Survivorship Update January 2015
The Royal Wolverhampton NHS
Trust
James Owen
Senior Cancer Services Manager
Background
CQUINs
 Patient Held Care Planning Document
 Urology transfer of follow up to community
Patient Held Care Planning Document






Patient seen
Discuss Treatment options and / or diagnosis
Copy of document goes to patient
Document scanned and saved on shared drive
Somerset Cancer Register updated
Put onto patients electronic record and sent
electronically to GP
Patient Held Care Planning
Document
Cancer Long Term Follow Up



Radically treated prostate cancer patients who are group are
those who are:

18 months or more on from completion of radiotherapy,
surgery or other radical treatments. On-going hormonal
therapy is not a contraindication.

With a stable PSA (as judged by the clinician) and no
other symptoms of metastatic disease

Stable toxicity of treatment with any appropriate
investigations completed (e.g. proctoscopy for rectal
bleeding)
Patients receiving palliative therapy

Biochemically and clinically stable (as judged by the
clinician)

Maintained on current therapy for 6 or more months

No uncontrolled symptoms of malignancy

Patient given information on MSCC.
Patients with Prostate Cancer on Active Surveillance

Patients initially assessed by the urologists and felt to be
suitable for community follow up.

PSA criteria for re-referral defined and documented on
transfer of care document (see appendix C)
Month Seen
Discharge to GP
Other
May
2
2
Jun
10
10
Jul
18
Aug
18
Sep
34
Oct
32
32
Nov
16
16
Dec
12
12
Grand Total
142
1
Grand Total
19
18
1
2
35
144
Paper based HNA
Table to Show the Number of Patients Diagnosed at New Cross Hospital and the Proportion of those that have had a Holistic Needs
Assessment completed on the Somerset Cancer Registry System (Jan - March 2014)
Jan-14
Feb-14
Mar-14
% With HNA
% With HNA
% With HNA
Cancer Site
No
Yes
No
Yes
No
Yes
Completed on SCR
Completed on SCR
Completed on SCR
Breast
9
16
64%
4
12
75%
9
18
67%
Lung
9
11
55%
2
14
88%
2
16
89%
Upper GI
9
7
44%
3
14
82%
7
7
50%
eHNA
• Reviewed use of paper HNA
• Visited Coventry to see it in action
• Submitted bid 14/4/14
• Bid Accepted June 2014
• Met with I.T, Macmillan and Governance July 14
• Final Agreement on kit and Governance August 14
• Ordered equipment and Mapped out pathways and surveyed signal strength
September 14
• Ipads arrived October 2014, configured Ipads and double checked all areas for
signal strength
• Correct Infection Prevention Ipad Cases arrived November 14
• Pilot Started December 14
How does eHNA work?
• Patient undertakes eHNA on Ipad
• Individual Careplan document template
created on web
• Nurse runs through Careplan document with
patient
• Careplan put on portal and SCR updated
National Evaluation
End of Treatment Summary
 SCR vs Letters
 Talked to Oncologists and Macmillan GP
Representative
 Audit Letters in Oncology
 Design Template (with Macmillan GP Representative)
for reference when dictating letters
End of Treatment Summary
Patient Details
Letter Date
Diagnosis
Diagnosis Date
Stage of disease
Treatment undertaken
GP actions required
Ongoing management Required
Symptoms for referral back to the service
Risk/late effects of Treatment
Does the patient have a Prescription charge exemption?
Is the patient on the Palliative Care or Supportive Register?
Has the patient had a DS1500 form completed?
Details of referrals made to other services
Summary of patient information given (i.e. leaflets etc)
Additional information relating to lifestyle
Trust Contact for queries regarding the patient
Health and Wellbeing Event / Follow
Up
 Colorectal Pilot
 End of Treatment supply HNA and Personalised
management Plan
 Prescribe relevant workshop
 Tailored, Nurse led, follow up coupled with workshop
attendance
Health and Wellbeing Event / Follow
Up
 Review how this could work with other MDT teams
Macmillan Information centre
 Operational Policy and Annual Report Update
 MQUISS Standards
 Volunteer Training Events
 Possible Refurbishment (MQUEM)
Going Forward
 Release Strategy Document (and keep to it)
 New Macmillan Funded Post
Thank you for Listening
James Owen
Senior Cancer Services Manager
James.Owen@nhs.net
01902 695249