeckOncology,inanattempttoestablish
best practice. Itisaprivilegetowriteaforeword
Thishasbeenthebenchmarkdocumentfortheman- for this superb document. Once
agement head and neck cancer in the UK on which to again our head and neck collea-
base our MDT decisions. It was and continues to be gues have demonstrated great
truly multidisciplinary. collegiality and teamwork to
Overtime,treatmentsareevaluated,soinlightofthe produce an outstanding consen-
advances made in radiotherapy delivery and che- sus document. It is also remark-
motherapeutic options, as well as new technologies ably user friendly and I am sure
e.g. transoral robotic surgery, the time is right to will provide a superb clinical resource for the benefit
relook at these guidelines and update them, of our patients. This approach along with improved
S2 FOREWORD
data collection and analysis will help keep British Members of all the contributing specialties are to be
surgeryat the forefront of care for many years ahead. congratulated on the degree of collaboration and con-
sensus reached and the high quality of the resulting
Professor Antony A Narula MA MB BChir FRCS document. The latest version of these comprehensive
FRCS (Ed) guidelines will support multidisciplinary teams
President working in head and neck cancer and help them
British Association of Otorhinolaryngology-Head & provide the best possible outcome for patients.
Neck Surgery Additionssincethelasteditionincluderecentadvances
in molecular pathology, particularly the development
of molecular evaluation for viral-induced cancers.
Such quality-assured pathology guidance provides
It is fascinating to compare these reassurance to clinical teams that pathology informa-
excellent, updated guidelines tionisbasedongoodevidenceandhastheconfidence
with the old version. Doing so of pathologists across the UK. Congratulations on an
unfolds a story of true multidis- excellent document, which I’m surewill bewelcomed
ciplinarycareleadingtoimproved by members of all specialties working in this area.
patient outcomes, where each
individual in a team knows that Suzy Lishman FRCPath
they cannot function without the President
others, and that everyone has skills and strengths to The Royal College of Pathologists
add to the whole for the benefit of the patient under
the team’s care. As a result of that multidisciplinary
care, the treatment of head and neck cancer has
changed very much for the better in the last two OnbehalfofTheRoyalCollege
decades, and I commend those involved in treating of Radiologists I very much
these patients for their dedication. In particular, the welcome the updating of these
head and neck surgeons deserve praise for being first important multidisciplinary
on board the National Flap Register, which is a testa- guidelines for head and neck
ment to their desire to continuously improve care and cancer. They provide avaluable
outcomes for this complex and heterogenous patient resource for all those across
population. Congratulationsto all! many specialties who are
involved in the treatment of patients with head and
Mr Nigel Mercer FRCS neck cancer and they should continue to be essential
President, 2015–2016 reading. The guidelines cover all aspects of head and
British Association of Plastic, Reconstructive and neckcancermanagement,fromepidemiologyanddiag-
Aesthetic Surgeons nosis through to treatment and outcomes, and I
commend the editors and authors – a number of
whom are Fellows of the RCR – for this tremendous
bodyofwork.I hopethis neweditionwillcontinueto
TheRoyalCollegeofPathologists
encourage and support multidisciplinary working and
is delighted to endorse this publi-
thereby help to improve patient care and ensure the
cation and I would like to take
highestpossiblestandardsareachievedandmaintained.
the opportunity to thank the
authors and editors for all their
hard work, particularly Professor Dr Giles Maskell
Helliwell and Dr Giles, who con- President
tributed the pathology content. The Royal College of Radiologists
TheJournalofLaryngology&Otology(2016),130(Suppl.S2),S3–S4. GUIDELINE
©JLO(1984)Limited,2016. ThisisanOpenAccessarticle,distributedunderthetermsoftheCreativeCommons
Attributionlicence(http://creativecommons.org/licenses/by/4.0/),whichpermitsunrestrictedre-use,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.
doi:10.1017/S0022215116000359
Introduction to the United Kingdom National
Multidisciplinary Guidelines for Head and Neck
Cancer
V PALERI1, N ROLAND2
1DepartmentofOtolaryngology-HeadandNeckSurgery,TheNewcastleUponTyneHospitalsNHSFoundation
Trust,NorthernInstituteofCancerResearch,NewcastleUponTyne,and2DepartmentofOtolaryngology-Head
andNeckSurgery,AintreeUniversityHospitalsNHSFoundationTrust,Liverpool,UK
Abstract
This is the 5th edition of the UK Multi-Disciplinary Guidelines for Head and Neck Cancer, endorsed by seven
national specialty associations involved in head and neck cancer care. Our aim isto provide a document can be
used as a ready reference for multidisciplinary teams and a concise easy read for trainees. All evidence based
recommendations in this edition are indicated by ‘(R)’ and where the multidisciplinary team of authors consider
arecommendationtobebasedonclinicalexperience,itisdenotedby‘(G)’asagoodpracticepoint.
