Identifying 111 hours of avoidable administrative time per week and £183,000 in annual financial risk across Royal Free London’s blood cancer pathways
| What the review identified |
|---|
| • Five tactical interventions that could remove approximately 111 hours of avoidable administrative and coordination time per week — around 3.0 whole-time equivalents of unpaid extra hours currently absorbed by the multidisciplinary team affecting the general well being of the team |
| • Medical workforce stabilisation that would protect 70 clinic slots a week and mitigate approximately £183,000 in annual risk to the Elective Recovery Fund |
| • A recommendation for strengthened cross-site governance to oversee Phase 2 strategic options and determine the future direction of the service across all four sites |
The challenge
The 28-Day Faster Diagnosis Standard (FDS) is an NHS target guaranteeing that patients urgently referred by their GP for suspected cancer receive a diagnosis, or have cancer ruled out, within 28 days. Trusts are required to meet this standard for at least 80% of patients.
Royal Free London (RFL) is England’s highest-volume provider of haematological malignancy FDS referrals, serving a population of 1.2 million across North Central London. The service operates across four sites: Barnet Hospital, Chase Farm Hospital, the Royal Free Hospital, and North Middlesex University Hospital. At the time of the review, performance against the 28-day standard had fallen below the required level, with a growing 62-day backlog and the shortfall concentrated in the complex diagnostic phase, placing pressure on both patient experience and the resilience of the cancer pathway.
Three challenges sat at the root of that underperformance: diagnostic bottlenecks limiting throughput, with delays concentrated in imaging turnaround, sample transport logistics and administrative tracking; variation in patient experience, access and coordination across sites; and, at the time of the analysis, significant challenges with recruitment and retention. Benchmarking against peers revealed that while RFL manages the highest diagnostic volume in the country, it operates with more limited resources and infrastructure than peers of similar size.
What the service lacked was not effort. It was evidence. There was no granular, integrated understanding of how the pathways actually operated across all four sites: where capacity was being lost, where patient experience was falling short, and what targeted interventions would release the most time. That was the gap TPHC was commissioned to fill.
Our approach
TPHC supported the Trust to strengthen its blood cancer diagnostic pathways through a comprehensive, integrated review. By combining detailed activity analysis with frontline clinical insight, patient feedback, and advanced demand-capacity modelling, we developed the first truly granular understanding of how these pathways operate in practice.
We conducted 14 in-depth interviews and facilitated multidisciplinary workshops at each of the four sites, alongside a cross-site virtual session, with leadership, medical, nursing, pharmacy, and operational staff. This allowed us to map complex clinical pathways and identify ‘hidden’ workloads that were driving pressure but not captured in standard reporting, including informal clinical advice, unrecorded triage, and complex cross-site coordination. We also deployed a targeted patient experience survey, collecting 157 responses to understand patients’ care journeys, particularly regarding communication and continuity of care.
The centrepiece was a demand-capacity model built across 148 clinical and administrative activities and 11 pathways, the first granular analysis of its kind for this service at RFL. By ensuring clinicians could see their own workshop data directly driving the quantitative findings, we established genuine clinical ownership of the evidence base. We also benchmarked the Trust’s performance against a peer group of similar scale and multi-site complexity, identifying where variation existed both internally and relative to national peers.
We examined demographic data across ethnicity, age and deprivation to understand the differing populations each site serves, and set this alongside site-level variation in patient experience and care coordination. We then produced a clear, integrated evidence base and transformation roadmap, covering immediate tactical interventions deliverable within existing budgets alongside longer-term, outline strategic options for consideration, including options for how services are organised across the four sites, addressing estates constraints, and transitioning to a sustainable multi-professional workforce model.
The impact
The review produced the first integrated evidence base and transformation roadmap for the service, giving the Trust a clear, quantified basis for its investment decisions.
For patients, site-level data revealed meaningful variation between sites in how involved patients felt in decisions about their care, a gap that had not previously been visible. Analysis of incident data indicated that existing clinical safety barriers were effective in intercepting issues before they reached patients. Recommendations for geriatric-oncology pathway considerations and providing more care closer to home, including local treatment and medication collection, would reduce the burden of travel and make care more accessible, particularly for elderly and frail populations who currently face long journeys to central London.
Five tactical interventions were identified that could remove approximately 111 hours of avoidable administrative and coordination time per week; around 3 whole-time equivalents of unpaid extra hours currently absorbed by the multidisciplinary team. Removing this burden protects clinical capacity and eases the pressure on staff. Separately, substantiating the case for consistent medical cover would protect 70 clinic slots per week. Group-wide SACT e-prescribing would remove manual, paper-based processes across the day units and release further administrative time. The proposed Band 4-5 Patient Pathway Coordinator roles would also create career progression opportunities within local cancer services.
For the system, immediate actions were identified that could mitigate approximately £183,000 in annual risk to Elective Recovery Fund income. The review recommends strengthened cross-site governance to oversee the Phase 2 strategic options appraisal and determine the future direction of the service, ensuring consistent collaboration across all four sites. The methodology, triangulating quantitative capacity modelling with qualitative discovery, is directly transferable to other complex, multi-site clinical reviews, particularly other North Central London cancer services navigating multi-site integration.
What our clients say
“TPHC’s analysis made visible—and quantified—the pressures we had been managing every day. It validated the issues the team had identified and turned what had felt overwhelming into a manageable challenge, giving us a much more positive outlook for change.”
Pratima Chowdary, Royal Free London NHS Foundation Trust
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