Living with and beyond cancer: The improvement story so far

NHS
CANCER
NHS Improvement

DIAGNOSTICS

HEART

LUNG

STROKE

Adult Cancer Survivorship Initiative

Living with and beyond cancer:
The improvement story so far

National Cancer Survivorship Pathway

Remission
Inpatients Remains
Symptoms Well

Screening
Ambulatory
Care
Consequences
MDT of Treatment
Survivorship
Straight Decision Assessment
Investigations to Test to Treat Care Plan
Primary
Care Recurrence
Assessment Primary (Living
Referral Diagnosis document End of Life
Treatment setting out Care
aftercare)

Primary
Care 2nd/
Subsequent
National Awareness and Early Treatments
Diagnosis Initiative (NAEDI)

Inpatients Patient Chooses Active/Advanced
Not to be Treated Disease
Survivorship - Living with
and Beyond Cancer

Living with and beyond cancer: The improvement story so far | 3

Foreword

S ome cancers are born chronic, some cancers become chronic,

some cancer patients have chronic illness thrust upon them by treatment

and some are not chronic at all
(apologies to W Shakespeare)

The cancer landscape has changed but
the public and professional view is National Cancer Survivorship Initiative (NCSI) five key shifts
lagging behind. Cancer is seen in simple
terms - completely cured and ‘back to • a cultural and attitudinal shift to focus on health and recovery;
normal’ or incurable disease and • a shift towards improving information;
‘terminal’. Reality is different. Some still • a shift towards assessment and care planning;
die within a year of diagnosis. Others • to shift towards providing tailored care pathways based on risk of
with incurable cancers live years with future problems associated with the type of cancer, the type of
their illness or experience treatment treatment and the particular circumstances of the individual;
consequences directly after cancer • a shift towards improved measurement through patient
treatment or years later, with similar reported outcome and experience measures.
illness patterns to a long term condition.

Traditionally, the focus of cancer services Evidence is also emerging that The cancer story continues to develop
is on cancer as an acute illness treated opportunities are being missed for with many more people living well with
and followed up by hospitals. There are secondary prevention of new primary cancer whether truly cured or not.
already two million patients in the UK cancers and other long term conditions, Measures to support recovery and
living with a diagnosis of cancer and this which are more common in cancer transition to self management need to
is expected to rise by around 3% a year. survivors. Given the above, current go hand in hand with the development
Recent work suggests that up to 70% follow up practice will become of the new anticancer treatments (drugs,
of recurrence for common cancers could unsustainable and no longer fit for surgery or radiotherapy) that will increase
be detected by patients noticing purpose. There is already evidence that life expectancy and quality for the
symptoms themselves with or without it does not adequately address the individual. The focus of the National
automated test surveillance. Many needs of patients. Where appropriate, Cancer Survivorship Initiative is living
patients have indicated that they would moving from traditional, hospital based with and beyond cancer.
prefer this type of self management as follow up visits - to alternative models
long as there is a fast, reliable route offers many benefits to the quality,
back to the specialist team if needed. safety and effectiveness of care.

The test communities within this Professor Jane Maher
programme are testing a number of Dr Alastair Smith
approaches that reflect the National
31 National Clinical Leads,
Cancer Survivorship Initiative (NCSI) NHS Improvement
five key shifts

4 | Living with and beyond cancer: The improvement story so far

Introduction
The purpose of this document is to give • The 2007 survey explored the views of
‘the story so far’ and includes the work 3,000 participants who included
that NHS Improvement, through the specialists from hospital care,
cancer adult survivorship improvement professionals from primary care and
team, has been undertaking on behalf of patients. The objective of the survey was
the National Cancer Survivorship Initiative to find out the perceptions and
(NCSI). The main focus is to present preferences for follow up practice. The
improvement stories from the test findings showed there was consensus
communities who are piloting elements of between the groups as to the
care and support to inform potential new perceptions for current follow up
models of care. The learning and practice; to monitor early complications,
improvement stories from the assessment to detect recurrences early, and to detect • Supporting and coaching national test
and care planning test sites will be late effects of treatment. With regard to communities to pilot elements on
included in the final report of the pilot preferences for the future, respondents potential new models of care for people
phase of testing in the winter. were more likely to prefer approaches living with and beyond cancer.
they had experienced, as opposed to
It is necessary to understand the context those they had not experienced. As our knowledge and learning has
and baseline work that has been This article is now in press as: Frew,G. developed and the demands on the
happening prior to and during the testing et al., Results of a Quantitative Survey to service have changed particularly through
work and the flexibility that has been Explore Both Perceptions of the Purposes the QIPP agenda, the test communities
required to respond to the challenges of Follo..., Clinical Oncology (2010), have risen to the challenge with flexibility
facing an ever changing NHS. Traditionally doi:10.1016/j.clon.2010.06.008 and professionalism. We would like to
cancer services have focussed on cancer as • The patient consensus meeting in 2008 thank the national test communities and
an acute illness with the emphasis post concluded that patients are not adverse the clinical teams who have put an
treatment on surveillance and monitoring to new approaches to follow up care enormous amount of work and effort into
for further disease or recurrence for a and support but need to have good testing new elements of care and support
period, usually up to five years. Primary quality information, rapid access to for individuals living with and beyond
care providers have therefore seen cancer specialist care as needed, and a care cancer.
care as the province of specialists, at least plan which is agreed by all those
until ‘discharged’ from secondary or providing care and is owned by the For those of you who are not currently
tertiary care. There is increasing debate individual patient. A copy of the notes part of this work we would recommend
regarding traditional follow up in the from the meeting can be found at: you seek further information from the
outpatient setting and whether it meets www.improvement.nhs.uk/cancer national team supporting this workstream
patients’ needs following cancer • A rapid review of current follow up or the test communities direct. The key
treatment, especially for those who practice, in three tumour sites, took contact for individual test communities
experience problems more than five years place across the cancer networks in can be found on their improvement stories
post treatment. There is a suggestion that England during the summer of 2009. and the contact details for the national
70% of people living with and beyond The findings showed a mainly medical team can be found at the back of this
cancer could self manage their symptoms model of care where one size fits all was publication or online at:
with support, information and access back the norm. There were, however, pockets www.improvement.nhs.uk/cancer
in to the ‘system’ should they need it (see of good practice around the country but
the suggested model of care pathway on this had not spread to other tumour
page 56). areas, clinical teams or across Gilmour Frew
organisations. Director: Cancer Improvement
NHS Improvement has been supporting The full report can be found at: NHS Improvement
the National Cancer Survivorship Initiative www.improvement.nhs.uk/cancer or
(NCSI), working with clinical teams and www.ncsi.org.uk
patients to better understand the current
service and the potential for the future:


Elements of new models of care

Client Relationship
Management System:
Bristol - Page 12 Survivorship Living
System Enablers
Well Courses

Patient information
development sites:
Hillingdon**
Christie*
Hull** Bristol - Page 12
Mount Vernon* Mount Vernon* - Page 38
Hereford - Page 28
Ipswich**
Guys*
South of Tyne & Wear - Page 43
Risk stratification: Clatterbridge - Page 18
Taunton** Birmingham* - Page 6

Community Telephone Primary Care
Support Management Led Services

Gloucester: Guys & St Thomas’ - Page 26 Luton - Page 31
Village Agents - Page 22 Birmingham* - Page 6 Birmingham* - Page 6
Medway - Page 36 Worcester - Page 53
Birmingham* - Page 6 Velindre Cancer Centre:
(Herceptin pathway) - Page 50

Exercise/ Workforce Education
Rehabilitation Development Day/Session

Sheffield - Page 41 Sheffield (Health Needs Bristol - Page 12
Bournemouth - Page 8 Assessment) - Page 41 Worcester - Page 53
Royal Free Hospital and Luton (Oncology Sheffield - Page 41
Marie Curie Hospice - Page 39 Awareness) - Page 34 Christie (user
Mount Vernon* (e Learning) engagement) - Page 16
Velindre Cancer Centre Velindre Cancer Centre
(Breathlessness pathway (Breathlessness pathway
professional education self management) - Page 47
package) - Page 47 East Kent (User focus
UCLH - Page 45 groups) - Page 20
Herefordshire - Page 28

* Indicates that additional improvement strories are available online at: www.improvement.nhs.uk/cancer
** Indicates that additional improvement strories will be available online when testing is complete

Those test communities currently testing assessment and care planning and treatment
record summaries will have their improvement stories online once testing is complete.


NHS Birmingham East and North Health Economy
The impact of a community Macmillan
nurse in curative care
Summary Improvement stories about progress in definition of services the MPCCN
Pan Birmingham Cancer Network and each of the five projects are available devised clinical outcomes, measures
NHS Birmingham East and North online. and a patient evaluation questionnaire.
(NHSBEN) have worked together The measures are captured on the
throughout the testing process to The following story focuses on patient administration system (PAS)
develop five projects within the NCSI specialist nurse care, testing the database including the number of
programme of work, targeting breast Macmillan Primary Care Cancer Nurse contacts and interventions with each
cancer patients within the PCT treated (MPCCN) service, a unique service patient.
at Good Hope Hospital. A focus group within NHSBEN and Macmillan. The
was held to test out the ideas that role steps away from the traditional role The MPCCN was integrated into the
came from some gap analysis which of the community Macmillan nurse in breast cancer multidisciplinary team at
gave valuable feedback to each of the end of life care. It is an innovative role GHH (MDT) and she attends the weekly
individual services which were involved which aims to provide complex, expert meetings.
within the Cancer Awareness and assessment to identify and address the
Recovery Enhancement (CARE) project problems faced by patients living with To raise the profile and develop an
and what became clear was that breast cancer. It also helps deal with the understanding of the role, the MPCCN
further definition of services was complexities and adverse effects of presented the service to the breast MDT
required to prevent overlap of the five acute oncological treatment whilst and oncology nursing team. Patient
work streams involved in the project. maintaining (where possible) the information leaflets were also devised
patient in the community setting. which would be made available to the
The five projects taken forward were: breast care team and oncology team to
• Bridges Care - Testing the use of a What was the problem? be given to appropriate complex
charity organisation offering Patients with breast cancer face not patients at time of referral. Clinical
individual needs assessment only the dramatic impact of their letters are sent to individual GPs
facilitating a bridge between health, cancer diagnosis but also prolonged following the initial and any
social and community organisations multiple modalities of treatment which subsequent holistic needs assessments
• Own Health Care – A partnership can have a profound impact on them, including information on each patients
with Pfizer Health Solutions, testing a physically, psychologically, sexually, individual care plan.
telecare model to provide support, spiritually and financially. If complex
assessment, signposting and referrals needs of breast cancer patients are not What difference has the testing
• Hospital Care - Ensuring addressed early this can affect how work made?
consistency of access to post they cope with their breast cancer Since testing began the MPCCN has a
treatment services irrespective of treatment but also how they cope with caseload of 35 complex patients who
treatment aim their transition from cancer patient to require Macmillan level 3 and 4
• Specialist Nurse Care – Testing a cancer survivor. intervention. Every patient who is
primary care based cancer nurse case assessed by the MPCCN is given an
management model for those What was done? individualised care plan which is
patients within Macmillan level For the purpose of this project the role reviewed at each subsequent visit;
3 and 4 of the MPCCN was re-designed to The MPCCN has prevented 11 accident
• Self Management Care – testing a provide support in primary care for and emergency admissions and over
six week post treatment self patients undergoing their cancer 100 outpatient attendances.
management course entitled HOPE treatment for breast cancer.
(helping overcome problems In response to the need for clear
effectively).


clinical supervision by giving the
Did the specialist report reduce the number of times you needed to MPCCN the opportunity to discuss
visit your GP or oncology unit? clinical issues with the team therefore
reducing the effects of isolation on the
5 post holder.
4
A clear patient need has been identified
for the majority of referrals with only
Frequency

3
one patient opting out of the service.
2
Next steps
1
The next steps for the MPCCN are to
0
continue with the testing, providing
Strongly Agree Agree specialist advice, assessment and care-
Reduce Appointments planning to complex breast cancer
patients, their families and carers in
their homes within NHS BEN. The
MPCCN will demonstrate the quality of
Evaluation forms are given to patients the findings to nurse managers and the care provided through the measures
four months after referral to the education and training department in data captured on PAS, and from the
MPCCN. Improvements currently being the PCT. clinical outcomes also identified in the
appraised by this evaluation include patient evaluation.
improved symptom management and Learning so far
self-management of treatment induced So far we have learnt that although Contacts
side effects. patient’s can be referred at any point
from diagnosis the majority of referrals Kelly Fisher,
The MPCCN utilises expert are received from the oncology team. Service Improvement Facilitator
communication skills to assess and Evaluation will determine if patients Pan Birmingham Cancer Network
explore the psychological impact on feel that they were referred to the Kelly.Fisher@westmidlands.nhs.uk
each patient, anxiety and depression service at the right time; the majority of
scores are undertaken where referrals are from nurses. However, Jayne Breen,
appropriate and to date there have oncology nurses reported that when Macmillan Primary Care Cancer Nurse
been seven referrals to the clinical they are busy or short staffed referrals jayne.breen@benpct.nhs.uk
psychology service for specialist may be missed and they found the
intervention. referral forms too time consuming. To
overcome this it was agreed that
Specialist support, training and telephone referrals would be accepted
supervision have been provided to and the MPCCN would aim to meet
district nurses to enable them to with the oncology team at least once a
maintain patient’s central venous week.
catheters at home throughout the
duration of their chemotherapy Attending the MDT has proved very
treatment. The MPCCN audited the beneficial. Attendance enables the
training needs of district nurses caring identification of potential new patients
for breast cancer patients disseminating and provides a forum for informal


