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If you would like to contribute to the art and science section contact: Gwen Clarke, art and science editor, Nursing Standard,
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National Chemotherapy Advisory
Group report:implications for nurses
Lennan E et al (2010) National Chemotherapy Advisory Group report: implications for nurse.
Nursing Standard. 24, 36, 35-40. Date of acceptance: March 5 2010.
Summary
As a group of senior cancer nurses, the UK Oncology Nursing Society
(UKONS) Board welcomes the recommendations from the National
Chemotherapy Advisory Group report, believing that it will improve
the services offered to patients and strengthen the leadership role of
nurses who work in cancer care. This article explains the key tenets of
the report from a nursing perspective and considers the effect it will
have on chemotherapy services and on the profession as a whole.
Authors
Elaine Lennan, vice-chair, UKONS Chemotherapy Nurses Forum,
and consultant cancer nurse, Southampton University Hospitals
NHS Trust, Southampton; Helen Roe, chair, UKONS Chemotherapy
Nurses Forum, and consultant cancer nurse, North Cumbria
University Hospitals NHS Trust, North Cumbria; Annie Young,
former UKONS president, and acting director, 3 Counties Cancer
Network, Gloucester; and Maggie Crowe, UKONS president, and
development manager, Macmillan Cancer Support, Crown
Chambers, Hampshire.
Email: elaine.lennan@suht.swest.nhs.uk.
Keywords
Acute oncology service, chemotherapy, nurse-led care,
patient-centred care
These keywords are based on subject headings from the British
Nursing Index. All articles are subject to external double-blind peer
review and checked for plagiarism using automated software. For
author and research article guidelines visit the Nursing Standard
home page at www.nursing-standard.co.uk. For related articles
visit our online archive and search using the keywords.
CHEMOTHERAPY SERVICES ARE facing a
challenge as therapies involving old and new
drugs become more complex and a growing
number of patients become eligible for treatment
(National Chemotherapy Advisory Group
(NCAG) 2009). In addition, there has been a rapid
expansion in the number and range of settings in
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which chemotherapy can be provided. Ten to 15
years ago, most patients with solid tumours
received chemotherapy as inpatients in specialist
cancer centres. Today, a high proportion of
chemotherapy treatment is delivered in the
ambulatory setting and in cancer units based at
district general hospitals. Some treatments are
administered in community settings and even in
patients’ homes.
While these advances are to be welcomed,
concerns have been raised about the safety and
quality of chemotherapy services. In particular,
serious shortcomings were highlighted in 2008
by the National Confidential Enquiry into Patient
Outcome and Death (NCEPOD). The NCEPOD
(2008) review of case notes from 546 patients who
died within 30 days of receiving chemotherapy
showed that 8% of care episodes were ‘less than
satisfactory’, and that there was ‘room for
improvement’ in a further 49% of cases.
Chemotherapy was judged to have caused or
hastened 27% of the deaths studied.
The NCAG was asked to investigate the
concerns raised in the review and to produce
a report for the National Cancer Director and
the Department of Health (DH) for England.
A consultation document was published by
NCAG in November 2008 and the UK
Oncology Nursing Society (UKONS) was
among the organisations that provided
comment. The final NCAG report, published
in August 2009, sets out recommendations
for improvements to chemotherapy services,
based on patient pathways, the establishment
and integration of an acute oncology service in
all hospitals that have an emergency
department, and clear, robust systems for
leadership, information, governance,
monitoring and chemotherapy commissioning
(NCAG 2009).
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There is potential conflict between the quality
agenda and the financial situation in health care,
embodied in the the task of trying to improve
quality, patient experience and safety without
extra funding. There is no funding attached to the
proposals in the NCAG (2009) report because
implementation is expected to be cost neutral. The
case of need should be made strongly by articulate
nurse leaders to ensure that necessary service
developments are viewed as an important priority.
The economic argument is never easy, but it would
be a false economy to ignore these important
service issues around a disease and treatment that
affects such a large proportion of the population.
UKONS supports this long-awaited report from
NCAG (2009). In this article, two UKONS board
members consider the implications of the NCAG
report for the delivery of chemotherapy and for
the role of oncology nurses.
