Systemic anticancer therapy service redesign
Intended for healthcare professionals
Evidence and practice    

Systemic anticancer therapy service redesign

Caroline Rennie Macmillan nurse consultant, cancer services, NHS Ayrshire and Arran, Kilmarnock, Scotland
Nicky Batty Macmillan practice development facilitator, cancer services, NHS Ayrshire and Arran, Kilmarnock, Scotland

Why you should read this article:
  • To better understand the implications of the growing demand for systemic anticancer therapy (SACT)

  • To read about the Future Service Delivery model project for SACT services in the West of Scotland

  • To learn how interim changes made to SACT services during COVID-19, aligned to the Future Service Deliver model, have been embedded in one West of Scotland health board

Demand for systemic anticancer therapy (SACT) has grown in recent years. To meet this rising demand, the West of Scotland Cancer Network (WoSCAN) initiated a regional two-phase project in 2015 to develop a safe and sustainable SACT service delivery model. NHS Ayrshire and Arran, one of four health boards in the West of Scotland, implemented some of the phase-1 initiatives in its SACT services before the coronavirus disease 2019 pandemic. This provided the groundwork for the rapid reconfiguration of SACT services that was required during the pandemic.

The reconfiguration was aligned with the WoSCAN service delivery model, which has supported sustainability of the changes. This article gives an overview of the WoSCAN Future Service Delivery model project, some of the initiatives implemented by NHS Ayrshire and Arran before the pandemic and some elements of the interim service redesign undertaken during the pandemic that remain in place.

Cancer Nursing Practice. doi: 10.7748/cnp.2024.e1849

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

caroline.rennie@aapct.scot.nhs.uk

Conflict of interest

None declared

Rennie C, Batty N (2024) Systemic anticancer therapy service redesign. Cancer Nursing Practice. doi: 10.7748/cnp.2024.e1849

Published online: 19 March 2024

In Scotland, the demand for systemic anticancer therapy (SACT) – which includes cytotoxic chemotherapy, biological therapy, targeted therapy, immunotherapy and advanced medicinal products – is rising at a rate of around 10% annually, which is placing severe pressures on services and the multidisciplinary workforce (Scottish Government 2023a, 2023b). The growing demand for SACT is multifactorial. Reasons for it include an increase in the incidence of cancer, emerging therapies creating new lines of treatment, the increasing complexity of treatments and evidence suggesting that patients should receive treatment until their disease progresses (Scottish Government 2023c). Cancer medicines account for the highest proportion of new medicines introduced in Scotland, and SACT services have been under increasing pressure to deliver these, largely unsupported by the investment in infrastructure and staffing that would be required to do so effectively (Scottish Government 2023c).

While there has been an increase of almost 86% in consultant oncologist posts in Scotland in recent years (Scottish Government 2020), unpublished data from the 2023 Scottish Cancer Network oncology workforce review suggest that this has not been matched by an increase in nursing and pharmacy posts. This has led to a situation where SACT services are struggling to prescribe and deliver treatments and have limited capacity to introduce new treatments without affecting capacity in another area. Financial investment and reform are vital to sustain SACT services (Scottish Government 2023c).

In 2015, in recognition of the need to ensure safe and sustainable SACT services delivered closer to home while meeting increasing demand, the West of Scotland Cancer Network (WoSCAN) established a two-phase regional project – the SACT Future Service Delivery model – to develop and implement a sustainable delivery model (NHS WoSCAN 2016). NHS Ayrshire and Arran, one of the four health boards in the West of Scotland, began implementing phase 1 of the project in 2018, introducing a number of initiatives to enhance SACT service delivery and patient experience. The advent of the coronavirus disease 2019 (COVID-19) pandemic meant that local consultation on the implementation of phase 2, which involved a restructuring of SACT services, had to be halted. However, the pandemic and associated restrictions meant that cancer services across the country had to quickly implement service redesign and restructuring to ensure patients would continue to receive treatment and to protect patients and staff. NHS Ayrshire and Arran aligned its pandemic-related SACT service redesign and restructure to the WoSCAN SACT Future Service Delivery model.

This article gives an overview of the SACT Future Service Delivery model project and describes some of the related initiatives implemented by NHS Ayrshire and Arran SACT services before the pandemic. The authors then describe the interim SACT service redesign and restructuring during the pandemic that have subsequently been maintained and outline future plans for service delivery.

