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  5. 4. Demand and capacity

Understanding, modelling, and managing demand and capacity is critical for delivering sustainable cancer services and meeting national standards. DCAQ methodology supports teams to balance resources with need, reduce delays, and improve flow through pathways. This element ensures that services are planned around actual demand, not assumptions. 

 

Case Study 1 – NHS Borders - Prostate Pathway

1. What was the issue/problem identified?

Over the past two years, performance against the 62-day cancer standard has declined significantly in NHS Borders. In Q1 2025, the Board reported the lowest performance in Scotland at just 45.6%. The prostate cancer pathway was the main driver, accounting for 80% of all breaches, with pathway performance falling to only 12%. This was linked to rising referral numbers combined with capacity pressures across the wider Urology service. 

2. What did you do?

We began by reviewing the diagnostic pathway and comparing local practice with that in other areas. This confirmed that the issues were a result of capacity rather than process. We then: 

  • Analysed referral numbers and conversion rates to confirm that the level of demand was appropriate. 
  • Carried out detailed breach analysis to identify which steps in the pathway were causing the most significant delays 

3. What was the outcome?

Breach analysis showed that patients were breaching during the local diagnostic pathway, independent of delays for treatment at the regional centre. Principally, there were delays in the steps between MRI scan and prostate biopsy. These delays were a result of capacity issues, but capacity to make clinical decisions was also an issue.  

To address this, we identified the need for additional administrative support and introduced a Pathway Navigator role. This enabled implementation of an ‘intentional’ pathway, where dates for next steps can be actively planned. For example, when a patient has a MRI scan, they are given an appointment to discuss results, based on when we know the scan will be reported.  Further improvement is still required, including working with the regional team to try and refine the process for MDT decision making, but early results are promising and reported performance increased to 50% in July 2025, and provisionally to 70% in August 2025.  

Contact

Steven Litster, Cancer Manager — steve.litster@borders.scot.nhs.uk 

 

Case Study 2 – NHS Highland - Improving Prostate Pathway

1. What was the issue/problem identified?

Performance on the prostate cancer pathway in NHS Highland was among the poorest in Scotland. At times, only 10% of men were meeting the 62-day cancer standard. This reflected longstanding challenges with capacity and pathway organisation. 

2. What did you do?

A series of improvement measures was introduced, focusing on both capacity and pathway redesign: 

  • Nurse-Led Pathway – Two nurses now lead the pathway from referral to decision-to-treat, taking ownership of each patient and proactively managing their progress against pathway milestones. 
  • DCAQ Review – Following a review additional capacity was created, with two TRUS biopsy lists and one or two prostate assessment clinics each week. Most patients now reach biopsy within 7–10 days. 
  • CfSD Methodologies – Consultants electronically vet referrals, with suspected prostate patients passed to the nurses within 24 hours. 
  • Cancer Support Worker – Introduced to provide enhanced, patient-centred care. 
  • PP+ Tracking System – Implemented to enable daily monitoring, and timely escalation of patients along the pathway. 
  • MRI Reporting Standard – Established a target of MRI test and report availability within 14 days of referral. Urology CNSs now “justify” MRI requests, saving 2+ days. 
  • Direct Appointment Booking – Patients are contacted by phone for appointments/biopsies, ensuring cancellations are filled and clinic time is maximised. 
  • Earlier Biopsy Lists – Moved one biopsy list to the start of the week, so results can be actioned by Friday. 
  • Decision-to-Treat Clinic – Scheduled immediately after MDT meetings. Patients recommended for hormones or radiotherapy are seen at once, with “all options” patients (including brachytherapy and robotic surgery) also attending to begin informed discussions.

3. What was the outcome?

While there is still progress to be made in achieving full compliance with the 62-day standard, performance has more than doubled since these measures were introduced. The combination of nurse-led pathway management, additional diagnostic capacity, and streamlined processes has created clear improvements and a more responsive service for patients. 

Contact

Derick MacRae, Service Manager — derick.macrae2@nhs.scot, Pamela Sutherland, Assistant Service Manager — pamela.sutherland@nhs.scot  

 

Resource and key links

The DCAQ course explains methods and practical tools to match demand, capacity, activity and queues. 

Introduction to Demand, Capacity, Activity and Queue