National cancer survivorship initiative – adult : CARE project

Aim: 

Objectives:

• To establish a primary care based follow up service that meets the holistic needs for breast cancer patients who are living with and beyond cancer.
• To increase patient and carer satisfaction within the survivorship phase of their pathway.
• To reduce the number of patients attending secondary care for follow up appointments which do not meet patient need and have no evidence of detecting disease.
• To demonstrate a reduction in the use of general practice/other services by providing a more holistic service that supports patients.
• To offer a ‘directory of services’ for patients to choose their preferred follow up options.
• To ensure patients are involved with each stage of the redesign and implementation process and that local charities are consulted.
• To test the model and then fully evaluate the service with the view to roll the programme out to other tumour groups.
• To implement a system to deliver yearly mammography for breast cancer patients for the first five years of their follow care.
• To measure the impact of healthy lifestyle advice given to patients on their long term health and to monitor co-morbidities that patients may have.
• To increase clinical satisfaction and confidence in primary care services.

Progress/outcomes:
Final report: Please click here for self management in the community: a successful implementation moving support into primary care.

Breast cancer patient initiated follow up

Aim:
To redesign and implement patient initiated follow up for breast cancer at University Hospital Birmingham Foundation Trust and at Sandwell and West Birmingham Hospitals NHS Trust.

Objectives:

• To establish which groups of patients would benefit from patient follow up.
• To establish patient initiated follow up within both trusts and for this to be sustainable.
• To reduce the number of patients attending follow up for appointments that do not meet patient need and have no evidence of detecting disease.
• To reduce the amount of patients who have appointments with both the oncologists and surgeons regarding the same condition.
• To test the model and evaluate the pathway with the view to rolling patient initiated follow up for breast cancer out across the other trusts within the network.
• To implement a system that would be able to implement a request for a mammogram without the patient needing to be seen for the first five years following the diagnosis of breast cancer.
• Encourage and promote to patients the importance and value of self management.
• To reduce the pressure of non value appointments on outpatient services.

Adult survivorship: developing and testing approaches for assessment, care planning and treatment summary records for lung and myeloma patients

Aim:
This project was initiated during November 2009 as part of the National Cancer Survivorship Initiative (NCSI) assessment, care planning and approaches to care following treatment.  The aim is to improve the experiences of patients living with and beyond cancer by developing assessment care plans and treatment record summaries at Sandwell and West Birmingham Hospitals NHS Trust (SWBH).

Objectives:

• To improve the information patients and their general practitioners receive.
• Support the effective self management of living with and beyond cancer.

Progress/outcomes:
Final report. During 2010 SWBH was one of 12 NHS test communities to pilot and evaluate assessment and care planning frameworks and treatment records. The work was tested across lung and myeloma tumour sites at both Sandwell and City hospitals.

Testing led to the development of documentation, adapted to the specific needs of SWBH clinics.

Results from the pilot have informed further national prototype testing through the national cancer survivorship initiative (NCSI).  The final reports from the 2010 testing along with additional information on the assessment and care planning process can be found on the NCSI website.

Documents developed by SWBH staff during and since the pilot have been shared across the network.  Documents have been well received and adapted for use in other tumour sites and hospitals.

Assessment and care planning/holistic needs assessments – haematology

Aim:
Develop approaches to assessment and care planning in order to improve the experiences of patients living with and beyond cancer at Sandwell and West Birmingham hospitals.

Objectives:

• Identify methods to ensure that all haematology patients are able to have a holistic needs assessment at or near the start of their treatment.
• Provide signposting for patients to support services linked to the holistic needs assessment domains.
• Modify the structure and format of clinical nurse specialist held information to link in to the holistic needs assessment domains.
• Addressing the affects of cancer beyond the medical needs.
• Provide patients with information to allow them to better access support services.
• To free up time for the clinical nurse specialist.

Progress November 2011:
This work stream has continued to build upon the resources developed during the testing of approaches to assessment and care planning undertaken during 2010. Documents developed by Sandwell and West Birmingham Hospitals Trust (SWBH) staff during and since the pilot have been shared across the network. The documents have been well received and are being adapted for use in other tumour sites and hospitals. Details and copies of the resources developed at SWBH can be found by clicking here.

Treatment record summary

Aim:
The Treatment Record Summary (TRS) is a summary of treatment provided to a patient’s GP by the patient’s consultant. Macmillan and NHS Improvement developed a TRS which we tested along side assessment and care plans during the adult survivorship project. The aim is to continue to develop and test approaches to treatment record summaries using national feedback from the adult survivorship project. Initially working within haematology services at Heartlands and Sandwell hospitals to then spread successful approaches to other sites across the network.

Objectives:

• To standardise the information that is provided to a GP to ensure sufficient detail is made available in a format that is easy to input and access.
• To aid the care of the patient in the community after treatment for cancer.