Future Service Delivery model project

The SACT Future Service Delivery model project, which was initiated before the COVID-19 pandemic, involved reviewing and redesigning whole-system patient flow in SACT services in the West of Scotland (NHS WoSCAN 2016, 2018a). Phase 1 of the project initially focused on a review and redesign of clinic appointment schedules, separation of prescribing and treatment delivery, pre-treatment phlebotomy, non-medical prescribing and the use of pre-filled SACT products. The short-term aim of phase 1 was to maximise the efficiency of SACT services and ease pressures on services and staff by ‘flattening out’ activity across the working week while optimising the use of treatment facilities (NHS WoSCAN 2016).

Building capacity across settings

The WoSCAN project team used principles developed by the Christie NHS Foundation Trust, the largest single-site cancer centre in Europe, as a basis for the emerging service delivery model. The Christie is recognised as a leader in adapting patient care to treatment advances and policy changes and in developing models to adapt to the evolving NHS, the requirements of patient-centred care and efficiency initiatives (Burns et al 2020). Drawing on the Christie’s principles and evidence supporting a model of care that builds capacity across settings to ensure appropriate levels of specialist care are available to patients as close as possible to home (Burns et al 2020), the WoSCAN project team proposed a new risk-stratified tiered approach to SACT delivery. Figure 1 shows the WoSCAN’s previous SACT service delivery model and Figure 2 shows its new model.

Figure 1.

Previous systemic anticancer therapy service delivery model

cnp.2024.e1849_0001.jpg
Figure 2.

Systemic anticancer therapy Future Service Delivery model

cnp.2024.e1849_0002.jpg

Two main changes with the new service delivery model were the introduction of tier 3 outreach facilities and the reduction of tier 2 cancer units, which are situated in acute hospital settings. The rationale was to consolidate clinical expertise to support service sustainability. The plan was that, in the Future Service Delivery model (Figure 2), most patients would receive at least their first two treatment cycles in a cancer unit (tier 2), with immediate access to medical support if needed, before ‘stepping down’ to an outreach facility (tier 3) for continuation of treatment. Outreach facilities would only deliver SACT to patients at low risk of hypersensitivity and/or anaphylaxis reactions so that treatment could be delivered safely with expert nursing support but no medical support.

Key points

  • The rise in demand for systemic anticancer therapy (SACT) can place severe pressures on services and staff

  • To meet increasing demand, the West of Scotland Cancer Network (WoSCAN) established a two-phase regional project to develop and implement a sustainable SACT delivery model

  • Delays in the SACT delivery process can be minimised by spacing out pre-SACT assessment and prescribing and pharmacy preparation and treatment administration

  • Stratifying patients’ risk of complications can enable some SACT to be delivered in outreach facilities closer to patients’ homes

  • Engaging with patients during significant service redesign projects can ensure that the changes meet their needs

Stakeholder engagement

The Future Service Delivery model project included a stakeholder engagement plan which involved a range of activities to engage people who had used SACT services, and their families or carers, in discussions about the future shape of these services. The activities included a patient experience survey across all units delivering SACT in the West of Scotland, the creation of a stakeholder reference group and patient and carer focus groups. Responses to the patient experience survey (n=802), undertaken in 2017, cited quality of care as the most important aspect, followed by travel distance, waiting times and treatment environment. In addition, respondents wanted to keep SACT services local (NHS WoSCAN 2018b).

Participants in the six patient and carer focus groups, which were held across the four West of Scotland health boards in 2018, supported the proposed delivery model and the recommendations for its implementation detailed in the SACT Future Service Delivery strategic review (NHS WoSCAN 2018a, 2018b). Importantly, participants acknowledged that SACT services could not always be provided at home or close to home and that value for money and the appropriate use of resources were important considerations.

Input from the stakeholder engagement activities informed the SACT Future Service Delivery model implementation plans. The WoSCAN project team identified the following success indicators for the new model:

  • Improvement in patient experience and outcomes.

  • Improved consistency of treatment provision, including access to clinical trials.

  • Increased level of non-medical prescriber-led clinics across the West of Scotland.

  • Reduction in medicines waste and increase in the use of pre-filled products.

  • Optimised use of existing estates and infrastructure.

  • Integrated working between community pharmacy, primary care and specialist services.

  • Optimal flow of specialty activity across the region.

