Solihull CCG Survivorship and Cancer
Pathway Programme
Jo Tolley.
Summary
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Primary Care Nurse Facilitator Role.
CQUIN & Contractual arrangements.
PN & Enhanced CCR’s.
Next Steps.
Background
• Primary Care Nurse Facilitator – Summer 2013
• Collected Patient Stories.
• “I feel like my comfort blanket has gone after treatment”
• “You can’t remember everything said to you at diagnosis and treatment”
H&W
• “there is a lack of communication between hospitals” TS
• “The GP disregarded the information the consultant had recommended
stating no you don’t need that” TS
• “I did not know about the warning signs of recurrence” TS, H&W
• “hospital not interested in me now they’ve got rid of my cancer” H
Colorectal Pathway
• CQUIN
– Health & Well Being Clinics + Breast
• 1 complete to date in colorectal.
• 3 in breast.
– Treatment Summaries – Colorectal pilot.
• Adapted from NCSI pack.
– 2 year CQUIN extending to 2 additional tumour
sites next year.
Treatment Summary
Insert GP Contact Details
Insert Trust Logo and Address
Dear Dr X
Re: Add in patient name, address, date of birth and record number
Your patient has now completed their initial treatment for cancer and a summary of their diagnosis, treatment and ongoing management plan are outlined below.
The patient has a copy of this summary.
Diagnosis:
Date of Diagnosis:
Organ/Staging
Local/Distant
Summary of Treatment and relevant dates:
Treatment Aim:
Possible treatment toxicities and / or late effects:
Advise entry onto primary care palliative or
supportive care register
Yes / No
DS 1500 application completed
Yes/No
Prescription Charge exemption arranged
Yes/No
Alert Symptoms that require referral back to specialist team:
Contacts for re referrals or queries:
In Hours:
Out of hours:
Secondary Care Ongoing Management Plan: (tests, appointments etc)
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Other service referrals made: (delete as nec)
District Nurse
AHP
Social Worker
Dietician
Clinical Nurse Specialist
Psychologist
Benefits/Advice Service
Other
Required GP actions in addition to GP Cancer Care Review (e.g. ongoing medication, osteoporosis and cardiac screening)
Summary of information given to the patient about their cancer and future progress:
Additional information including issues relating to lifestyle and support needs:
Cancer Care Reviews &
Practice Nurse Course
Patient comments
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“I think I had a review but I don’t remember”
“I feel aftercare was lacking, although the hospital was brilliant”
“I don’t feel like I can trouble anyone”
“Just left to it”
“I’ve just carried on”
“Practice nurse good point of contact and know patient well”
“We soldiered on”
“I’ve been in a black hole since treatment”
“No contact from GP surgery”
“Saw GP who said I needed antibiotics, didn’t ask about cancer – no
interaction, would have been nice”
• “I didn’t know I could get a free wig on the NHS”
• “I had lymphoedema, I wasn’t told about skin care or how I could massage
my arm”.
• “Many ladies feel isolated at the end of treatment”
Macmillan PN Course
Course Aims
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Improve Knowledge, skills, attitude and confidence
Identify transferrable skills
Encourage “Cancer champions”
Improve relationships
Encourage opportunistic reviews
Encourage a more proactive approach
Encourage supported self management
Course Examples
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What is cancer?
Changing cancer story
The Recovery Package
Cancer care reviews
Living with cancer
Treatment pathways
Motivational
interviewing
• Difficult conversations
• Role of Clinical Nurse
Specialist
• Fatigue, Anxiety,
Breathlessness
• Nutrition and cancer
• Late effects
• Transition to palliative
care including advanced
care planning
Enhance CCR
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Nurse makes contact with patient
Patient completes the questionnaire.
Patient has 20 minute appointment
MAP of Medicine used to tailor care plan
Treatment summary will support CCR
Care plan completed on computer
template/carbonated copy
Patient comments
If CCR routinely carried out, how soon after
diagnosis should it be offered?
• “Once treatment has started”
• “The offer of a review needs to be soon”
• “About 6 months after diagnosis, you need to
come to terms with things”
• “ASAP”
Patient comments cont.
Did you find CCR with the nurse a positive or
negative experience overall? Why?
• “Positive but came a little late for me”
• “Positive; it was good to talk to someone who
understands your position, and who is not a
friend or relative”
• “Positive; the nurse showed genuine sympathy
in my situation, giving relevant leaflets and a
support service if needed”
Patient comments cont.
One model of care would be to have a telephone call at
the point of diagnosis by a doctor or nurse and offered a
more detailed CCR at about 6 months, comments?
• “A call from the surgery would be good as I felt a little
that my doctors just forgot me”.
• “Phone call initially ok, but not the same as face to face.
I also think 6 months is too long. I had a family and
friends, not everyone has”.
• “Depends on the individual, the option could be offered”.
• “Before 6 months ASAP after diagnosis. Support is of the
upmost (It can be a very stressful and anxious time)”.
Summary
1. QOF payments are significantly lower than for
other chronic diseases, consider best practice
2. All patients are individuals with very different
supportive needs
3. Practice nurses are ideally placed to support
cancer patients
4. Enhanced CCR ensures a holistic approach to
care and support
Enhanced CCR
• Use remaining Macmillan funding to pilot.
• Enhanced Payment to support PN’s.
• Enhanced Cancer Care reviews – as previously
described.
Next Steps
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Evaluating PN Course.
Pilot Enhanced CCR
Roll out H&W Clinics in Colorectal and Breast.
Use CQUIN 2015/16 to extend Survivorship
Agenda
– Introducing H&W Clinics into 2 more tumour sites.
– Roll out TS into 2 further tumour sites.
Questions?