Bournemouth Test Community
Cancer survivors exercising their way back to health

Summary stamina, self esteem, poor sleep and What difference has the testing
• The Bournemouth After Cancer weight gain work made?
Survivorship Project (BACSUP) is an • These could potentially impact on the The implementation of robust
innovative collaboration between survivor, their partners and significant assessment and care planning practices
Royal Bournemouth and Christchurch others. BACSUP used a range of tools is essential to assess and meet the
Hospitals NHS Foundation Trust, The and one to one assessment with health needs and support the delivery
Littledown Leisure Centre specialist nurses to measure these of individualised care for cancer
(Bournemouth Borough Council), health issues more accurately survivors. It can also improve
Bournemouth and Poole Primary Care • Focus groups were held with communication and manage the
Trust, Macmillan Cancer Support, representatives from each of the transition from secondary to primary
Dorset Cancer Network and three tumour sites and interviews care.
Bournemouth University to deliver an with representatives from each
individualised three-month physical multidisciplinary team and primary Some staff identified personal
activity programme; Living Active & care to ensure the project was education needs to improve their
Well Programme, to 200 cancer focused, relevant and timely. delivery of the survivorship agenda.
survivors (breast, colorectal and Within the project this was mainly
melanoma) following treatment What was done? addressed by the sharing of relevant
• The aim was to promote physical, From the focus groups and interviews research material. Preliminary results
psychological, social, and spiritual with survivors, health care, and leisure from the QOL tools suggest a trend
health and wellbeing and include services staff, the following issues were towards improvement between pre and
strategies to promote self care for incorporated into the planning and post intervention scores in keeping with
living with and beyond cancer delivery of the project: the objective scores from the physical
• Provisional outcome results (69:200) fitness assessments.
from objective and subjective • Monthly multidisciplinary, multi
measures suggest the project has organisational steering group ‘The teams knowledge
successfully achieved its aims. It also meetings established with dedicated
aims to improve communication project management support and expertise was
between survivors and health • Assessment and care planning astounding and I felt
professionals by introducing • Assessment tools – quality of life,
assessment and care planning, and fitness etc energised to pursue.’
between secondary and primary care • The issue of ‘safety’ in relation to
by reviewing current processes and physical activity post cancer
exploring the potential of the care treatment. ‘The team were
plan being a live document that • Weight management wonderful… very
facilitates the transition from primary • Nutrition education
treatment in secondary care back to • Improve communication between encouraging. I got
primary care. primary and secondary care. enjoyment and noticeable
• Identify and/or create documentation
The project can be viewed on YouTube: and assessment tools to support the
improvements from the
www.youtube.co.uk/activehealthlink projects aims such as various relevant programme.’
quality of life tools
The issues • Development of a project database
• A local test project identified a range • Identification of important issues for
of health issues reported by breast tumour site teams e.g for the breast
cancer survivors included reduced team, shoulder function and the
physical function (e.g. range of colorectal team, weight
shoulder movement), levels of fitness, management.


‘Top tips’
Living Active and Well Programme outcomes Before the project starts:
• Clearly identify suitably qualified
Outcomes of those who successfully completed 12 weeks administrative support.
(numbers shown out of the total for whom the outcome was relevant for): • Appropriate IT support.
• Staff ‘buy in’ before the project
Tested
starts. Is it realistic to expect them to
Improved CV fitness: (93%)
add this commitment to their current
Improvements to BP (of those with starting BPs >130 SBP and >85DBP): (90%)
work load?
Weight loss (59%)
• Are there contingency plans to
Self reported sustain the project if a key member
Improved feelings of wellbeing: (97%) of the project team is absent for a
Less fatigue: (94%) period of time?
Improved shoulder function: (77%)
Improved lymphoedema: (66%) Next steps
Improved self-image: (100%) • A package of information will be
Improved flexibility: (94%) developed for treatment side effects
Will continue to exercise after the 12 week period: (100%) and self care strategies for insertion
Number of partners also engaged in the programme: (25%) into the care plan to promote safe,
consistent advice from professionals
• Completion of two research projects
identified in response to issues
The learning so far • Participants that wanted a partner or identified during focus groups on
• Mutually beneficial, strong, significant other to take part found nutrition and shoulder function.
collaborative relationship has that they both achieved health
developed between the health and benefits Contacts
leisure services staff • Some survivors of breast cancer Layne Hamerston,
• Shared learning has changed reported that body image concerns Partnership Development Manager
attitudes and raised awareness and the open plan design of many layne.hamerston@bournemouth.gov.uk
among health service staff of the swimming pools prevented them
benefits of physical activity. It is now from returning to swimming after Dexter Perry,
more routinely raised in treatment. A suitable pool was Consultant Surgeon,
consultations. Media events and identified and exclusive classes set dexter.perry@rbch.nhs.uk
word of mouth have raised up. The experience was rated as
awareness amongst other cancer highly successful by those who
survivors participated. A survivor representative
• Teams who were not undertaking on BACSUP is planning to take this
formal assessment and care planning forward as a survivor-led swimming
prior to BACSUP, recognise the level group.
of undiagnosed unmet health and
social needs is significant and
requires action
• Greater success was achieved where ‘The programme was tailored for me and I am
weight loss management was
targeted with both physical activity pleased to be invited to participate and am happy
and diet, involving a lifestyle coach with the results.’