The model was supported by the West of Scotland chief executive group and work began in 2018 to implement service changes in SACT services in the four West of Scotland health boards.

Implementation of the Future Service Delivery model in NHS Ayrshire and Arran

This section gives an overview of some of the initiatives introduced by NHS Ayrshire and Arran SACT services in 2018 and 2019, before the COVID-19 pandemic, as part of the implementation of phase 1 of the Future Service Delivery model project. Two main aims of phase 1 were to improve patient flow, experience and safety and to address workforce and capacity pressures. In addition, health boards were expected to engage with patients, staff and the public before implementation of phase 2, which involved a restructuring of services.

Improving patient flow, experience and safety

In 2018, NHS Ayrshire and Arran introduced a two-step process for SACT service provision where a period of 24-72 hours was introduced between pre-SACT assessment and prescribing and pharmacy preparation and treatment administration. Previously, these two elements had been undertaken in one day, which created bottlenecks due to delays between each element. The two-step process aimed to minimise delays and reduce the pressure on pharmacy and nursing staff.

The increase in demand for SACT had resulted in a significant effect on GP practices. Practices were struggling to respond to the increase in pre-SACT blood test requests from secondary care services, which compounded delays in SACT prescribing and administration. NHS Ayrshire and Arran piloted a community phlebotomy service that SACT services were able to use as part of the two-step process described above, to ensure blood test results would be available at the patient’s planned clinic time to support real-time prescribing and reduce delays. In addition, oncology clinics were redesigned to allow time for pharmacists to verify SACT prescriptions so that treatment could be made up and/or dispensed and delivered to treatment areas for the appointed patient treatment time.

Since the full implementation of the two-step process in 2019, over 95% of SACT at NHS Ayrshire and Arran is delivered in this way. A patient experience survey across SACT services in NHS Ayrshire and Arran showed that 96% of patients believed the two-step process was better than the previous system, as waiting times between prescribing and administration were reduced and the process was less tiring.

Addressing workforce and capacity pressures

One aspect of addressing workforce and capacity pressures on SACT services within the Future Service Delivery model was to increase SACT non-medical prescribing by 50%. To facilitate this increase, the WoSCAN developed a regional non-medical prescribing competency framework and service development tool.

Alongside increasing non-medical prescribing, NHS Ayrshire and Arran also aimed to reduce nurse-led prescribing in its SACT services. Before the project, nurse-led prescribing was undertaken by senior SACT day unit nurses following a nurse-led guideline with strict criteria for patient management and authorisation. The health board wanted to replace this with non-medical prescribing to provide a more robust service that would enable non-medical prescribers to authorise treatments, make dose adjustments and prescribe supportive medicines such as anti-emetics.

Internal data from NHS Ayrshire and Arran show there was an increase in the number of SACT non-medical prescribers from four (three nurses and one pharmacist) in 2017 to 17 (ten nurse prescribers and seven pharmacy prescribers) in 2023. This has led to an increase in non-medical prescribing from 21% in 2017 to 52% in 2023 and a concurrent reduction in nurse-led prescribing from 11% in 2017 to 4% in 2023. Non-medical prescribing practice is audited annually. Table 1 shows NHS Ayrshire and Arran SACT prescribing data for 2017-23.

Table 1.

NHS Ayrshire and Arran systemic anticancer therapy prescribing data for 2017-23

cnp.2024.e1849_0001_tb1.jpg

The challenge was to increase non-medical prescribing without increasing the existing nursing and pharmacy workforce, while providing cover from experienced SACT day unit or oncology pharmacy staff. Prescribing figures and the prescribing workforce were reviewed across specialties, non-medical prescribing clinic service agreements were developed to ensure appropriate support and governance structures were embedded in SACT non-medical prescribing practice. Maintaining non-medical prescribing has proved challenging when there are clinical pressures in the wider nursing or pharmacy team or when non-medical prescribers leave the service. Non-medical prescribing education and SACT competency training take more than a year to complete, which can result in significant service gaps while new staff are being trained.

Patient, public and staff engagement on phase 2 implementation

In January 2020 the health board convened a stakeholder reference group – comprising patients, carers, members of the public and representatives of cancer organisations – to consider the local implications of phase 2 of the Future Service Delivery model project, which involved restructuring of services. The engagement activities included focus groups, a survey, discussions with patients and carers in clinical settings, dissemination of public information and local media coverage. Since the restructuring had been identified by Health Improvement Scotland as a major service change, a three-month formal consultation period was required. However, the restrictions associated with the COVID-19 pandemic meant that the consultation had to be paused.

