Oncology Nurse Led Clinics
An economic assessment of Breast Open Access follow up and Uro-Oncology
Clinical Nurse Specialist Clinics
Understanding the service
The Great Western Hospital Foundation Trust provides cancer services primarily to
people living in Swindon and North Wiltshire. Predicted activity figures across all
tumour sites demonstrates a steady rise in cancer diagnoses (Appendix 1 and 2).
The number of people living with cancer is expected to increase from 2 million to 4
million by 2030 [National Cancer Survivorship Initiative (NCSI), 2013]. This means the
number of people requiring specialist care and support will increase through the cancer
pathway. The NHS Five Year Forward Report (2014) acknowledges, the healthcare
system cannot remain in status quo but needs new models of care to support service
delivery. The Cancer Clinical Nurse Specialist can help to improve the quality of life for
people with cancer. They can also help empower patients to self-manage their
conditions leading to reduced costs for health care providers through hospital
appointments, emergency admissions and consultant time.
The National Cancer Survivorship Initiative (NCSI) in collaboration with NHS England
and Macmillan reviewed follow up practice and made recommendations on the
stratified cancer pathway. The table below provides suggested pathways.
1
For the purpose of the economic assessment, the Breast and Uro-Oncology nurse led
clinics were selected to undertake an economic assessment of the nurse-led clinics
against traditional practice. Clinical Nurse Specialists (CNS) provide specialist advice
and support for patients diagnosed with cancer acting as key worker in accordance
with National Cancer Peer Review requirements. With an aging population and more
people being diagnosed with cancer, the teams have developed their service to meet
the needs of their patient population. CNSs are at the front-line of cancer care; they
are the main point of contact for patients and as a result help to deliver personalised
care for each patient according to need and patient choice, which contributes to wider
cancer priorities. CNSs play an important role in enabling care to be delivered closer
to home and in improving patients’ ability to self-manage symptoms and side-effects
of treatment.
The supportive care and information element of the Cancer Clinical Nurse Specialist
role should not be underestimated in enhancing the patient experience. This includes
providing support for the patient/carer at initial diagnosis, individualised information
provision, assisting and supporting with treatment decision making, advice on
management of symptoms and side effects, support and assistance with practical
issues such as finance, providing emotional and basic (level 2) psychological support,
signposting to specialised and support services providing continuity of care. Both
during and at the end of treatment the CNS can provide holistic follow-up within a
nurse-led clinic. The most recent national cancer strategy 2015-2020 “Achieving World
Class Outcomes” emphasizes the importance of the role of the cancer clinical nurse
specialist and is the single most important factor for ensuring a positive patient
experience.
To support the increasing activity and pressures on traditionally medically led clinics,
the CNS team have introduced nurse-led clinics to enhance efficiency in the pathway
and patient experience. The team have the appropriate skill and education to provide
the nurse-led clinic providing a more holistic assessment and ensuring all questions
are answered meeting the patient’s needs. This skill is acknowledged by the wider
cancer multi-disciplinary teams (MDT) with the MDTs supportive of the clinical
development. Whilst no additional CNS were recruited for the delivery of these clinics,
the development of clinics would have been difficult if the team had not increased in
size to support the increasing patient numbers. It is through improved efficiency in the
clinical pathway that the team have been able to include this activity.
The following are a summary of nurse led clinics held by the breast clinical nurse
specialists. The clinic to be evaluated in the economic assessment is the breast open
access follow-up (OAFU). Whilst the tariffs can be provided, it is evident following
discussion with the finance team that the elements making up a tariff are not clearly
known. With the OAFU clinic a specific tariff was negotiated with the local clinical
commissioning group reflecting the time and activity provided in this clinic.
2
The nurse led clinics for Breast CNS:
Clinic
Frequency
Activity Description
Traditionally-led
Breast Open
Access follow-up
clinic
Weekly
5 patient slots
1hour each
End of treatment
summary, Holistic
Needs Assessment
Signposting to Living
Well events
Clinical Oncologist
Surgeon annually
for up to 5 years.
Ad-hoc & virtual
clinics
As required
Seroma
drainage/surgical
clinics
Telephone clinics
which stop a traditional
outpatient appointment
Surgeon
Oncologist
Breast Enhanced
recovery clinicpre-operative
assessment
Weekly
45 minute slots
8 patients
Clinic supporting
enhanced recovery for
breast surgery
Surgeon
The Uro-Oncology CNS nurse led clinics:
The following are a summary of the range of nurse led clinics held by the urooncology clinical nurse specialists. For the focus of the economic evaluation, the