Brighton and Sussex University Hospital NHS Trust
Improving quality for patients with lung cancer

Summary • Inadequate time with the patient for Local measures were set to ensure that
A process mapping exercise highlighted a detailed assessment of all their these changes were monitored both in
areas for improvement in the care of needs terms of their effect on the demand on
patients with lung cancer and led to a • Lack of access to other services the service and quality of care provided.
newly designed pathway. A weekly particularly psychological support.
multidisciplinary Combined Cancer An Access® based electronic database
Clinic (CCC) within the Sussex Cancer What we did? for the completion of the Treatment
Centre at BSUH has now been We held a process mapping exercise Record Summary and the ACP was
established where patients at any stage attended by all healthcare workers developed as completion of paper
in their treatment pathway post- involved in the lung cancer service. A based records during consultations
diagnosis have a holistic assessment detailed map of the current service was proved to be very time consuming. This
carried out. The clinic has been reviewed and areas of potential risk replaced the previous standard letter to
designed to be more flexible to suit were identified. An ideal pathway of the patients GP.
patients’ needs, allowing them to care was designed/agreed by the MDT.
trigger an appointment or cancel if not As part of the improvement, a Local measures included:
required and rebook for a later date. combined cancer clinic with • Change in distress thermometer
During the consultation a Treatment multidisciplinary input was established scores (using DT) recorded at each
Record Summary (TRS) is produced and held in the Sussex Cancer Centre. attendance in outpatients
which is given to the patient either at • A local questionnaire assessing
the clinic or sent to them and their GP This clinic was designed for follow up patients’ experience of the previous
within 24hrs. The patient also has a of anyone known to have lung cancer system of care with plans to reassess
detailed assessment and care plan (i.e. at any point beyond the the effect of CCC on their
(ACP) completed by the specialist consultation where the bad news was experience
nurses. All documents are given to the broken). Patients could be seen by • The number of lung cancer patients
patient to be kept in their own patient- respiratory physicians, palliative admitted monthly as unscheduled
held record. Early feedback from both medicine specialists and the Macmillan attendances via A&E compared with
patients and staff has been very cancer nurses, with input from the same time frame in previous
positive. Results from local and national oncology. The duration of the years
measures are still awaited as the study appointment was extended to • The number of outpatient
period is not yet complete. Further acknowledge the amount of additional appointments triggered/cancelled
development of the CCC will see the work created by carrying out the and DNA
inclusion of a dedicated oncologist and Treatment Summary Record and ACP. • Referrals made to services outside the
a thoracic surgeon. These documents were given to the MDT (e.g. psychological support/
patient in clinic once complete where dietician/physiotherapy etc).
The problem possible and kept in a dedicated
A few issues were noted with the patient-held record. This enabled access What difference has the
current lung cancer patient pathway: by the patient/carer, GP, community testing work made?
• Multiple clinics where patients services to vital information regarding Early indications are that the new service
were seen ongoing treatment plans, side effects model is working. The ability to tailor
• Multiple sites where clinics were held and complications, as well as signs appointments to suit the patients’ needs
• Suboptimal Macmillan nurse which may need further assessment by has been noted both by patients and
availability a health professional. Patients were also staff as beneficial and has led to a sense
• Periods when care passed between given the option of cancelling/delaying of better quality care. Overall, although
different services with the risk that their appointment if not needed, or the number of questionnaires given out
patients could be lost self-triggering a consultation if has been a little onerous only one
required. patient has declined to complete one.


Non elective emergencies appear to be
reducing compared to data in previous A&E admissions relating to lung cancer
years. Of those patients admitted
between February and May 2010 none 14
were patients who had received care 2008 2009 2010
12
through the new service suggesting
Number of admissions

that we are helping to avoid 10
unscheduled admissions.
8
Because of the setting of the clinic and 6
the increased time allotted to each
patient, we have been able to carry out 4
certain procedures in the cancer centre 2
(e.g. pleural aspiration), thereby
avoiding need for emergency admission 0
Jan Feb Mar Apr May Jun
or re-attendance at a later date for an Months
outpatient procedure, all of which
patients have found distressing.

The baseline CESU questionnaire
indicated a high level of satisfaction Learning so far • The process of ACP is time
with the original service but also • Reviewing the whole care pathway consuming.
suggested that 25% of patients felt for lung patients has provided a
their worries about their condition or sound baseline for sustainable Next steps
treatment weren’t discussed, that they improvements to the quality of care The study is ongoing. Further
or their carers weren’t given enough • Sharing the issues identified by the development of the CCC will see the
information about their condition or mapping event with the whole inclusion of a dedicated oncologist and
treatment (30%), that they would have respiratory team and jointly agreeing a thoracic surgeon. It is intended to
liked to receive written information priorities for action has accelerated report individual case studies. A new
before they left the OPD (25%) and progress A&E electronic tracking system will flag
that they were not told who to contact • The identification of baseline up any lung cancer patients admitted
if they were worried about their measures and recording of data is and alert lung clinicians and cancer
condition or treatment (50%). We providing valuable evidence to nurses by e-mail. There is a training
await the results of the second support improvements in practice need of further clinicians and other
questionnaire assessing the CCC. and will help support the vision to staff for sustainability of the new
establish a similar service on other system.
Of the 20 patients contacted by the hospital sites and amongst other
CNS a week before their appointment, tumour groups Contact
4 opted to cancel their appointment as • The appointment of a project Dr Sarah Doffman
there was no need to attend. These manager, the development of an Consultant Respiratory Physician,
slots were filled by either new patients electronic database, and the strong sarah.doffman@bsuh.nhs.uk,
or patient triggered appointments. support of clinicians and nurses
currently involved in lung cancer
patient treatment and care are
important steps in ensuring
successful participation in this
project


North Bristol NHS Trust
Self management programmes and different
models of follow-up care in cancer survivorship
North Bristol NHS Trust is the largest Big Clinics: Information and support The colorectal team were not convinced
surgical cancer treatment centre in the days 4-6 months post treatment of the benefits therefore only booked a
South West. In recent years, teams have Uptake for all four tumour sites half day. They were surprised by almost
transferred responsibility for follow up between 60-70%. 100% uptake with an unexpected
from medical personnel to clinical nurse outcome of the group consisting
specialists (CNS); however they have Colorectal Big Clinic patient predominantly of men.
been continuing to follow a medical feedback
model. • Good opportunity to review Big Clinics for prostate, kidney and
current/future regimes bladder cancer had very similar results
The aim of this project was to explore • Exercise programme was useful and reporting of 70-95% relevance in topics
the quality of support, information and the surveillance programme and covered. There has been such an
follow up for cancer survivor’s following symptoms to look out for were good interest in the success that the Lung
treatment. A health needs analysis • It has given me the incentive to do and Upper GI cancer teams approached
and focus group, inviting users to more exercise the cancer services team to run their
explore unmet needs was undertaken • To review my diet and exercise own big clinic days. Due to these
in four tumour sites: breast, colorectal, • Change diet and exercise more tumour sites having patients with
urology and haematology. This helped • To maintain regular exercise poorer prognosis at the outset we were
us identify gaps in service provision and • Look after my diet more keen to see the teams’ approach and
to design a model that delivers • Feel more confident to engage in evaluations.
supported self care and holistic needs physical exercise
assessment (HNA). • Sessions very informative.