Interim service changes during the pandemic in NHS Ayrshire and Arran

Early in the pandemic, evidence emerged to suggest that the rate of COVID-19 infection in people with cancer was higher than in the general population (Dai et al 2020, Sud et al 2020). The potential risk of developing COVID-19 while receiving immunosuppressive SACT regimens resulted in a 29% decrease in adults attending for SACT in Scotland in March and April 2020 (Baxter et al 2021). However, by July 2020 patient attendance had returned to pre-COVID-19 levels, which reflected a coordinated national approach to managing cancer services during the pandemic in Scotland (Scottish Government 2020).

A rapid reconfiguration of SACT services was required to protect patients and staff. NHS Ayrshire and Arran’s implementation of initiatives in phase 1 of the Future Service Delivery model project provided the groundwork for this. The subsequent changes in interim services, which aimed to protect vulnerable patients while fulfilling organisational and national COVID-19 requirements, were aligned, where possible, with phase 2 of the Future Service Delivery model project.

Reconfiguration of local services

The aims of the NHS Ayrshire and Arran COVID-19 interim SACT service reconfiguration were to:

  • Release acute hospital real estate for admissions related to COVID-19 at University Hospital Ayr (UHA).

  • Transfer the UHA inpatient SACT ward to University Hospital Crosshouse, near Kilmarnock (tier 2).

  • Provide high-level COVID-19 infection control precautions on the inpatient SACT ward.

  • Risk stratify SACT regimens for the five main specialties (breast, colorectal, haematology, lung, urology).

  • Develop a South Ayrshire outreach unit (tier 3) for treatment delivery outside the acute hospital setting.

  • Develop standard operating procedures for resuscitation and care of the unwell patient for the outreach unit.

The UHA inpatient SACT ward (eight beds) and day-case SACT unit (ten chairs) were closed and all inpatient SACT delivery was transferred to University Hospital Crosshouse to support maximum infection control precautions, consolidate multidisciplinary expertise and maintain safe staffing levels. The site had been chosen due to its proximity to other services, including an intensive care unit, 24-hour laboratories, inpatient renal dialysis facilities, an aseptic pharmacy and maternity services. While the location meant that treatment was delivered further from home for some patients, it also meant that appropriate staffing levels could be maintained – the Future Service Delivery model project (NHS WoSCAN 2018b) stakeholder engagement activities had shown that care further from home was acceptable to patients if it meant that a safe specialist service could be maintained.

An outreach day-case unit – the Kyle Chemotherapy Unit, which is close to a local hospital that has an aseptic pharmacy – was identified for administering low-risk SACT. Day-case chair capacity was increased from ten to 18 and a dedicated space for pharmacy, non-medical prescribing, clinical nurse specialist and visiting medical teams was made available to support multidisciplinary working. All outpatient oncology and haematology clinics were moved from UHA to the outreach unit.

Risk stratification

To support the service reconfiguration, NHS Ayrshire and Arran developed a risk stratification tool to identify patients’ risk of complications associated with their SACT regimens and determine where they could safely receive treatment. To be eligible for SACT delivery in outreach facilities (tier 3), patients have to meet the following criteria:

  • Performance status of ≤2 on the ECOG Performance Status Scale (ECOG-ACRIN Cancer Research Group 2022), which provides standard criteria for measuring how the person’s disease affects their daily living.

  • No hypersensitivity reaction or anaphylaxis to current SACT regimen – re-challenges are not permitted in tier 3.

Patients with grade 3 toxicities on their current regimen are reviewed by their oncology or haematology team and can proceed with outreach treatment delivery where appropriate, for example if the patient is prescribed a change of anti-emetics when experiencing nausea. Where possible, the selection of a tier 3 delivery site is based on the patient’s postcode, service capacity and patient preference.

During the pandemic, most patients received cycle 1 and cycle 2 of their SACT at University Hospital Crosshouse (tier 2) then moved to the outreach unit (tier 3) for continuation of treatment closer to home. This is still the case at the time of writing.