prostate biopsy results clinic will be used.
Clinic
Radiotherapy Follow-up
Clinic
PSA/Support Clinic
PSA Telephone Clinic
E-HNA Clinic
Andrology Clinic
TURBT Clinic
Prostate Biopsy result
clinic
Virtual
Activity Description
Men reviewed 6 weeks
following radical/palliative
radiotherapy to the prostate
Monitoring PSA results in
clinic
Monitoring stable PSA
results via telephone clinic
Holistic Needs Assessment
Clinic
Erectile Dysfunction style
clinic
Provision of bladder
histology results following
surgery
Provision of prostate
biopsy results following
MDT discussion
Telephone and in person
review ad hoc supporting
patient need and reducing
need for consultant
review/admission
Traditionally-led
Clinical Oncologist
Urologist
Urologist
Nurse-led
Urologist
Urologist
Urologist
Nurse-led
3
Breast OAFU Clinic:
In 2012, in line with the NCSI recommendations, the breast MDT with patient
involvement, reviewed standard follow up practice for patients following adjuvant
breast cancer treatment. Metastatic breast patients are not included in this pathway.
Adjuvant follow-up included annual review by the surgical and oncology teams for 5
years. Most patients were discharged at this time but for some psychologically they
preferred on going annual review to ensure access to the system if required.
With the breast open access follow up clinic (OAFU), following the completion of
adjuvant treatment (surgery, chemotherapy & radiotherapy) the patient is referred for
an end of treatment summary, holistic needs assessment and signposting to living well
events and support groups. The patient is given written information listing treatment
to date and advice on symptoms that require rapid access back into the healthcare
system. A telephone number is provided to call if required for an urgent appointment
in the breast clinic within 2 weeks.
This stops the follow up of adjuvant breast cancer patients on an annual basis in both
the breast surgical clinics and oncology clinics for up to 5 years. This type of follow up
reduces the anxiety associated with routine follow up and empowers the patient to
access at time of need with symptoms of concern. Anecdotally recurrence is often
diagnosed between routine appointments and results in a person requiring an
additional appointment or people waiting with symptoms until the next follow up
appointment.
Whilst 18 patients have re-accessed the service to date no one was diagnosed with a
recurrence. This correlates with national work where the figures are presumed small.
Financially the nurse led service is cost effective, meets national guidance and has
met the patients’ needs demonstrated in a patient experience survey and Family &
Friends testing. There have been no complaints received nor any incidents reported
for this service.
One Band 7 CNS conducts the OAFU clinic but two other CNS are also skilled to
conduct the clinic to ensure it is not cancelled at times of leave. The nurses have
completed the breast care module at the Royal Marsden Hospital. These clinics require
suitably trained specialist staff.
The nurses do not receive any health care assistant support to run the clinic nor prep
the notes. The CNS spends approximately 2 hours per week prepping clinics. The
patient pathway facilitator supports the maintenance of the OAFU database,
approximately 2 hours/week. For a small cost, a health care assistant supporting the
clinic and note preparation would reduce CNS time. It would also provide equality in
service provision. Support of medical clinics is a given within the Trust but not
supported for nurse clinics providing similar activity.
4
Traditional Medical Follow-up
Early Breast Cancer- Surgery,
Chemotherapy, Radiotherapy, Hormone
treatment as required
Traditional follow-up:
Annual outpatient appointment with
Breast Surgeon (4 OPA)
Annual outpatient appointment with
Oncologist (4OPA)
CNS may also be in attendance at this
appointment.
Annually, 230 clinic slots released for
both
← breast surgery and oncology
allowing the consultant to see new
patient/increasing activity. This will result
in increased income for the Trust from
new patient tariff.
This is about efficiency in the pathway
and the release of outpatient
appointments for increasing predicted
activity and the more complex patient
pathway. This will increase service
capacity allowing consultants to see
more new patients and this comes with a
higher tariff.
Cost of a 3 hour consultant clinic
(usual sessional clinic time- BMA
reference cost) £891
Open Access Follow-Up
CNS led
Early Breast Cancer- Surgery,
Chemotherapy, Radiotherapy, Hormone
treatment as required
Open Access Follow-Up (OAFU)
1 Nurse led appointment (1hour) to
complete End of Treatment Summary,
Holistic Needs Assessment and signpost
to living well/support groups
OAFU Tariff £164
5 appointments weekly
£164 x5= £820
£820 x46 clinics/year=£37720
Annual number of patients: 230
230 patients x 8 OPA (1 patient f/u OPA
over 4 years) = 1840 appointments
released for new patients. It is
acknowledged the Trust and nationally we
are seeing increasing predicted activity &
more complex patient pathways.
From 1 year of activity,
920 Breast surgery appointments
released over 4 years
920 Breast oncology appointments
released over 4 years.
A small percentage of patients will reaccess the service.
Cost for Breast OAFU clinic £572
£654 with HCA support
5
Key benefits of this innovation
For those using the service:

Enhanced patient experience

Patient pathway meeting NCSI guidance supporting Living Well & National
cancer strategies.

Fewer appointments at the hospital, possibly reduction of 4 years follow-up.

Psychological benefit allowing patient to move forward, live well & selfmanage.

Holistic patient assessment
To the healthcare system:

Efficiency in pathway

Enhanced tariff

Release consultant time to see new patients improving access to service &
receiving enhanced activity

Cost effective service- right band/right skill

New patient tariff from increasing activity and OPAs released for Consultant
activity

Quality service
To the wider health and social care system:

Appropriate tariff for OAFU clinic

Release of consultant time to new or more complex patients. Increasing
activity figures- support clinical demand.
Key costs of this innovation:
The set up and running costs are listed in more detail in Appendix 3 and 4
Set up costs
Direct
£6043
Indirect
Nil
Total
£6043
Weekly Running costs
£572
£654 with HCA support
Training costs
Breast Marsden Module £970
Nurse-led clinics conference £175
It should be acknowledged that these costs are listed in the set-up costs but the CNS
requires this training for the specialist role.
6
Demand for this clinic is outstripping supply. The clinic currently has a 6 month waitlist
which does not meet national recommendations. A further clinic is required.
Uro-Oncology Clinics:
The uro-oncology clinical nurse specialists have established numerous nurse-led
clinics to support patient need and increasing patient numbers. The clinics have
ensured timeliness of access to treatment for patients with urological cancers within
national treatment target times.
The prostate cancer biopsy clinic improves efficiency in the patient pathway,
particularly and will be the focus of this economic assessment. The CNS provides the
diagnosis and treatment options following multi-disciplinary team (MDT) discussion
and arranges onward referral to appropriate team (urology or oncology). This is
releasing consultant Urologist capacity to see more complex and new patients which
brings additional revenue at a higher tariff. The CNS supports the patient decisionmaking to determine which clinic the patient returns (surgical or oncology).
On average this improves the patient pathway and experience reducing timed pathway
by 14 days. Cancer patients will be on a timed pathway subject to 31 & 62 day targets.
The CNS clinic will on average release 2 outpatient consultant appointments improving
capacity with the consultant clinics for the increasing activity and the more complex
patient.
The three nurse specialists can support any of the clinics to ensure cover throughout
the year and at times of leave. The nurses do not receive any health care assistant
support to run the clinic nor prep the notes. The CNS spends approximately 4 hours
per week prepping all clinics that could be undertaken by a band 2 health care
assistant. The prostate biopsy clinic takes up to one hour to prep.
The tariffs have not been included for the uro-oncology clinics but following discussion
with the finance team the breakdown of the tariff is not known. No specific tariffs have
been negotiated for these clinics.
7
Weekly Clinic Timetable
Clinic
Day
Radiotherapy
Follow-up Clinic
Monday PM
No of
patients
4
Length of
appointments
30 minutes
Total: 120 mins
PSA/Support
Clinic
Tuesday PM
5
10 minutes
Total: 50 mins
PSA Telephone
Clinic
Tuesday PM
12
10 minutes
Total: 120 mins
E-HNA Clinic
Wednesday PM
Weeks 1 & 3
3
45 minutes
Total: 135 mins
Andrology Clinic
Thursday PM
Weeks 2 & 4
4
45 minutes
Total: 180 mins
TURBT Clinic
Prostate Biopsy
result clinic
Friday
AM week 1 & 3
PM week 2 & 4
5th Friday if needed
5
Friday
AM week 2 & 4
PM week 1 & 3
5th Friday if needed
5
20 minutes
Total: 100 minutes
30 minutes
Total: 150 minutes
This does not include virtual activity.
8
Prostate Biopsy Results Clinic
Traditional medical follow-up
Uro-Oncology CNS follow-up
Consultant first appointmentAssessment
Consultant first appointmentAssessment
TRUS Biopsy- Radiology
TRUS Biopsy-Radiology
MDT Discussion
MDT discussion
Results provided with Consultant and
CNS
MRI arranged as required
MDT discussion following MRI
Results provided by CNS
MRI arranged as required
Results OPA & treatment discussion by
Consultant & CNS
Results OPA & treatment discussion by
CNS
Surgical or Oncology OPA
Cost for a 3 hour consultant clinic
£891 (BMA reference costs)
MDT discussion following MRI
Surgical or Oncology OPA
Cost for a CNS clinic £138
With HCA support £158
& release of 2 consultant
appointments
9
Suspected Prostate Cancer Patient Pathway- Timed pathway comparison
Appointment Previous
Schedule
Pathway
Number New
of days Pathway
Doctor
CNS
Assessment
OPA
11.8.15
TRUS Bx
20.8.15
Results OPA
11.9.15
Consultant 22
& CNS
13.11.15
MRI
21.9.15
10
25.11.15
Results OPA
& Treatment
discussion
9.10.15
Consultant 18
& CNS
Consultant
20.10.15
9
Total Days
16.11.15
Consultant 38
& CNS
Doctor
97 days
Consultant
27.10.15
7
CNS
17
12
4.12.15
CNS
8
(some
consultants
45 days
may
continue
with this
element of
the
pathway)
11/1/16
Oncology
OPA
38
CNS
83 days
59 days
Oncology
OPA
Number
of days
Not only did the CNS pathway save 14 days from time of referral to appointment with
an oncologist, it also released two consultant appointments on the pathway. This is
significant when considering patient numbers expected in the future. This would
improve consultant clinic capacity and allow the doctor to see more complex or new
patients. New patient appointments receive a higher tariff to follow up.
To provide the clinics two of the CNS have completed the Royal Marsden Hospital UroOncology module and attended the nurse-led clinic study day. Both staff are
undertaking Master’s programme. These clinics need suitably trained specialist staff.
Key benefits of this innovation
For those using the service:

Enhanced patient experience

Expedite patient pathway- reducing cancer diagnostic pathway for prostate
cancer by 14 days & stopping 2 Urologist appointments.

Holistic patient assessment
10
To the healthcare system:

Two consultant appointments released

Efficiency in pathway and possible reduction in cancer breaches. Patient
pathway subject to 31 and 62 days cancer target.

Release consultant time to see new or more complex patients improving
access to service

Cost effective service- right band/right skill

New patient tariff from increasing activity and OPAs released for Consultant
activity

Quality of service
To the wider health and social care system:

Appropriate tariff

Release of consultant time to new or more complex patients. Increasing
activity figures - support clinical demand.
Key costs of this innovation:
The set-up and running costs for this clinic are listed in more detail in Appendix 3 and
4.
Set-up Costs
Direct
£1106
Indirect
Nil
Total
£1106
Weekly running costs
£138
With HCA support
£158
There is a potential for further savings by a health care assistant supporting the clinic
and prepping notes. This would release 2 hours of a band 7 CNS time for clinical
activity.
Training costs
GU Marsden module £970
Nurse-led clinics conference £175
This training is required as part of the specialist role and not specifically just for this
clinic.
11
Conclusion:
The running for each of the clinics incurs similar costs except for the difference in
staffing costs and HCA support to the clinic. The weekly running costs have been
compared with only the differences listed as per the running templates in Appendix 4.
Where costs have been the same, they have not been included.
Summary of clinic set-up and running costs
Clinic type
Traditional
Medically led
Consultant clinic
Prostate Biopsy
Clinic- UroOncology CNS
Breast OAFU
clinic Breast
CNS
£1106
£6043
£138
£572
£158
£654
Saving: £24.69 &
release 2 hours
CNS time for
clinical activity
This would
potentially
release 1 hour
of CNS time to
see an
additional
patient.
Release 2
consultant
appointments for
new activity at a
higher tariff.
Reduction in
follow-up
appointments
for possibly 4
years.
Cost for 3 hour
clinic
Set up costs
Weekly running costs
With HCA support:
£891
Not supported currently
Additional benefits
Annual
appointment
with surgeon
and oncologist
cease. This
releases
consultant
appointments
for new activity
at a higher
tariff.
Enhanced tariff
for nurse-led
clinic
12
The biggest impact from the nurse-led clinics is to the patient having a reduced timed
pathway to treatment and also to the Consultants who will see the release of sessions
each week for new & more complex patients. The Trust also benefits from additional
revenue from the consultants seeing more new patients at a higher tariff.
Feedback from patient survey’s and from family & friends testing for nurse-led clinics
has been very positive with all comments positively acknowledging the holistic and
comprehensive assessment supporting shared decision-making.
Whilst comparison of outcomes demonstrates more patients are reviewed in the
medical clinic, the medical clinic will see a wider variety of specialty patients including
non-cancer and cancer patients. For patients with a cancer diagnosis, the feedback to
date suggests, that the outcomes from a nurse-led clinic experience is equivalent with
having health care needs met but with more quality time having concerns listened to
and supported. The patients in nurse-led clinics are reviewed earlier in the pathway in
comparison to a medical pathway. No complaints or incidents have been noted in these
clinics suggesting outcomes for both types of clinics are similar and worthy of
comparison.
The economic assessment has demonstrated the value of nurse-led clinics providing
a service positively evaluated by patients that is value for money. Clinical teams also
value the support of nurse led clinics and the time this releases for more complex
patients and new patients. Clinical Nurse Specialist clinics improve quality of the
service, release capacity in medical clinics and generate income via tariff.
Recommendations:

Where additional clinics are required; Trusts to recognise value of nurse led
clinic and not default to further medical services.

For this economic assessment to be repeated across all oncology clinical
nurse specialist clinics

An additional OAFU clinic be resourced to meet patient demand allowing
appropriate capacity

Health care assistant support provided for all nurse led clinics to improve
efficiency and ensure right staff with right skill doing the job.
13
References
1. National Cancer Survivorship Initiative (2013) “Living with and beyond cancer:
Taking action to improve outcomes”, London.
2. Royal College of Nursing (2010) Clinical nurse specialists: adding value to
care. An executive summary. London.
3. http://alisonleary.co.uk/docs/RCN%20Study%20Adding%20Value%20to%20
Care%20the%20work%20of%20the%20CNS..pdf (Accessed 25November
2015)
4. https://www.rcn.org.uk/employment-and-pay/nhs-pay-scales-2015-16
(Accessed 13 December 2015)
5. http://bma.org.uk/support-at-work/pay-fees-allowances/payscales/consultants-pay-england (Accessed 13 December 2015)
6. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file
/300549/Annex_4A_Additional_info_on_currencies_with_national_prices.pdf
(Accessed 13 December 2015)
7. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file
/214902/PbR-Guidance-2013-14.pdf (Accessed 13 December 2015)
8. https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
(Accessed 28 January 2016)
9. http://www.cancerresearchuk.org/sites/default/files/achieving_worldclass_cancer_outcomes_-_a_strategy_for_england_2015-2020.pdf
(Accessed 30th January 2016)
10. http://www.bma.org.uk/support-at-work/pay-fees-allowances/fees/feefinder/fee-finder-government-agreed-fees-consultants (Accessed 30th
January 2016)
11.
https://www.rcn.org.uk/employment-and-pay/nhs-pay-scales-2015-16
(Accessed 30th January 2016)
January 2016
This case study was completed by Lyndel Moore, Cancer Nurse Consultant,
Trust End of Life Lead Nurse at The Great Western Hospital Foundation Trust
in January 2016.
Lyndel successfully completed a collaborative learning programme designed to
empower nurses to understand, generate and use economic evidence to
continuously transform care. The programme was delivered by the Royal
College of Nursing and the Office for Public Management, funded by the
Burdett Trust for Nursing and endorsed by the Institute of Leadership and
Management.
You can contact Lyndel by email lyndel.moore@gwh.nhs.uk.
14
Appendix 1
The following table provides indicative figures for cancer diagnoses locally for the next
twenty years. This is then broken into predictive figures for the two main Clinical
Commissioning Groups (CCGs)- Swindon and Wiltshire, however patients may also
attend from Berkshire, Oxfordshire, Gloucestershire and Avon.
Table 1 : Forecast increase in cancer diagnosis for GWH
15
Appendix 2:
Table 2 : Swindon CCG – forecast new diagnoses at GWH
NUMBER OF PATIENTS DIAGNOSED
BLADDER
BREAST
CERVIX
CNS
COLON
ENDOMETRIUM
HEAD AND NECK
HODGKIN LYMPHOMA
KIDNEY
LEUKAEMIA
LUNG
MELANOMA
MYELOMA
NHL
OESOPHAGUS
OTHER TUMOURS
OVARY
PANCREAS
PROSTATE
RECTUM
SARCOMA
STOMACH
TESTIS
TOTAL
2015
30
167
7
15
92
27
29
6
28
25
114
41
13
33
29
110
23
25
116
27
6
23
8
995
2016
31
169
7
15
94
27
29
6
29
26
116
42
14
33
29
112
23
26
119
28
6
23
8
1010
2017
31
171
7
15
96
28
30
6
30
26
117
43
14
34
30
114
23
26
122
28
6
23
8
1026
2018
31
172
7
15
98
28
30
6
30
26
119
44
14
34
30
115
23
27
125
29
6
23
8
1042
2019
32
174
7
15
100
29
31
6
31
26
121
46
14
35
31
117
23
27
128
29
6
24
8
1058
2020
32
176
7
16
101
29
31
6
32
27
123
47
14
35
31
119
23
28
131
30
6
24
8
1075
2026