Itisanenormousprivilegeandagreatpleasuretointro- (SIGN) grading of recommendations. In 2013, SIGN
duce the 5th edition of the UK Multi-Disciplinary abandoned its ABCD grading method2 as it became
Guidelines for Head and Neck Cancer. Akin to the evident that not all research would fit within the
4th edition,1 each aspect of the guideline has been constraints of this system. Scottish Intercollegiate
developed by an expert team, often multidisciplinary. Guidelines Network has since adopted the system
An affirmation of the true multidisciplinary nature of developed by the Grading of Recommendations
these guidelines is the endorsement by seven medical Assessment, Development and Evaluation (GRADE)
specialty organisations involved in head and neck working group.3 Having studied the GRADE method-
cancer care in the UK: British Association of ology in detail, we concluded that a guideline such as
Endocrine and Thyroid Surgeons, British Association this, generated bya multidisciplinary group of practis-
of Head and Neck Oncologists, British Association of ingclinicians,simplydidnotpossesstheresourcesand
Oral and Maxillofacial Surgeons, British Association the time to use the GRADE methodology. Similar to
of Otorhinolaryngology-Head and Neck Surgery, some of the more recent SIGN guidelines, all evi-
British Association of Plastic, Reconstructive and dence-based recommendations in this edition come
Aesthetic Surgeons, The Royal College of Pathologists without a grade attached, indicated by ‘(R)’ and
and The Royal College of Radiologists (Faculty of where the multidisciplinary team of authors consider
Clinical Oncology). The guidelines will be of interest a recommendation to be based on clinical experience,
across the spectrum of healthcare professionals who it is denoted as a good practice point ‘(G)’.
lookafterpatientswithHeadandNeckCancer. The 5th edition will again provide a robust clinical
Ouraimwastoproducemultidisciplinaryconsensus document, which can be used as a ready reference.
recommendations on the management of Head and and a concise easy read for trainees and all involved
Neck cancer based on the expertise and experience in Head and Neck cancer care. In conjunction with
invested within the UK-based international experts the upper aerodigestive tract cancer guidelines pub-
and their appraisal of the current evidence. The remit lished recently by the National Institute for Health
oftheseguidelinesistoprovideevidence-basedrecom- and Care Excellence,4 the recommendations across
mendationsthat will help identifyan optimal manage- these two publications should improve the care pro-
mentstrategy.Itshouldbeappreciatedthattheultimate vided to this complexdisease.Thetremendous amount
decision for the management should rest with the of work put in by the authors is being recognised by
multidisciplinary team, which takes into account all individually indexed publications; however, we would
clinical data pertaining to the patient and his or her recommend that readers use this supplement in the
own social circumstances and individual preferences. JournalofLaryngologyandOtologyasa singledocu-
Incontrasttothe4thedition,wehavemigratedaway ment owing to the cross-referencing within it. We are
from the Scottish Intercollegiate Guidelines Network confident that the publication of the 5th edition as a
S4 VPALERIANDNROLAND
journalsupplementwill enhancereadershipandfacili- 2 Scottish Intercollegiate Guidelines Network (SIGN). Methodo-
tate greater dissemination across the Head and Neck logicalprinciples.http://www.sign.ac.uk/methodology/index.html
(accessed15October2015)
community.
3 Grading of Recommendations Assessment, Development and
Evaluation Working Group. http://www.gradeworkinggroup.
org/(accessed15October2015)
Acknowledgements
4 NationalInstituteforHealthandCareExcellence.Cancerofthe
We would like to express our deepest gratitude to the col- upper aerodigestive tract: assessment and management in
leges,societiesandrepresentativesthathavemadethispos- peopleaged16andover.London:NationalInstituteforHealth
and Care Excellence, 2016. https://www.nice.org.uk/guidance/
sible and most of all for the generous time contributed by
ng36(accessed27April2016)
the authors of each subject topic. We are indebted to Aled
Hills and the team at Cambridge University Press for their
Addressforcorrespondence:
exceptional diligence, and the Trustees of JLO (1984) Ltd VinidhPaleri,
fortheirgeneroussupport. DepartmentofOtolaryngology-HeadandNeckSurgery,
TheNewcastleuponTyneHospitalsNHSFoundationTrust,
NorthernInstituteofCancerResearch,
References NewcastleUponTyne,UK.