The implications of commissioner-driven
local services
There has been a gradual, but significant, shift
in England over the past couple of years from
older, less consistent methods of commissioning
to the World Class Commissioning of
chemotherapy services. This is a government
initiative to promote and encourage innovation in
NHS commissioning with the aim of improving
quality of care, cost efficiency and productivity
(DH 2007a). This move was supported first by the
11 World Class Commissioning competencies
(DH 2008) and then – since the downturn in the
economy – by the government’s Quality,
Innovation, Productivity and Prevention (QIPP)
agenda (DH 2009). Furthermore, all four UK
countries are looking to shape chemotherapy
services for the 21st century by increasing
productivity while searching for ways to improve
efficiency in this high-spend area.
The purchasers of services, primary care
trusts, no longer hand over a block of funding
and ask the providers to deliver as they wish.
Commissioners work with all providers of
chemotherapy services, interrogate the activity
data and, based on the evidence, lay down
a delivery framework or specification for
network-wide agreed chemotherapy pathways,
including the governance arrangements.
Multiple providers can bid against this
specification, which is monitored regularly.
The arrangement provides an opportunity
for nurses to bring their expertise and
knowledge to the fore through the development
of care pathways and guidelines to ensure that
36 may 12 :: vol 24 no 36 :: 2010
services remain sharply focused on meeting
patient needs.
With their strong leadership skills and key role
in patient advocacy, nurses are ideally placed to
engage with commissioners to help shape the
future of chemotherapy through strategic planning
and cancer network groups. Cancer network nurse
directors are increasingly becoming commissioners
in many different areas of practice and will support
other practitioners in the commissioning process.
However, chemotherapy information systems
currently do not meet the quick, reliable and simple
interrogation required to support the management
of patient care.
In England, payment is divided into the
‘procurement’ of the whole course of
chemotherapy and the cost of the delivery episode.
There are procurement codes for each and every
course of chemotherapy and ten delivery codes,
dependent on the ‘infusion time’ needed to deliver
the chemotherapy. This is often referred to as
‘chair time’ – a term that does not always reflect
the ‘nurse time’ spent with the patient.
It is encouraging to see that chapter five of
the Chemotherapy Services in England report
(NCAG 2009) is dedicated to patient-centred
commissioning of chemotherapy services.
This aims to ensure that:
Patients who might benefit from chemotherapy
are able to access quality services.
Treatments delivered are appropriate to the
patient’s condition.
Services are delivered safely.
Services are convenient for patients.
The patient experience is good.
Services represent good value for money.
Following implementation of the NCAG (2009)
recommendations, there will inevitably be a
balance between localisation and centralisation of
services, according to the chemotherapy regimen;
but also, more importantly, according to the
wellbeing of patients, who will be involved in
deciding where or indeed whether their treatment
will be administered. Many novel models of care
help to avoid admission to hospital. Examples
across the country range from use of mobile
telephones to assist monitoring of chemotherapy
side effects to the development of acute oncology
services. However, community support
programmes are essential to many of the new
models of care, and are not yet in place everywhere.
Care in an appropriate setting
Most patients are reviewed by a doctor in the
acute hospital setting initially to plan the
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treatment and to have chemotherapy administered.
There are many nurse-led services available to
streamline this process. These range from a full
review of the whole treatment course – the doctor
is not involved until completion of treatment – to
a shared care model where the patient is seen on
alternate visits by the doctor and the nurse.
The NCAG (2009) report focuses on care
outside the cancer centres and provides
a platform for real change in district general
hospitals. Oncology services may now follow
the approach that has been established in
haematology, with inpatient beds for those who
require complex interventions because of his or
her disease or the side effects of chemotherapy.
Chief executives of district general hospitals
should ensure provision of high quality care
as near to patients’ homes as possible, not
necessarily within an acute setting. A robust
infrastructure in primary care will become
central to the delivery of care in the most
appropriate setting for the patient, as well as
his or her chemotherapy regimen.
The government makes its commitment to the
delivery of cancer care in the most appropriate
setting clear in the Cancer Reform Strategy (DH
2007b). The NCAG (2009) report provides a
practical solution for all stakeholders, offering
strong models of care. However, where care
outside of the acute setting is deemed appropriate,
services cannot simply be shifted to the
community without careful attention to planning,
commissioning and governance arrangements.
Oncology nurses will need to work with the
multidisciplinary team to identify cost-effective
models of care and to establish a partnership
with professionals in the community based on
a strong foundation of education and training.
For example, if community nurses wish to
provide cancer care, oncology nurses in the acute
sector will first need to provide them with training
on how to communicate with cancer patients
and provide care along the cancer pathway. Only
then can community nurses learn how to
administer chemotherapy.