The Penny Brohn Cancer Centre and Feedback from evaluation forms
University of the West of England
(UWE) have been working
collaboratively with us on this project. Colorectal Big Clinic evaluation results

Lifestyle management
105
The models of self management chosen
Good and relevant

to test were: 100
99.5
• Big Clinic days run by the clinical 95
teams
90 92.85
• 10 week course, one day a week run
by Penny Brohn Cancer Care 85
85.7 85.5 85.73
• Residential weekend course run by
80
Penny Brohn Cancer Care
• Cognitive Behavioural Therapy (CBT) 75
Venue Diet Complimentary Fitness Recurrence
course for breast and prostate cancer Advice Therapy & Exercise Symptoms
patients run by clinical psychologists
and CNSs.


Lung Big Clinic evaluation results Can you list two ways in
which your life may change
following today’s event?
120 • Being more positive
• Try to be more active
Good and relevant

100
• Start living normally again
80
• Do more exercise
60 • That I can exercise
40 • To stop using my cancer as an
escape
20
• Exercise with confidence
0 • Not to make excuses and to
Venue Patient Diet Physio Treatments Living Life start doing housework again
Story to the Full
• Go on holiday
• More positive outlook
• Don’t panic and give up.

The lung team ran a Big Clinic and now Patient feed back from the Further comments:
run them on a rolling three monthly Big Clinic day • Follow up sessions would be
basis. The evaluation highlighted some extremely helpful
patients would benefit from more in- • Very worthwhile it would be
depth support from one of the more Can you list two things that good to have regular sessions
structured courses. you have learnt from today? • Thought the venue could not
• Meeting others that have the be bettered
same problems • Very useful morning
• Available support • Very useful knowing parking
• I am not alone spaces were reserved
• Diet and travel information • Very good day – thank you
• To realise that I am not • We enjoyed the day, its been
discarded very beneficial and was well put
• Not to be concerned about together.
shortness of breath
• Physio info was good I have
learnt you don’t have to stop
when you feel breathless
• Confidence and how important
it is to work through anxiety
• Not as gloomy and outlook is
more positive
• Allowances and benefits
• Diet and activity
• Feel there is support
• You can do more than you
think
• Breathing.


Obtaining user’s and clinical teams’ Client Relations Management
views, and in setting up the lifestyle (CRM) system
management programmes during CRM systems are used by large
scoping, it became evident that companies to track important
different models of follow-up care information about their customers,
could be used dependant on level of so whenever contact is made with a
risk of recurrence and levels of customer, they can have all of the
intervention needed. These would relevant information to hand, and any
consist of a combination of: actions can be initiated and tracked.

• Supported self management with self
referral back into system Client Relations Management System
• Self management with remote
follow-up through telephone clinics
• Self management and face to face
follow-up
• One of the above plus appropriate
surveillance tests.

To increase confidence for clinical
teams to move away from a medical
model they needed assurance that
patients would not get lost to follow
up. Equally, proposed changes, would
not impact on identifying recurrence of
cancer in any way.

Therefore an information gathering
process began on how patients in each Having explored whether an ‘off the • Alert the CNS when the patient has
tumour group re-presented with shelf’ CRM could be adapted it was felt not had any contact for a year in
recurrence: surveillance examination, that building a system to meet our order that action can be taken.
OPA or self referral and this audit is still needs would be better.
ongoing with results pending. Progress and learning so far
The system will enable: • High level of administration for
Additionally we identified that there • Summary of episodes by linking to all lifestyle management - will improve
wasn’t an information system that Trust systems This will include with CRM system
allowed collection of HNA, access to attendance at lifestyle management • Benefits have been recognised by
self management and generally to act events and when HNA has been done other teams
as an alert system if the patient failed • Diary management of lifestyle • Tumour specific sessions provided too
to have the appropriate interactions. management events indicating when late in patient’s journey therefore
Therefore we are developing a new IT invites should be sent out to patients would not be included in future
system, the Client Relations • Holistic needs assessment via Distress
Management System (CRM), which is Thermometer recording care plans
jointly funded by Macmillan and the and reports to help determine
Trust’s IM&T department themes to target Big Clinic topics and
other support needed


• Some sessions found not relevant to
all participants dependent on
treatment, i.e. surgical, radiotherapy
or hormonal. Courses redesigned so
groups have core sessions as a whole
then split into sub groups for more
treatment specific relevant sessions
• Analysis of evaluation of Penny Brohn
courses in progress.

Next steps
• Qualitative analysis of lifestyle
management approaches using focus
groups in collaboration with UWE
• Redesign of follow up protocols to
adopt different model incorporating
self management
• Complete audit on recurrence
presentation
• Run and evaluate CBT courses in
breast and prostate
• Economic evaluation
• Enable other cancer teams to
replicate model
• Write up of pilot, disseminate and
development of commissioned
service.

Contacts

Dany Bell
Lead Cancer Nurse and Cancer
Manager – Project Lead
Dany.Bell@nbt.nhs.uk

Marika Hills
Assistant Lead Cancer Nurse – Project
Manager
Marika.Hills@nbt.nhs.uk


