About The Programme

Dear Colleague,

 

In August 2006, NICE issued a technology appraisal recommending laparoscopic resection as an alternative to open surgery for people with colorectal cancer in whom both procedures were suitable. NICE estimated that the surgery would result in shorter bed stays and significantly improve the patient experience. On 31 October 2006, the Department of Health waived the 3-month funding direction to implement this appraisal as it was recognised that there were insufficient surgeons trained in the procedure. The waiver is due to be reviewed in 2009.

 

As part of the Cancer Reform Strategy implementation plans the Department of Health and the National Cancer Action Team have developed and funded a programme to train colorectal surgeons to a level of competence in laparoscopic surgery to perform such procedures independently and safely.

 

As we now have the mechanism in place to train consultant surgeons we would urge you to support all your colorectal surgeons and their teams already in training or who wish to start training, to enrol in the national programme. The programme offers surgeons a flexible, supportive and tailored package of training accompanied by a means of acknowledging the level of competence achieved.

 

Ten training centres based in 16 hospitals have been appointed to deliver the programme, which will allow the NHS to build up the expertise to ensure that the existing colorectal consultant surgeon workforce is trained to deliver high quality colorectal cancer surgery in line with the NICE appraisal.

 

The attached management note gives further details on the background and suggests actions the NHS will want to undertake. The NICE appraisal was very clear that patients should be able to make an informed choice between open or laparoscopic procedures following discussion with their surgeon.

 

1)            In August 2006, NICE issued a technology appraisal recommending laparoscopic resection as an alternative to open surgery for people with colorectal cancer in whom both procedures were suitable. On 31 October 2006, the Department of Health waived the 3 month funding direction to implement this appraisal.

 

2)            This note sets out the reasons for this waiver and the action that the NHS will want to take as a result.

 

 

 

3)            There are around 30,000 new cases of colorectal cancer (cancer arising in the lining of the colon or rectum) registered in England and Wales each year. Complete surgical excision of the tumour is essentially the only potential cure and suitable in approximately 75% of diagnosed individuals.

 

4)            The current UK standard for the surgical resection of primary colorectal tumours is open surgery which involves open laparotomy (surgical incision into the abdominal wall) and removal of the tumour via the abdominal incision. This procedure is associated with significant postoperative pain. While techniques such as epidural analgesia can effectively control postoperative pain, associated complications may require high-dependency care.

 

5)            Laparoscopic or laparoscopically assisted resection involves inserting laparoscopic instruments through a number of ports (openings) in the abdominal wall to dissect tissues around the tumour – the tumour is then usually removed through an abdominal incision, the length of which depends on the size of the tumour. A patient who has laparoscopic surgery is likely to make a quicker post surgery recovery and NICE estimate that a laparoscopic colorectal procedure (a highly complex procedure) would result in a shorter hospital stay - 1.4 days less than for open surgery. However, the leading experts in this procedure in the country are seeing savings significantly higher than this (in the region of a saving of 4-10 bed days per patient) – whilst it would clearly be unrealistic to expect such savings from less experienced surgeons, NICE’s estimate should be considered as a starting point on which greater savings could be possible as expertise builds.

 

 

6)            In August 2006, NICE issued an updated technology appraisal on the use of laparoscopic surgery for colorectal (bowel) cancer. It recommended that laparoscopic (including laparoscopically assisted) resection was an alternative to open surgery in people with colorectal cancer in whom both laparoscopic and open surgery were considered suitable.

 

7)            The appraisal noted that the decision about which of the procedures (open or laparoscopic) was undertaken should be made after informed discussion between the patient and the surgeon and that the following should be considerations:

 

a)      the suitability of the lesion for laparoscopic resection;

b)      the risks and benefits of the two procedures;

c)      the experience of the surgeon in both procedures.

 

8)            Associated with the recommendation about surgeon experience, NICE recommended that laparoscopic colorectal surgery should be performed only by surgeons who had completed appropriate training in the technique (criteria to be determined by relevant national professional bodies) and who perform the technique often enough to maintain competence. This is crucial as this is a highly complex procedure.

 

9)            NICE made it the responsibility of cancer networks and constituent Trusts to ensure that any local laparoscopic colorectal surgical practice met the recommended criteria as part of their clinical governance arrangements.

 

 

10)        Positive NICE appraisals are usually covered by a 3 month funding direction – this places an obligation on PCTs to fund the service recommended in the guidance in order to make it "normally available". In the case of the laparoscopic colorectal appraisal, this would have meant that PCTs should have funded full implementation so that laparoscopic colorectal surgery was “normally available” by 23 November 2006.

 

11)        However, a waiver to a funding direction can be issued by the Department of Health if it is felt that it is not feasible to expect the NHS to make a service normally available within 3 months.

 

12)        On 31 October, the Department of Health waived the 3 month funding direction to implement the laparoscopic colorectal cancer appraisal.

 

 

13)        NICE made clear in its appraisal that laparoscopic colorectal resections should be performed only by surgeons who had completed appropriate training in the technique and who performed the procedure often enough to maintain competence. In NICE’s associated costing template & report it notes that it has been suggested that a surgeon perform either a minimum of 2 procedures a month or 12 annually in order to maintain competence.

 

14)        Of the 30,000 new patients diagnosed with colorectal cancer in England and Wales each year about 75%  - around 22,500 cases are likely to be suitable for complete surgical excision. Of these, the proportion performed laparoscopically is unclear but is estimated by NICE to be about 2.4% - around 540 procedures compared to around 22,000 open surgical procedures each year.

 

15)        Although NICE has not recommended that laparoscopic colorectal surgery is better than open surgery it has recommended that it should be seen as an alternative. NICE has assumed that around 25% of patients would be suitable to have this procedure (about 5,600 patients) and have estimated that over 460 surgeons (carrying out at least 12 resections per annum) would be needed to support this caseload in the NHS.

 

16)        It is of course possible that more patients would be suitable for, and choose, laparoscopic colorectal surgery. For example, in prospective analyses undertaken at Yeovil District Hospital (part of East Somerset NHS Trust) and Colchester General Hospital (Part of East Rivers Healthcare NHS Trust) more than 90% of patients undergoing elective resection of their colorectal cancer were considered suitable for laparoscopic resection. This would increase the number of procedures each year and surgeons needed significantly.

 

17)        In 2006 it was estimated that there were approximately 45 surgeons in the United Kingdom, performing laparoscopic colorectal resections with a further 30 being trained annually. Whether the proportion of laparoscopic colorectal procedures is 25 or 90% in the future, it is clear that there are insufficient surgeons adequately trained at the present time to manage this volume of patients.

 

18)        Although the cost of laparoscopic colorectal surgery should not be a barrier to provision (NICE estimate that it only costs about £265 more than open surgery) it is clear that the infrastructure to support this appraisal (in term of adequately trained surgeons and their teams) is not sufficiently in place to ensure that PCTs could commission “normally available” safe and timely service for all suitable patients across the country. If the 3 month funding direction were to have remained in place this could have led to:

 

a)      patients being treated by surgeons not sufficiently expert in the procedure leading to increased risk of complications and poorer long term outcomes for patients;

 

b)      patients having to wait a long time (significantly more than the 31 day cancer treatment target) to see a suitably qualified surgeon – this could have serious implications as a patient’s cancer could potentially progress and become incurable if they have to wait too long for treatment.

 

19)        A waiver to the 3 month funding direction was therefore issued to give the NHS sufficient time to build up the expertise to ensure that the existing colorectal consultant surgeon workforce is trained to deliver high quality laparoscopic colorectal surgery in line with the NICE appraisal.