There has never been such an opportunity to
be so bold in the location of NHS chemotherapy
services. The NCAG (2009) report legitimises the
investigation of new approaches to treatment
delivery, where appropriate and according to local
needs, using district general hospitals, mobile
chemotherapy units, community hospitals, GP
clusters and hospices, as well as patients’ homes.
Monitoring chemotherapy toxicities
Chemotherapy has significant and predictable
toxicities, the most serious of which are likely to
develop while the patient is at home between
treatment cycles. Chemotherapy-induced
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neutropenic sepsis is a notable example of
a side effect that is predictable, preventable and
manageable, but which can prove fatal if treatment
is delayed or is inappropriate. The first line of
defence against chemotherapy-induced
neutropenic sepsis is prevention. This may include
the prophylactic use of growth factors or
antibiotics when the risk of neutropenic sepsis is
considered to be high, for example based on the
documented level of myelosuppression associated
with the patient’s chemotherapy regimen. The use
of colony stimulating growth factors in this setting
is enshrined in international and European
guidelines (Aapro et al 2006, Smith et al 2006,
Crawford et al 2009), although there is less clarity
on how and when to use prophylactic antibiotics
(Cullen and Baijal 2009). Furthermore, as the
NCAG (2009) report notes, the DH has formally
asked the National Institute for Health and Clinical
Excellence (NICE) to develop guidelines for the
prevention as well as the management of
neutropenic sepsis.
Patients who develop the symptoms of
chemotherapy toxicity need prompt expert
assessment and management. Serious side effects
such as neutropenic sepsis are likely to warrant
urgent hospital-based intervention. Hence, the safe
and effective management of patients receiving a
course of chemotherapy depends on having a
knowledgeable workforce and robust systems for
obtaining and recording information on patients’
symptoms. Management of chemotherapy toxicity
begins with clear information and instructions for
patients about what to do if they develop side
effects. Provision of such information has been part
of cancer practice for some years, but the
NCEPOD (2008) report showed that in practice
health professionals do not always get it right.
All patients should be given a 24-hour
emergency number as well as information on
who to contact and how, particularly outside
normal chemotherapy clinic hours. It is therefore
the responsibility of the patient and/or carer to
make contact with the expert centre when
necessary. The NCAG (2009) report
recommends that this should be rehearsed in case
an incident occurs. UKONS has been working on
a national tool for emergency patient contact,
and pilot studies are under way to demonstrate
the wide range of options available. However, it
remains the responsibility of the organisations
and their commissioners to choose the most
appropriate method for them.
The NCAG (2009) report calls for the
provision of early, proactive patient assessment
by telephone ‘to identify problems before they
become serious’. Such proactive contact with
every patient may seem an unachievable goal.
However, there should be a clear aim to carry out
a risk assessment on all patients and to contact
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Common Toxicity Criteria (CTC) system
patients who fall into certain categories: those
who have recently received their first cycle of
chemotherapy, those deemed to be at particular
risk of toxicity, and any patient who has been
discharged following hospitalisation to manage
a side effect.
It is vital that systems are in place to record
toxicities that patients develop. As recommended
by NCEPOD (2008), the patient’s performance
status must be recorded at every visit. This simple
measure of general health can help to determine
whether an individual is fit to receive the planned
treatment. An example of a commonly used
system for assessing performance status is shown
in Table 1.
Toxicities can be readily assessed using the
Common Toxicity Criteria (CTC) system
(National Cancer Institute 1999) (Table 2), which
is known to most oncologists and nurses and
is regularly used in clinical trials. However, the
CTC system tends to be used inconsistently across
the chemotherapy pathway. UKONS would
welcome the introduction of the CTC system as
a formal assessment and communication tool
in all services that manage chemotherapy
patients. It is easy to incorporate into patient
chemotherapy assessment documentation –
one of the measures recommended as part of
the chemotherapy peer-review process
(NCEPOD 2008).
Management of side effects is central to all those
working with the administration of chemotherapy.
However, many cancer settings lack the structure
needed to provide expert assessment of symptoms
in a timely fashion. Furthermore, toxicities can
TABLE 1
Eastern Cooperative Oncology Group (ECOG) scale
for assessing a patient’s performance status
ECOG score
TABLE 2
Patient’s performance status
0
Fully active, able to carry out all pre-disease performance
without restriction.
1
Restricted in physically strenuous activity, but ambulatory
and able to carry out work of a light or sedentary nature.