The Christie Test Community
The importance of establishing peer group
support for survivors of pelvic cancers
Summary • The lack of opportunities for user • The other breakout group discussed
The Christie is a tertiary centre treating involvement highlighted the need to ideas around the support group,
over 40,000 cancer patients a year, host a user group meeting that specifically the organisation of when,
serving a population of 3.2 million included clinicians and patients and how often to meet and who
across Greater Manchester and • A date/time/venue to hold an initial would take on the key roles.
Cheshire. Due to the nature of tertiary ‘user group’ meeting was agreed. However, these issues were carried
referrals, 26% of the referrals are from The afternoon included lunch forward with a view to enabling the
outside the area. This project focuses /networking, some appropriate users to make these decisions once
on support for patients experiencing clinicians gave formal lecture style there is a core membership, to ensure
the late effects of radiotherapy presentations, chaired by the project’s ownership and purpose of the group
treatment for pelvic cancers in a peer clinical lead is clear.
support group setting. We have • Following this initial user involvement
achieved greater user engagement and meeting, we established a database What difference has the testing
are working on the sustainability of the of patients who have been identified work made or identified?
peer support group. We are also by our clinicians as suffering from the • The feedback from attendees is good
looking at patient information and the late effects of pelvic radiotherapy and they appreciate the group,
oncolink web based care planning tool • Post meeting, a letter asking users to indicating a need to continue
to help patients with supported self put forward ideas to include at the offering a framework for accessing
management and understanding the next session – including the peer support amongst the target
sign and symptoms of late effects. establishment of a peer support population
group and a panel session where • The attendees present and those
The problem clinicians answer written questions approached to attend have helped to
A lack of support for survivors of pelvic submitted anonymously by users establish a large number of engaged
cancers experiencing late effects was • Questions submitted ahead of the individuals who could also be called
evident from concerns and problems event included: upon to participate in other aspects
identified at the late effects clinics at • ‘does lifestyle influence cancer?’ of the project e.g. commenting on
the hospital. This coupled with the • ‘what is the risk to other members oncolink and patient information
professional’s desire to empower of the family and friends during booklet content.
patients to self-manage their symptoms treatment with radiotherapy?’
of late effects to improve their quality • One of two ‘breakout’ sessions asked Learning so far
of life and establish an effective peer attendees to look at the ‘Oncolink’ • Good attendance, apparently well
support network for patients led to the online care planning system as a received sessions from verbal or
following testing and development. presentation and then try it at home. informal feedback, however, there
Ten people tried this and sent back was no evaluation form for attendees
What was done an evaluation with mixed reviews. to fill in following the first few
• Information was collated around:- One patient stated in answering the sessions – therefore it was difficult to
• the prevalence of late effects question ‘how easy did you find quantify the event’s success, or which
• the level of contact with healthcare generating your own care plan?’ ‘not parts were most useful
professionals following the acute very easy, do not know which part is • A lot of feedback related to what
treatment phase the care plan, would have to be told attendees would like in future
• the provision of patient information a bit more’ highlighting the issues of sessions. This demonstrated the
• how individuals share their care planning can be at a very basic enthusiasm for peer-to-peer
thoughts, stories and advice with level networking and a keenness to be
people in a similar position involved in the planning and
delivery of future events. This will
ensure we have a clear idea of what
is required, the Q&A panel with pre-


submitted questions was the
patients’ idea and gave patients a Did you have a chance to say everything you wanted?
chance to be heard, (see the
evaluation graph on the right) 8
• The feedback received in relation to
Number of respondants
7
the Oncolink care plan was very 6
7

useful and demonstrates the 5
necessity for patient feedback to
4
inform service developments 4
• For the group to be sustainable, the 3
issue of its administration needs to be 2
2
addressed as it can be challenging 1
1
to engage patients in this work. At 0
present the group is being facilitated Yes, Yes, to some N/A No
definately extent
by the project team and this
consumes a lot of time.

Next steps
• The establishment of a user-led
support group that is self sustaining
and with patients in key roles running
the group, without reliance on trust
led facilitation
• Continue to host user group
meetings during the life of the
project and assess sustainability.

Contact
Ben Heyworth
Project Manager
Tel: 07917 628 672


Clatterbridge Centre for Oncology
Moving forward (or initially backwards!): setting up a
successful education programme for patients living with
and beyond pelvic cancer
Summary The problem mirrored those of the group
Clatterbridge Centre for Oncology has The programme was aimed at pre- participants. 67 patients invited, 21
an average of 50 patients treated on empting some of the problems that attended, six of whom turned up
each accelerator every day and over patients regularly encounter living with having not responded but brought
7,000 new patients registered at the and beyond cancer which are identified SPARC with them, five returned
hospital each year. In the delivery of at the late effects clinic. We conducted completed SPARCs but couldn’t
services, the Trust works alongside a baseline case note audit for 45 attend the sessions.
other hospital trusts within the patients (15 gynaecological, 15
Merseyside and Cheshire Cancer prostate, 15 colorectal) looking for What difference has this testing
network, both as part of a joint multi- documented post treatment side effects work identified?
disciplinary team approach to treatment e.g. sexual health issues, bowel and Positives
of patients and in the provision of out- bladder problems, to see whether there • Patient needs identified from the
patient and day care services within was any documented care plan or baseline audit and SPARC
those trusts. evidence of onward referral to assessments showed the same types
appropriate agencies. The audit of emotional and information issues
The aim of the project was to educate confirmed the results from the Picker being raised
patients in a ‘Moving Forward’ group to baseline survey where patients • SPARC responses identified post
live with and beyond cancer. We indicated that they had concerns about treatment side effects e.g.
completed a baseline case note audit to late effects and would have liked more psychological issues, fatigue, exercise,
establish if patients who have had information regarding these and where getting back to work
treatment for pelvic cancers (colorectal, to access help and advice. • The casenote audit and completed
prostate and gynaecological) identify SPARCs revealed that there were no
common post treatment side effects What was done consistent onward referrals. This has
during their medical review in the late • The baseline audit set the educational resulted in greater awareness within
effects clinic. The aim was to establish agenda to address the common post the Clatterbridge team and clear
the prevalence and management of treatment side effects for the first onward referrals pathways and
symptoms and identify existing primary programme. 67 patients were robust partnership working
care services to which patients are invited, 15 phoned to confirm • Effective cross boundary working and
referred. attendance and returned a sharing of expertise.
completed SPARC before the course
Patients were invited to attend the commenced. Some minor alterations Negatives
‘Moving Forward’ group and to i.e. dietetic advice were added • If additional needs are identified after
complete a Sheffield Profile for following collation of the data from the agenda has been set, timescales
Assessment and Referral for Care the returned SPARCs can make it difficult to access other
(SPARC) Holistic Needs Assessment • During this first session some Allied Health Professionals for their
(HNA) to ascertain whether our signposting was done for identified input
baseline case note data correlated with level 3 needs as defined in the SPARC • When SPARC is completed
patients’ identified needs. This tool i.e. a patient that feels that in anonymously only general
information then formulated the the past month they have been signposting for further support
content of the sessions and provided distressed or bothered by the services could be done as part of a
evidence of need. problem ‘very much’ group session. A robust policy for the
• Interestingly, some patients who use of SPARC in this setting is
declined to attend still sent back the essential.
SPARC and their identified needs


Learning so far We are also liaising with highlighted
• SPARC is easy to use, easy to services to establish whether there has
interpret. Participants are happy to been an associated increase in number
complete and appropriateness of referrals, e.g.
• Format of the group sessions needs speaker from continence service has
further exploration as small breakout highlighted the number of referrals
groups were problematic, before the from programme session on
group developed confidence in one continence.
another
• Group sessions were held in a very Contacts
accessible community centre which Mhairi Hawkes
offers a less formal opportunity to Cancer Nurse Specialist
chat to health professionals mhairi.hawkes@ccotrust.nhs.uk
• Having a run through of the each
session prior to delivering it to Hannah Roberts
participants would perhaps have Occupational Therapist
identified issues i.e. more facilitators, hannah.roberts@ccotrust.nhs.uk
different room placements,
appropriate Health Care Professionals
• Don’t change the day the group
runs!! We changed the day due to
the hall being unavailable and despite
this being highlighted as much as
possible, several patients still turned
up on the wrong day.