Remote consultations and digital working

Infection control measures during the pandemic, including social distancing, required the rapid implementation of remote consultations so that patients could continue to receive treatment and care. For patients, remote pre-SACT assessments meant less direct contact with staff and reduced travelling time (which can be lengthy due to the rural nature of the region) and/or time spent finding a parking space. Patients could have face-to-face appointments if they preferred or if this was considered necessary by their clinical team, for example to discuss consent or changes to treatment regimens or when a physical examination was required.

Internal data from NHS Ayrshire and Arran show that pre-SACT assessments by telephone were as safe and robust as face-to-face, with few patients presenting with new toxicities or being unwell on the day of SACT administration and requiring treatment deferral. Remote consultations have therefore continued to be offered to patients in most specialties since the pandemic. Table 2 shows the types of SACT pre-assessment appointments (face-to-face or telephone) in the five main specialties in September 2022.

Table 2.

Systemic anticancer therapy pre-assessment appointment type by specialty in September 2022

SpecialtyFace-to-face appointmentTelephone appointment
Breast25%75%
Colorectal56%44%
Haematology19%81%
Lung78%22%
Urology23%77%

To support the interim service changes, NHS Ayrshire and Arran introduced digital working in haematology and oncology clinics and in the outreach unit. Pre-SACT assessments were documented in real time on a digital platform, which allowed instant access to other members of the multidisciplinary team (MDT) as required. All patients receiving day-case SACT in the outreach unit were allocated a ‘digital SACT booklet’ in which staff would record information, such as pre-SACT toxicities, which was then instantly accessible to all members of the MDT. Using this type of technology helped to avoid treatment delays – caused for example by the time taken to locate and collect patients’ medical notes – and enhanced MDT communication, since the digital notes were automatically uploaded onto the electronic patient record.

Feedback on interim service changes

Throughout the interim service changes, NHS Ayrshire and Arran gathered feedback from staff and patients on how the services were working to learn from their experiences. Examples are shown in Box 1.

Box 1.

Examples of feedback from patients and staff on the interim service changes

Patient comments

  • ‘Everything to do with the new Kyle unit [the outreach unit] is very positive and supportive. The whole environment is, compared to even station 15 [the previous systemic anticancer therapy (SACT) day unit at University Hospital Ayr], exceptional and should remain such. Safety is total’

  • ‘The Kyle unit is amazing. I can park close and need no help. I only walk a matter of metres. I don’t mix with non-cancer patients. The rooms are open, bright and spacious, whereas previous locations have not been’

Staff comments

  • ‘I have worked in oncology for many years and this is the safest the unit has been’

  • ‘Patients and staff appreciate the response and service changes. We have all been kept protected. Reduced anxiety among patients coming in. Feels safer’

  • ‘The facilities here feel custom made for our needs. Patient safety and comfort are very high here and it’s an extremely safe working environment. The COVID response needs to be made permanent’

Sustainability and future plans

Although COVID-19 presented significant challenges for healthcare services, it also provided opportunities to implement new practices that enhance person-centred care. The consolidation of inpatient SACT services and implementation of local outreach SACT services in NHS Ayrshire and Arran reduced the risk of COVID-19 transmission for patients and staff. In addition, the outreach unit delivered safe and effective low-risk SACT regimens to patients closer to home, which was one of the aims of the Future Service Delivery model project. WoSCAN SACT prescribing data for January-June 2022 showed that patients living in South Ayrshire received 84% of their SACT day-case treatment at the outreach unit in Ayr. Since October 2021 there have been only two SACT hypersensitivity reactions in the outreach unit, which were appropriately managed with no requirement for acute admission.

Some very low-risk oncology and haematology cycle 1 and cycle 2 SACT regimens are now being delivered in tier 3 outreach supported by the risk stratification process described earlier in the article. Data from the health board’s risk stratification document in March 2024 showed the following:

  • Of 47 oncology SACT regimens, 17 can be delivered from outreach from cycle 1.

  • Of 36 haematology SACT regimens, eight can be delivered from outreach from cycle 1 and 14 can be delivered from outreach from cycle 2.

Clinical teams can request a risk stratification review of any SACT regimen via SACT clinical governance meetings and all new treatments will be risk stratified following this process.

In 2023, NHS Ayrshire and Arran SACT services reconvened the stakeholder reference group to inform and guide a review of the interim service changes. It also resumed the three-month public consultation process (in February to May 2023), that had been put on hold at the beginning of pandemic, as per Scottish Government (2023d) guidance on community engagement and participation.