2
Ambulatory and capable of self-care, but unable to carry
out any work activities. Up and about more than 50% of
waking hours.
3
Capable of only limited self-care, confined to bed or chair
more than 50% of waking hours.
4
Completely disabled. Cannot carry out any self-care.
Totally confined to bed or chair.
5
Dead
(Oken et al 1982)
38 may 12 :: vol 24 no 36 :: 2010
CTC grade
Severity
1
Mild
2
Moderate
3
Severe
4
Life-threatening
5
Death
(National Cancer Institute 1999)
occur at any time, and it is particularly challenging
to provide expert advice and oncology assessment
out of hours.
In response to this challenge, the NCAG (2009)
report recommends the development of a system
whereby advice is available from oncologists 24
hours a day, with clear treat and transfer
arrangements as required. This service should be
overseen by an acute oncology service.
It is paramount that chemotherapy nurses
examine their practice in the detection and
management of chemotherapy toxicities. In
particular, they should reflect on incidents where
the reporting of toxicities has been delayed or
management has been inappropriate. The way
forward is real-time monitoring of chemotherapy
toxicities, with electronic alert systems, for
example via mobile telephones, to enable timely
nurse and medical interventions where needed.
Acute oncology service:assuring
communication and specialist expertise
Communication is key to chemotherapy service
improvement. The primary failures in services
highlighted in the NCEPOD (2008) report
focused on this issue. There is often a lack of
communication on where and when patients are
admitted, how they are managed and how they
are monitored. This criticism applies to elective
as well as emergency services.
All patients with cancer who require acute
inpatient care ideally should be admitted to
specialist cancer areas in a hospital. However, this
does not always happen (NCEPOD 2008). Some
patients may stay on a non-cancer ward for
several days before seeing a visiting oncologist.
Some are admitted and discharged without the
oncologist even being aware that the patient has
received inpatient care.
The development of an acute oncology service
is one way to draw together all expertise –
oncology, emergency medicine, general medicine –
with a clear understanding of each specialty’s
abilities and constraints. There are two strands to
an acute oncology service. First, a governance
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group of representatives from all disciplines and
specialties comes together to design and oversee
policies and procedures for the service, taking
account of the complexities of the referral
pathway and facilities. Second, an acute oncology
operational team covers the service 24 hours a day,
seven days a week, and offers expertise whenever
required. The acute oncology service should also
provide a forum for collaborative working in
terms of audit, discussion and learning. It should
be welcomed as the foundation of future cancer
services both in organisations and across
professional boundaries. Resources for
education and training in all departments and
disciplines need to be established to ensure that
a consistently high standard of patient care is
delivered in all settings.
Most importantly, patients require access to
appropriate cancer advice and to be reassured that
their oncologist is aware of their predicament.
If a patient dies, the acute oncology service will
have a responsibility to discuss the case at
a mortality and morbidity meeting, so that
any learning opportunities can be identified
and understood, as outlined in the NCEPOD
(2008) report. Additionally, the NCAG (2009)
report makes a new recommendation that the
cases of all patients who die within 30 days of
receiving chemotherapy should be referred to
the coroner’s office.
Opportunities for nurse leadership
The NCAG (2009) report endorses leadership
roles for nurses, acknowledging the importance
of current developments in cancer nursing. Its
recommendations include: ‘All cancer networks
and the providers of chemotherapy services
should urgently assess the potential for nurse-led
and/or pharmacist-led chemotherapy and
agree appropriate working protocols.’ In its
consideration of the specialties required to provide
an effective acute oncology service, the NCAG
(2009) report also states: ‘The acute oncologists
and nurses provide the cohesion between [these]
staff groups.’ It is clear that nurses must be included
in the development of every acute oncology service,
and may take on leading roles.
Nurse-led chemotherapy services, based on
agreed working protocols, offer opportunities to
increase capacity and flexibility and hence reduce
patient waiting times. Nurse-led services also
enable at least some aspects of care to be delivered
closer to the patient’s home. There are many added
benefits of nurse-led services for patients and
carers. These apply when the clinics do not simply
replicate a medical model of care, for example
substituting a nurse in place of a doctor, but instead
introduce a broader, holistic, needs approach to
assessment and care (Corner et al 2003). Nurses
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should seize the opportunity to work with medical
and pharmacy colleagues to develop services
further. It is essential that nurses do not work in
isolation, but are key team players. Isolated
practice would be a great disservice to patients and
to the nursing profession.