Next steps
In the next course we will:
• Pair sessions together where
information follows a similar theme
e.g. continence and sexuality, fatigue,
exercise and work
• Adjust times of sessions to cater for a
wider range of patients e.g. run on
consecutive evenings rather than
weekly in the afternoons
• Ensure availability of identified
speakers, to co-ordinate with
availability of venue and dates
arranged.


East Kent Hospitals University NHS Foundation Trust
Patient group involvement in shaping assessment
and care planning (ACP)
Summary • 31% didn’t know who to contact in • A ‘wellness’ tool, based on the
The East Kent Hospitals University NHS hours and 74% patients didn’t know Velindre Cancer Centre breast cancer
Foundation Trust (EKHUFT) comprises who to contact out of hours if they health questionnaire, was developed
three hospitals with a population of had a problem. and implemented. This prompts
750,000 people. The cancer centre is discussion between the patient and
based at Kent and Canterbury Hospital A further local baseline assessment of breast surgeon in follow up
with further diagnostic and outpatient 100 sets of case notes for patients with consultations.
services provided in Margate and a diagnosis of breast cancer identified
Ashford. The focus of the survivorship that whilst medical needs were Learning
project was to develop with patients documented there were few General
and clinical teams an improved model psychosocial or support needs • Feedback from the focus groups was
of care for survivorship that listens to recorded. that patients were pleased to support
and responds to patient needs. the project, be ‘given a voice’ and the
What was done? opportunity to influence care. For
A series of focus groups with patients • Patients were invited in via local professionals, user involvement has
who are living with or beyond a support groups to attend focus group provided a unique insight into the
diagnosis of cancer over the last year meetings to identify service gaps and care provided and areas for
have identified ways to improve explore ways to help others move improvement
services across the cancer pathway forward following treatment • The development and review of the
focusing specifically on the survivorship • The team mapped the current and assessment tools within a CNS
phase and to advise on the use of future care pathway for breast project group has created interest,
assessment and care planning tools. patients treated with curative intent. enthusiasm and ownership, taking
This work supported the emerging the project forward
The problem ideas from the focus groups: • Feedback states the ‘wellness tool’ is
Focus group participants reported that 1)To test whether a discussion at the a useful prompt for discussion.
following treatment they experienced end of initial treatment and between during clinic consultation with
feelings of isolation, abandonment and first and second follow up visit would patients and professionals finding the
anger, with little opportunity to discuss improve the patient experience. tool simple to use
their needs. They didn’t know who to 2)To develop a tool for assessing the • CNS’s felt that an end of treatment
contact and felt their GPs had limited overall ‘wellness’ of the patient at assessment identified needs that may
information about their condition and each surgical outpatient visit otherwise have been missed.
treatment. They were confused about • A team of clinical nurse specialists However, both patients and staff felt
the role of the Cancer Nurse Specialist from across the Trust were convened the process should commence at
(CNS) and key worker. to test this approach and test two diagnosis and be reviewed at key
types of tools: points in the pathway
The national Picker Institue baseline 1)The full NCSI ACP framework tool • Not all patients were willing to
survey of 70 breast cancer patients was tested on 16 patients. It included complete a self assessment, many
reflected similar feedback and found a patient self assessment tool, an preferring the professional to
that: assessment record completed by the complete the checklist with them
• 87% patients didn’t have a care plan professional and a management and • An assessment can be successfully
• 34% didn’t know what to expect at support plan for the patient to keep. completed by phone. Assessment
future appointments 2)The Distress Thermometer tool. This times ranged between 15 to 60
• 58% received insufficient information was tested on 14 patients
and advice • Face to face and telephone
assessments were carried out by the
CNS or oncology nurse


minutes with an average of 35 • The patient working group preferred
minutes, however, they took longer the DT tool over the NCSI tool. They
and were less productive where the suggested the thermometer be kept
professional was not known to the but replaced with title ‘The stress
patient prior to the meeting scale’ so it is less medical and more
• Professionals and patients benefit if patient friendly.
the assessor has completed advanced
communication skills training Next steps
• Testing suggested that a structured 1. Report user group views to CNS
job plan with dedicated assessment team to agree an assessment tool
time is required to enable roll out and that can be tested earlier in the
sustainability across the organisation. pathway
2. Map the whole care pathway for
Learning from using the NCSI each tumour to agree the key points
assessment and care planning at which an ACP discussion should
framework tool occur, the location, the tools and
• Of the 16 patients asked to complete with whom the results are
the self assessment section none communicated to ensure a
opted to complete it. Reasons cited standardised approach to ACP across
were: form too complex, difficult to the Trust
use and not patient/user friendly 3. Review job plans for CNS staff to
• Professionals felt the two assessment support implementation of ACP
tools would be more useful as a 4. Test the NCSI Treatment Record
baseline assessment at diagnosis. Summary for GPs to improve
One patient said ‘I would have liked primary/secondary care interface
this prior to treatment starting’ communication
• Some staff felt the documentation 5. Work with network wide breast
was too long and took excessive time group to use the ACP process as an
to complete. It was difficult to enabler for stratifying patients into
complete live and required flicking supported self management
between pages. pathway as alternative to traditional
follow up
Learning from using the Distress 6. Undertake second national Picker
Thermometer Tool Institute survey for patients who
• Patients and staff disliked the term have participated in the new
‘Distress Tool’ for patients in recovery pathway
and several CNS’s felt that the 7. Test the use of ‘wellness tool’ with
domain headings in the tool rather breast patients prior to attending
than the thermometer itself provided follow up clinic.
a better prompt for discussion. The
CNS team proposed a more Contact
professionally led ‘concerns tool’ Mary-Anne Lovett
using tick boxes to identify key issues Lead for Cancer Survivorship Project
with the patient mary-anne.lovett@ekht.nhs.uk