The stakeholder review and public consultation reports were presented to Healthcare Improvement Scotland and NHS Ayrshire and Arran health board, which agreed that the changes should be made permanent. This paves the way for further development of outreach services and the potential transfer of treatment delivery from the tier 1 cancer centre in Glasgow to the local cancer unit and outreach service in Ayr for residents of NHS Ayrshire and Arran.

Conclusion

Demand for SACT will continue to rise as new treatments emerge and patients receive long-term treatment regimens. In the West of Scotland this is being addressed through the Future Service Delivery model project, a coordinated whole-system approach to service development. Implementation of some of the initiatives in phase 1 of the project provided the foundation for the rapid interim redesign and reconfiguration of NHS Ayrshire and Arran SACT services during the COVID-19 pandemic. While the pandemic presented challenges for service provision it also provided opportunities to test service changes, such as further development of outreach SACT delivery, and to implement new practices such as remote pre-SACT assessments. In addition, the delivery of outreach day-case SACT for patients at low risk of complications has been shown to be safe and efficient. It is essential to engage with the public, patients and staff during significant service change and reconfiguration projects to ensure the changes meet their needs and to support sustainability.

References

  1. Baxter MA, Murphy J, Cameron D et al (2021) The impact of COVID-19 on systemic anticancer treatment delivery in Scotland. British Journal of Cancer. 124, 8, 1353-1356. doi: 10.1038/s41416-021-01262-8
  2. Burns V, Misra V, Paton N (2020) Systemic anti-cancer therapy delivery in the home: a service model. British Journal of Nursing. 29, 10, S22-S29. doi: 10.12968/bjon.2020.29.10.S22
  3. Dai M, Lui D, Lui M et al (2020) Patients with cancer appear more vulnerable to SARS-COV-2: a multicenter study during the COVID-19 outbreak. Cancer Discovery. 10, 6, 783-791. doi: 10.1158/2159-8290.CD-20-0422
  4. ECOG-ACRIN Cancer Research Group (2022) ECOG Performance Status Scale. http://ecog-acrin.org/resources/ecog-performance-status (Last accessed: 6 March 2024.)
  5. NHS West of Scotland Cancer Network (2016) Systemic Anti-Cancer Therapy Future Service Delivery – Phase 1 Interim Report. http://www.woscan.scot.nhs.uk/wp-content/uploads/SACT-Future-Service-Delivery-Phase-1-Interim-Report-v1.0-22nd-Feb-16.pdf (Last accessed: 6 March 2024.)
  6. NHS West of Scotland Cancer Network (2018a) Systemic Anti Cancer Therapy Future Service: Strategic Review and Emerging Future Service Model. http://www.woscan.scot.nhs.uk/wp-content/uploads/SACT-Future-Service-Strategic-Review-FOR-WEBSITE-1-v2.0-170418.pdf (Last accessed: 6 March 2024.)
  7. NHS West of Scotland Cancer Network (2018b) SACT Future Service Delivery: Stakeholder Engagement Report. http://www.woscan.scot.nhs.uk/wp-content/uploads/SACT-Future-Service-Delivery-ENGAGEMENT-REPORT-FOR-WEBSITE-v1.0-200418.pdf (Last accessed: 6 March 2024.)
  8. Scottish Government (2020) Recovery and Redesign: An Action Plan for Cancer Services. Scottish Government, Edinburgh.
  9. Scottish Government (2023a) [Revised] Guidance for the Safe Delivery of Systemic Anti-Cancer Therapy. http://www.publications.scot.nhs.uk/files/dl-2023-15.pdf (Last accessed: 6 March 2024.)
  10. Scottish Government (2023b) Cancer Action Plan 2023 to 2026. http://www.gov.scot/publications/cancer-action-plan-scotland-2023-2026/pages/3 (Last accessed: 6 March 2024.)
  11. Scottish Government (2023c) Cancer Strategy for Scotland 2023-2033. Scottish Government, Edinburgh.
  12. Scottish Government (2023d) Planning with People: Community Engagement and Participation Guidance. Scottish Government, Edinburgh.
  13. Sud A, Torr B, Jones ME et al (2020) Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: a modelling study. Lancet Oncology. 21, 8, 1035-1044. doi: 10.1016/S1470-2045(20)30392-2

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