Given the current shortage of chemotherapy
nurses, trusts face the challenge of how to obtain
the skilled workforce they need to embrace these
new opportunities while maintaining an already
overstretched oncology service.
The provision of outreach services away from
the acute hospital is a key theme of both the NCAG
(2009) report and a recent DH (2008) document
on World Class Commissioning. Again, nurses will
play a leading role in the development and delivery
of these initiatives. Outreach means that
chemotherapy regimens that have traditionally
been administered in the acute hospital may
be delivered elsewhere, for example in a GP
surgery, a community hospital or the patient’s
home. Such services are already available in some
areas, but not yet on a national scale. Challenges
to outreach include care of unwell patients
and control of the supply of medications.
Chemotherapy nurses are highly experienced
in the management of such issues.
Non-medical prescribing, whereby many nurses
and pharmacists can prescribe medications,
including chemotherapy, following assessment of
the individual patient, has greatly enhanced
autonomous – although, importantly, not isolated
– practice in chemotherapy services. Non-medical
prescribing offers an opportunity to lead and
deliver patient care, and take ownership of
decisions. It is not without its critics, including
some in oncology, and a culture shift is required.
It is clear that some areas will not achieve nurse-led
clinics without a great deal of persuasion,
encouragement and persistence. However, to
ignore the key role that nurses play in the support
of patients through chemotherapy, and the
knowledge and skills that many now have as high
level decision makers and prescribers, would be
to prevent improvements in the efficiency, quality
and safety of chemotherapy services. The NCAG
(2009) report and the new QIPP agenda
(DH 2009) can only help clinical services
to develop and promote nurse-led care, and are
to be welcomed by the profession in this regard.
While non-medical prescribing liberates
practice, it is not always necessary to have a
prescribing qualification to deliver a
chemotherapy service. Many nurses deliver
robust systems through the use of pre-prescribing
or patient group directions. There is scope for
inefficiencies in such systems, but it is up to
individual services to design and determine the
most effective chemotherapy pathway based on
local needs and local support.
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Implications for the workforce
The increasing use of chemotherapy in cancer
care looks set to continue as more drugs become
available, more people become eligible for
treatment (particularly in the adjuvant setting),
the number of courses of chemotherapy increases
and individuals live longer with a cancer
diagnosis. However, this growth in demand
has exceeded the growth in the workforce
(NCAG 2009).
Many at the front line of chemotherapy
services feel the effect of the expanding demand,
but it has been difficult to gain a clear
understanding of workforce issues in cancer
nursing. There has been investment in additional
medical training places since the NHS Cancer
Plan (DH 2000) was published, but there has
been less investment in either cancer nursing or
oncology pharmacy, and there is a shortage of the
data needed to understand workforce needs in
these areas (NCAG 2009). Cancer networks will
now be charged with trying to gather a national
picture of the nursing workforce to inform
robust workforce plans and succession planning.
In addition to the creation of new oncology
nursing positions such as consultant practitioner,
advances in specialist training are also needed.
Potentially, the training of the future will include a
‘chemotherapy passport’ that allows nurses to
move easily between trusts and health sectors
without re-training. The national Skills for Health
programme has developed competencies for skills
related to chemotherapy (Skills for Health 2010),
although these will be updated. There is also
potential for the development of multidisciplinary
training, similar to the advanced communication
skills training courses that are already delivered
across professional boundaries (DH 2007b).
Conclusions
The NCAG has delivered a practical report
showing how a clear national policy will help
local practitioners, particularly nurses, negotiate
with healthcare organisations to develop safe and
robust chemotherapy services that will improve
patient care (NCAG 2009). National policy will
also validate the development of nurse-led
services in areas of the country that have been
resistant to change. The NCAG (2009) report
clearly sets out the expectations of the future
acute oncology service, requiring collaborative
working across disciplines and specialities. Much
of the report can be delivered by service redesign,
but there will still be significant challenges around
obtaining a fit-for-purpose workforce to deliver
and evaluate new approaches to care.
Governance and risk management are key
issues and are integral to the recommendations.
All staff in health care will need to be fully trained
to better understand the issues involved in
chemotherapy delivery. The impetus to change
services will come from strong cancer nurse
leaders. The NCAG (2009) report has created an
excellent opportunity for oncology nurses to lead
the delivery of care in acute and community
sectors, and to develop nursing roles NS
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