35
186
7
16
113
32
35
6
37
28
136
57
15
39
34
130
23
31
150
33
6
25
8
1182
Table 3 : Wiltshire CCG – forecast new diagnoses at GWH
NUMBER OF PATIENTS DIAGNOSED
BLADDER
BREAST
CERVIX
CNS
COLON
ENDOMETRIUM
HEAD AND NECK
HODGKIN LYMPHOMA
KIDNEY
LEUKAEMIA
LUNG
MELANOMA
MYELOMA
NHL
OESOPHAGUS
OTHER TUMOURS
OVARY
PANCREAS
PROSTATE
RECTUM
SARCOMA
STOMACH
TESTIS
TOTAL
2013
30
162
9
13
83
21
23
5
24
24
90
45
16
36
20
47
17
21
131
33
6
15
5
878
2014
30
163
9
13
85
22
24
5
25
25
92
47
16
36
20
48
17
22
134
34
6
15
5
892
2015
31
165
9
13
86
22
24
5
25
25
93
48
16
37
21
48
17
22
137
34
6
16
5
906
2016
31
167
9
13
88
22
25
5
26
25
95
50
17
37
21
49
17
23
140
35
6
16
5
921
2017
32
168
9
13
89
23
25
5
26
25
96
51
17
38
21
50
17
23
144
35
6
16
5
936
2018
32
170
9
14
91
23
26
5
27
25
98
53
17
38
22
51
17
23
147
36
6
16
5
951
2019
33
172
9
14
93
24
26
5
28
26
100
54
17
39
22
51
17
24
150
37
6
16
5
966
2020
33
173
9
14
94
24
27
5
29
26
101
56
17
40
22
52
17
24
154
37
6
16
5
982
16
2026
36
184
9
14
106
26
30
6
33
27
112
68
19
43
24
57
17
27
176
41
6
17
5
1,083
Appendix 3 Set Up Costs:
Uro-Oncology CNS clinic
Identify
Additionality
Set Up costs-Direct costs 2015
Apportion
Full costs
Real
terms
1CNS Band
yes
Yes- 8hrs
8hours £18.36
Yes 2.5%
7- time to set
of CNS
x 8= £146.88
inflation
up clinics &
time
+ 22.5%on
(1 year)
writing
costs
protocol,
=£169.38
£173
(2015)
discussing
Agenda for
with MDT
change- mid
point
payscales
(2014)
2 Band 6
Yes
Yes-
4 hours each=
Yes 2.5%
CNS (PCUK
apportion 8
8hours total
inflation
funded x 1)-
hours
£15.37
(1 year)
time to set up
x8=£122.96 +
clinics,
oncosts
reading
22.5% =
policy,
£149.89
discussing
£153.63
(2015)
Agenda for
with MDT
change- mid
point
payscales
(2014)
Training staff
No- required
No
within role
Each CNS:
No
£970 Royal
Marsden
Module
£175 Nurseled clinic
conference
MDT
approval of
protocols for
follow-up
yes
yes
£760
1 hour £207
BMA
Consultant
Yes 2.5%
inflation
(1 year)
£779
hourly rate: +
on costs
17
22.5%=
£253.57
Urologist,
Medical
Oncologist,
clinical
oncologist
Indirect costs
Telephone
From existing
resource
Patient
From existing
information
resource
Premises
In kind from
Estates
IT support/
In kind from
computer
corporate
Secretarial
From existing
support
resource
Total:
£1106
18
Breast OAFU clinic
Identify
Additionality
Set Up costs-Direct costs
Apportion
Full costs
Real
terms
2012
OAFU Working
yes
8 hours
Group- Medical
8hours
1 hour £207
Oncologist,
BMA Consultant
Surgeon,
hourly rate x 2
Cancer
Consultants =
Manager, CNS,
£3312 +22.5%=
patient
£4057
representative,
Lead Cancer
CNS8hours
Nurse
£18.36 x 8=
£146.88 +
Yes
2.5%
inflatio
n (4
year)
£4372
2012
£187
22.5%on costs
=£169.38
Band 8 NHS
AFC mid-point
manager & Lead
nurse £25.55 x
2= £51.10 x8=
£408.80 +22.5%
£553
oncosts=
£500.78
Patient
Representativevoluntary
1 Band 7 CNS
1 week 37.5
Yes
time to set up
hours total
2.5%
clinics, writing
£18.36
inflatio
policy, writing
x37.5hrs=£688.5
n (4
patient
0+ oncosts
year)
information,
22.5% = £843.41
setting up new
process
discussing with
Yes
37.5hrs
£931
Agenda for
change- mid
point payscales
MDT
19
Training staff
No required
No
for role
Each CNS:
No
Royal Marsden
module £970
Indirect costs
Premises
In kind from
Estates
IT support/
In kind from
computer
corporate
Telephone
In kind from
corporate
Secretarial
From existing
support
resource
Total:
£6043
20
Appendix 4 Running Costs per week:
Uro-Oncology CNS Running costs-Direct costs
Identify
Additionality
Apportion
Full costs
Real
terms
Uro-
5 hours
yes
5hours
2.5%
Oncology
£18.36 x5=
inflation-
CNS Band 7
£91.80 +
1 year
22.5%on
£115
costs
=£112.45
(2015)
Agenda for