1 RolandNJ,PaleriV,eds.HeadandNeckCancer:Multidisciplinary
ManagementGuidelines,4thedn.London:ENTUK,2011 E-mail:[email protected]
TheJournalofLaryngology&Otology(2016),130(Suppl.S2),S5–S8. GUIDELINE
©JLO(1984)Limited,2016. ThisisanOpenAccessarticle,distributedunderthetermsoftheCreativeCommons
Attributionlicence(http://creativecommons.org/licenses/by/4.0/),whichpermitsunrestrictedre-use,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.
doi:10.1017/S0022215116000839
Organisation and provision of head and neck cancer
surgical services in the United Kingdom: United
Kingdom National Multidisciplinary Guidelines
F STAFFORD1, K AH-SEE2, M FARDY3, K FELL4
1SunderlandRoyalHospital,Sunderland,2DepartmentofOtolaryngology – HeadandNeckSurgery,Aberdeen
RoyalInfirmary,Aberdeen,UK,3UniversityHospitalofWales,Cardiff,UK,and4NHSEngland(Midlandsand
East),CNSTumoursandHeadandNeckCancers,UK
Abstract
Thisistheofficialguidelineendorsedbythesurgicalspecialtyassociationsinvolvedinthecareofheadandneck
cancer patients in the UK. This paper summarises the current state of play in the organisation and provision of
headandneckcancersurgicalservicesintheUK.
Introduction
recommendations in the Health and Social Care Act
Thequalityandavailabilityofcareforpatientswithhead
2012.5 This is the fifth major reorganisation of the
and neck cancer has improved immeasurably over the
NHS structure since 2000. Primary Care Trusts and
past30years.Improvedtraining,applicationofevidence-
StrategicHealthAuthoritiesweredisbandedandreplaced
basedpractice,multi-disciplinaryworking,improvedsur-
with211ClinicalCommissioningGroups(CCGs)made
gical and radiation techniques, chemotherapy, public
up of local GPs covering populations of over 250000
health education, subspecialisation and in particular the
undertheumbrellaofTheNHSCommissioningBoard,
NationalInstituteforHealthandCareExcellence(NICE)
whichbecameNHSEnglandandbeganfunctioningon
Improving Outcomes guidelines,1 the previous editions
1st April 2013.Clinical CommissioningGroupsdonot
of the Multidisciplinary Head and Neck Cancer guide-
commissionGPorspecialisedservicesasthesearedirect-
lines2andpeerreview haveall playedtheirpart.Despite
lycommissioned.6Someserviceshavebeendesignated
this,theavailabilityofsometreatmentoptionsandsurvival
as ‘specialised’ and based upon principles laid out in
outcomesintheUKstillseemtolagbehindotherWestern
the Carter Report and the Department of Health white
countries.Furtherimprovementisrequiredbutthefinan-
paper ‘Equity and excellence: liberating the NHS’.7 In
cialconstraintsintheNationalHealthService(NHS),high-
addition, a structure for prescribing and identifying
lighted over recent months, could overwhelm us and
theseservicesisnowinplace.
consequentlycouldaffectprogressindevelopingclinical
NHS England became responsible for directly
servicesfortheforeseeablefuture.
commissioned services (including specialised services)
SincetheinceptionoftheNHS,healthcarespending
inApril2013(ScotlandandWaleshavetheirowncom-
intheUKhasincreased4percentperyear.In1960,it
missioning structures). This structure is currently under
was less than 5 per cent of gross domestic product
reviewand manyof the designated specialised services
(GDP), 50 years on it is now about 10 per cent of
may have commissioning devolved to the CCGs. The
GDP. Current estimates suggest that within 10 years,
NHS England website defines specialised services as
unchecked healthcare spendingwill outstrip economic
those provided in relatively few hospitals, accessed by
growth and is not sustainable, and by 2050 spending
comparativelysmallnumbersofpatientsbutwithcatch-
would increase to over 20 per cent of GDP.3 The
mentpopulationsofusuallymorethan1million.These
Five Year Forward View, published in October
servicestendto belocated in specialised hospital trusts
2014,4 describes ways in which the NHS intends to
that can recruit a team of staff with the appropriate
tackletheexponentialrisesinthecostofNHSservices.
expertise and enable them to develop their skills.
Specialised services account for approximately 14 per
cent of the total NHS budget, about £13.8 billion per
Commissioning healthcare services
annum. The commissioning of specialised services is a
England prescribed direct commissioning responsibility of NHS
Commissioning of healthcare in all its aspects under- England.Themanualforprescribedspecialisedservices
went a total organisational restructuring based upon 2013/2014 identifies 143 services.8
S6 FSTAFFORD,KAH-SEE,MFARDYetal.
A description of the new structure for commission- powerful drivers for political intervention and
ing specialised services is given in detail on the NHS change. Thus, over the past 10 years many providers
England website. Commissioning has been devolved in England have moved towards some forms of cen-
to six programmes of care (POC) each with its own tralisation model in response to the National Institute
team of commissioners: for Health and Care Excellence (NICE) improving
outcomes guidance (IOG) for head and neck
(cid:129) internal medicine cancers, although this is not universal.