Gloucestershire Test Community
A real life example of partnership working

Summary • Can speak a number of languages to In terms of cost; there has been
The Gloucestershire Survivorship project reduce barriers experienced by black concern that the Village Agent service
involves cancer patients and carers, and minority ethnic communities may be viewed as an ‘add on service’
employees from the 3 Counties Cancer • Have ongoing support to help them but the focus of increasing quality of
Network, Gloucestershire Hospitals NHS with this role. life as well as early signposting by
Foundation Trust, Gloucestershire agents could have positive long-term
Community and Adult Care, This project is therefore an exciting consequences. If this pilot was rolled
Gloucestershire Rural Community opportunity to work in partnership with out as part of health and social care
Council and Macmillan Cancer Support social care providers to develop a across the country it would enable all
all working together to support cancer distinctive service for cancer survivors people living with and beyond cancer
survivors. The local initiative is delivered and their carers in the county. access to timely support regardless of
through a pre-existing Village Agent the stage of the cancer pathway.
service originally launched in 2006. This What was done
pilot has expanded the remit of the • Recruited and identified eight Village Outcomes so far
existing Village Agent service to cover Agents willing to support this project • 27 people have contacted the VA
all areas of Gloucestershire and to and work an additional 10 hours per service; 14 female, 13 male. Of
support anyone aged 18 and over who month which 19 have diagnosis of cancer;
is living with or beyond cancer. • Developed training and support the remaining eight have a friend or
Gloucestershire has a population of package to undertake this role family member who has cancer
582,600, a third of whom are classified through CNS, clinical psychologist • The cancer diagnoses have ranged
as living in rural communities and and other health care professionals from prostate cancer to kidney cancer
44,000 are recorded as experiencing • Development of a manual as a source with the most common being
extreme poverty. of reference to support signposting prostate and bowel cancers
and contact details • Average age of contacts: 74; ranging
Village Agents: • Developed publicity materials such as 43 – 93 years
• Bridge the gap between local GP, local community and bus • Seventeen of the contacts have been
community and statutory and advertisements and leaflets self-referral with the rest ranging
voluntary organisations • Developed learning sets/supervision from family referral to Police
• Act as facilitators and provide high for continuing support. Community Support Officer referral
quality information • The most common reason for
• Are based within the community and Learning so far contacting an agent has been a need
visit people in their own homes Whilst there is full support for the for home or practical help. Other
• Are unique to Gloucestershire and added value of this project, we’ve reasons for contact include
have been commended nationally experienced difficulties such as lower help/support with benefits and
• Are employed to work about 10 numbers of referrals than expected transport and requests for
hours per week accessing a Village Agent. The team information about respite care and
• Can identify unmet needs (e.g. has worked hard on advertising support groups
financial, practical, social, emotional) however; this largely depends on • The numbers of pre and post contact
and signpost to a wide range of people self-referring and an local evaluation questionnaires
services opportunity for people to become received have not been sufficient to
• Offer help and support when familiar with the service. Village Agents draw conclusions about the impact of
required have found ‘word of mouth’ and the VA service in addressing the
• Have undergone further training in ‘familiarity’ to be the most effective needs of those living with and
preparation for this project in strategies historically. As this is a pilot, beyond cancer, however local
assessment, care planning and there have also been concerns whether evaluation is ongoing and will be
identifying needs for patients with this service will continue to be available assessed once sufficient evaluation
cancer if people refer their patients. questionnaires have been received.


How are clients referred to a Village Agent?


Assessment and signposting


Next steps
• Continue to collect data to evaluate
service
• Liaison with GPs to raise the profile
of this initiative
• Continued publicity of this initiative.

Contact
Sarah Dryden
Project Manager
Gloucestershire Survivorship Project
sarah.dryden@glos.nhs.uk

Fran Callen
Project Manager
Gloucestershire Survivorship Project
fran.callen@glos.nhs.uk


Guy’s and St Thomas’ NHS Foundation Trust
Surviving cancer living life – a nurse led telephone
service for breast and prostate cancer survivors

Pfizer Health Solutions Guy’s and St Thomas’ NHS
NHS Foundation Trust

Summary Following an initial assessment, the
Surviving Cancer Living Life (SCLL) is a patient and the care manager identify
telephone based support service priorities and and develop an individual
launched by Guy’s and St Thomas’ NHS care plan, focusing on the areas of
Foundation Trust (GSTT) in May 2008. greatest need. Telephone calls are
This pilot service is offered to people planned, usually starting fortnightly,
who have recently finished active before moving to monthly. Patients
treatment (surgery, radiotherapy, usually access the service for between
chemotherapy) for breast or prostate six and nine months.
cancer, that received any part of their
treatment at these hospitals. The problem
SCLL is run by the Trust in partnership • The steering group, formed in the
with Pfizer Health Solutions (PHS), autumn of 2007, consisted of staff
financially supported by Guy’s and St from GSTT, PHS and King’s College
Thomas’ Charity. By May 2010 over London (KCL), identified a lack of
570 breast and prostate cancer patients support for cancer survivors
have used the service and it has been • PHS had already developed a
extremely well received. telephone-based support service for • Steering group set up with
people with chronic conditions such representatives from all organisations
Two experienced cancer nurses referred as COPD and were interested in and the project plan signed off
to as care managers give personalised developing the model to include • Evaluation meetings, project working
telephone-based support. This holistic cancer patients group meetings and meetings with
service uses the concepts of • It was decided to pilot this telephone- various stakeholders also took place
motivational interviewing and health based support service with breast and regularly during the development
coaching to help people to: prostate cancer patients as they are a phase
• Better understand factors that affect large patient group of both sexes. • Barriers and challenges at this point
their health included recruiting the care managers
• Build confidence and skills to cope What was done (band 7 oncology nurses) and
with, and overcome, the anxiety of Project Scoping integrating the Trust IT system and a
living life after cancer In October 2007 the two main parties new PHS software system to record
• Acquire the skills, knowledge and GSTT and PHS agreed to pilot a patient’s details and care plans
habits in order to remain fit and telephone service, with Kings College • The care managers five week
healthy London to evaluate the service. training programme included
• Follow their treatment programmes Contracts were signed off. motivational interviewing, advanced
correctly communications, detailed sessions on
• Understand how to engage with, and Development phase the role of the care manager and IT
use, local NHS, social and voluntary December 2007 – May 2008 system training
services more effectively.

Living with and beyond cancer: The improvement story so far

Living with and beyond cancer: The improvement story so far

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (17)

En vedette

En vedette (11)

Similaire à Living with and beyond cancer: The improvement story so far

Similaire à Living with and beyond cancer: The improvement story so far (20)

Plus de NHS Improvement

Plus de NHS Improvement (20)

Dernier

Dernier (20)

Living with and beyond cancer: The improvement story so far