changemid point
payscales
CNS
1hours
1hours
2.5%
Prepping
£18.36 +
inflation-
and
22.5%on
1 year
supporting
costs
clinic
=£22.49
£23
(2015)
Agenda for
changemid point
payscales
£8.29 x 2=
HCA Band 2
2 hours
£16.58
supporting
+22.5%=
clinic &
£20.31
prepping
notes (not
provided nor
funded
currently)
Potentia
l saving
if HCA
support
s clinic :
£24.69
&
release
2 hours
CNS
time
21
Indirect costs (Add rows as required, and indicate year)
Premises
In kind
Computer/te
In kind
lephone
Patient
charity
information
Secretarial
In kind
Support
Total
£138
Weekly
running
cost:
£158
With HCA
support
Potential
£24.69
saving if
&
HCA
release
supports
2 hours
clinic :
CNS
time for
clinical
activity
22
Breast OAFU Running Costs-Direct costs
Identify
Breast CNS (Band
Additionality
10 hours/week
Apportion
yes
7)
Full costs
Real terms
10hours
(4 years
£18.36 x10=
inflation
£183.60 +
2.5%)
22.5%on
£248.25
costs
=£224.91
Agenda for
change- mid
point
payscales
Breast MDT Co-
1 hours/week
yes
ordinator (Band 4)
£10.66
£14.41
+22.5%=
£13.05
OAFU MDT
Agenda for
change- mid
point
payscales
Patient Pathway co-
2 hours/week
yes
ordinator (Band 4)
£10.66 x2=
£28.82
£21.32
+22.5%=
Updating OAFU
£26.11
database
Agenda for
change- mid
point
payscales
Breast Medical
1hours/week
yes
1 hour £207
Oncologist (for
BMA
OAFU MDT)
Consultant
£279.90
hourly rate
+22.5%=
£253.57
HCA Band 2
8 hours
£8.29 x 8=
supporting clinic &
£66.32
prepping notes (not
+22.5%=
provided nor funded
£81.24
currently)
23
Indirect costs (Add rows as required, and indicate year)
Premises
In kind
Computer/telephone
In kind
database
In kind
Patient information
charity
Total weekly
running
costs=
£571.38
24
Urology Consultant Clinic Running costs-Direct costs 2015
Identify
Additionality
Apportion
Full costs
Real
terms
Oncology CNS
3 hours
yes
Band 7
3 hours
2.5%
£18.36
inflation-
x3= £55 +
1 year
22.5%on
£69
costs
=£67.50
2015
Agenda
for
changemid point
payscales
Urologist
3 hours
yes
3 hour
£780
£207 BMA
Consultant
hourly rate
+22.5%=
£760
HCA Band 2
4 hours
£8.29 x 4=
supporting clinic &
£33.16
prepping notes
+22.5%=
£41.63
£40.62
Indirect costs (Add rows as required, and indicate year)
Premises
In kind
Computer/telephone
In kind
Patient information
Charity
Secretarial Support
In kind
Total
Weekly
running
cost:
£891
25
Appendix 5 Pathways to Outcomes:
Input
Direct costs• Skilled Breast Care
Clinical Nurse Specialist
to provide Breast OAFU
clinic
• Breast MDT discussion
• Service provided in
outpatient setting 1 day/
week
• Clinic room
• Telephone service for
assessment and rapid
re-access of service if
required
• Telephone line
• Computer to record
Holistic Needs
Assessment (HNA)and
End of treatment
summary
• Patient information on
service and Living well
information
• IT to access PAS and
cancer services system
• Admin staff to upload to
IT system & send to GP
• No direct funding of
service
Indirect Costs
• Hospital accommodation/
overheads for clinic room
• Outpatient team
• IT support
Input
Direct costs• Skilled Uro-oncology
Clinical Nurse Specialist
to provide variety of
follow-up
• Uro-oncology MDT
discussion
• Service provided in
outpatient setting
• Clinic room
• Telephone service for
PSA clinic
• Telephone line
• Computer to record
Holistic Needs
Assessment (HNA)and
clinic assessment and
letter
• Patient information on
service and Living well
information
• IT to access PAS and
cancer services system
• Secretarial support to
send to GP
• PCUK funding for 1
WTE Band 6
• Macmillan 1WTE Band 7
funding (historicalpicked up by Trust)
• 1WTE funded by Trust
Indirect Costs
• Hospital accommodation/
overheads for clinic room