(cid:129) cancer Potentially, the HNCRG can have a great deal of
(cid:129) blood and infection influence on the future structure of services nationally
(cid:129) mental health by setting clear standards to the commissioners who
(cid:129) trauma control the funding. To influence this process, readers
(cid:129) women and children. to contact their respective senate representative.
More information about CRGs is available from the
The national Cancerand Blood POC coversthe pre- NHS England website. http://www.england.nhs.uk/
scribedspecialisedservicesininfection,cancer,immun- ourwork/commissioning/spec-services/npc-crg/
ityandhaematology.Thisrelatestobothspecialisedand
highlyspecialisedprescribedservices,andincludesboth
Scotland
surgicalandmedicalservices.Thereare74specialistser-
viceswithinthePOC,andtheseareclusteredintoClinical The NHSin Scotland is a devolved service run bythe
ReferenceGroups(CRGs)tosupportthenationalworkin ScottishgovernmentoutofparliamentinEdinburgh.It
theseareas.TheCancerProgrammeofCarecoverssome is delivered by 14 Regional Health Boards that cover
oftheprescribedspecialisedandhighlyspecialisedser- the disparate geography of Scotland. The Scottish
vices. Complex head and neck is one of 17 specialised NHS budget is approximately £11.9 billion
services in the Cancer and Blood Programme. These (2013–2014 budget).
service-specific CRGs also work with other CRGs Head and neck cancer services are delivered by the
where key service interfaces and interdependencies three major Cancer Networks within Scotland: North
betweenCRGareasoccur.Apublicconsultationtoamal- of Scotland cancer network (NOSCAN), South of
gamateCRGsiscurrentlyunderway;theimpactforhead Scotland (SCAN) and West of Scotland (WOSCAN).
andnecksurgerywillbethecreationofasuperCRGthat These cancer networks work closely together to
includes all of cancer surgery. provide a full and comprehensive head and neck
The CRG for a specific specialty will advise the cancer service to the estimated 5.5 million population
designated commissioners on service standards and inScotlandwhichisspreadacrossawiderangeofgeo-
requirements, and will complete designated tasks graphic areas from dense urban to remote and rural
requested by the commissioners. Each CRG consists sites. Over 1100 new cases of head and neck cancer
of achairandmembers (up to 15) consisting of repre- are diagnosed in Scotland per year.
sentativesfromthe12ClinicalSenates,relevantprofes- In Scotland, commissioning groups have not been
sional organisations and patient groups. England has introducedinthesamewayasinEnglandandthedeliv-
been divided into 12 Clinical Senates similar (but not eryof theNHS inScotland still followsthe traditional
identical) geographically to the new Cancer Networks NHSmethodofGPreferraltothelocalsecondarycare
providingmembersforthedifferentCRGs.Moreinfor- centrewith‘urgentsuspicionofcancer’referralguide-
mation is available on the NHS England website linespublishedbyNHSScotlandinplace.Thissetsthe
(http://www.england.nhs.uk/ourwork/part-rel/cs/) standardof62daysfromreferraltotreatmentforcancer
The Complex Head and Neck Clinical Reference cases (http://www.healthcareimprovementscotland.
Group (HNCRG) covers complex benign and malig- org/our_work/cancer_care_improvement/programme_
nant head and neck services and refers to a group of resources/scottish_referral_guidelines.aspx).
very different tumours, including oral (mouth, lip Quality improvement processes are in place in
and oral cavity), larynx, pharynx, thyroid and saliv- Scotlandincludingtheintroductionofqualityperform-
ary glands tumours amongst others. It may become ance indicators (QPIs) to set the standards for cancer
the responsibility of the CRGs to advise specialised carewithin all cancer groups including head and neck
commissioners and NHS England on ways to cancer.TheQPIs have beendevelopedcollaboratively
improve efficiency and reduce costs without affect- with the three Regional Cancer Networks (NOSCAN,
ing quality or provision of care. An example is the SCAN, WOSCAN), Information Services Division
NHS England policy on Transoral Robotic Surgery and Healthcare Improvement Scotland. The Scottish
that has been developed under the aegis of the Government has asked Healthcare Improvement
CRG which is undergoing public consultation at Scotland to provide performance assurance against
the time of this paper going to press. The apparent cancer QPIs and to publish their findings on a three
poor comparisons with other European cancer yearly basis (http://www.healthcareimprovementscot-
outcome audits and a wide national variation in pro- land.org/our_work/cancer_care_improvement/cancer_
vision of services and outcomes have become qpis.aspx).