• Outpatient team
• IT support
Breast Open Access Follow-up (OAFU): Pathways to
Outcomes model
Activities & outputs
• Number of patients
seen in OAFU clinic
•Number of patients
awaiting an
appointment
•Number of calls
•One hour clinic
appointment with CNS
to complete end of
treatment summary
(ETS) reviewing history,
long term side-effects of
treatment, possible
signs of recurrence,
ongoing care e.g.
mammograms & Dexa
scan. Hormone
treatment.
•Holistic Needs
Assessment (HNA)
•Advice on self
management
•Referral to Living well
day
•Patient support groups
•Information on reaccessing service
•ETS & HNA to GP
•Patient information
•1 Nurse led clinic (1hr
clinic review/patient)
completing above.
Follow-up practice for
next 4 years no longer
required releasing
consultant colleagues to
see more complex and
rising activity of new
patients
Outcomes
Groups targeted
Staff outcomes
For intervention
• Adjuvant/early diagnosis
breast cancer patients.
•Breast surgeons
•Breast MDT
•Medical & Clinical Oncologists
•Administrative support
•Outpatients department
For training
•All Breast CNS
•Patient Pathway facilitator
For partnership
• Swindon and Wiltshire
Clinical Commissioning
groups
• GP
For delivery
• As for intervention
•Ability to deliver high quality care &
streamline follow-up practice for
breast cancer patients
•Improves quality of patient/nurse
experience. Satisfaction of delivering
a quality service meeting individual
patient needs
•Nurse-led clinic activity
•Medical teams release capacity to
see more complex and increasing
new patient activity.
Patient outcomes
•Patient access to specialist advice
supporting Living well and beyond
cancer initiative
•Improved patient experience; less
anxious about follow up appointment
•Psychologically patients able to
move forward and live well
Organisational outcomes
•Prevention of inappropriate followup
•Meet National Cancer survivorship
initiative
•Evidence of economic impact of
change
•In house skills – economic
evaluation
•Trust Presentations at external
events
•Potential publications
V1 21 June 2015
1
Uro-Oncology Clinical Nurse Specialist clinics: Pathways to
Outcomes model
Activities & outputs
• Number of patients
seen in each clinic
•PSA clinic
•Post Radiotherapy
clinic
•Prostate histology
clinic
•Bladder histology clinic
•HNA clinic
•Andrology clinic
•Holistic Needs
Assessment (HNA)
•Advice on self
management
•Referral to Living well
day
•Patient support groups
•Patient information
Outcomes
Groups targeted
Staff outcomes
For intervention
• Uro-oncology patients.
•Urologists
•Urology MDT
•Medical & Clinical Oncologists
•Administrative support
•Outpatients department
For training
•All Uro-oncology CNS
For partnership
• Swindon and Wiltshire
Clinical Commissioning
groups
• GP
For delivery
• As for intervention
•Ability to deliver high quality care &
streamline follow-up practice for
urology cancer patients
•Improves quality of patient/nurse
experience. Satisfaction of delivering
a quality service meeting individual
patient needs
•Nurse-led clinic activity
•Medical teams release capacity to
see more complex and increasing
new patient activity.
Patient outcomes
•Efficiency in patient pathway. Time
to treatment more efficient
•Improved patient experience
•Consultant OPA x2 released
allowing review of more complex and
increasing patient numbers.
Organisational outcomes
•Efficiency in service with consultants
time released to cope with increasing
demand and more complex patients.
•Evidence of economic impact of
change
•In house skills – economic
evaluation
•Trust Presentations at external
events
•Potential publications
January 2016
1
26