The role Christine Millard, Clinical Nurse SpecialistElisabeth Summers, Assistant Psychologist

Who we areNorth Bristol NHS Trust (NBT) are an Acute NHS Trust which is directly commissioned to provide services in respect of nine main cancer groupings. NBT participated in the National Cancer Survivorship Initiative (NCSI) during 2011/2012 piloting innovative approaches to follow-up care for breast, prostate and colorectal cancer patients and is now committed to scaling up and embedding these approaches into routine practice for all cancer patients. The NCSI demonstrated that such an approach can bring improved patient outcomes, cash savings and improved productivity. Evaluations at NBT have revealed high levels of patient satisfaction reinforcing further service redesign.

What we’re doing Embedding and extending work already undertaken to reform and improve care for prostate cancer patients as part of the National Cancer Survivorship Initiative. Developing improved evidence based practice for healthy living and self-management programmes for prostate cancer patients.

Who is involved? • Individuals: Urology clinical nurse specialists and

clinicians, cancer services psychology team, patients, carers and families, outpatient and ward staff.

• Internal Groups: Prostate Cancer Survivorship Steering Group, Cancer Services Team, IT department, finance department, evaluation team and, patient experience group.

• External Groups: GPs and district nurses, Prostate Cancer UK, and local support groups, SSGs, clinical commissioning groups.

What we’re trying to achieveThe existing cancer follow-up pathway was not sustainable with increasing numbers of new diagnoses as there was no unified follow-up pathway for men coming out of active treatment.

The aim of this project is to implement an integrated model of survivorship into the care pathway for every person diagnosed and treated for prostate cancer at North Bristol NHS Trust (NBT) as per the National Cancer Survivorship Initiative.This will be achieved by: 1. redesigning aftercare services so that all patients

are stratified to an appropriate pathway based on clinical and individual needs and preferences

2. developing supported self-management pathways for all those living with and beyond cancer.

This involves collaborative working between patients and health professionals and across organisations involved in providing care, developing evidence-based information for healthy living and self-management programmes to support the changes and adjustments involved in long term recovery and recuperation. We have developed strategies and resources, training and evaluation methods, and we have built up expertise about how to successfully implement improvements for the health and well being of men who have been treated for prostate cancer.

In practical terms, this will involve providing living well days to all patients, living well courses to those who opt in, Health Needs Assessments (HNAs),

treatment summaries and increasing the number of men being remotely monitored.

This integrated survivorship model will improve the outcomes and experiences for all cancer patients by establishing a patient centred partnership as part of a unified and streamlined ‘self- management system’. Key to this project is the personal engagement of patients with their cancer journey while at the same time seeking to ‘bend the cancer cost curve’ and maximise efficiencies within service delivery and design.

How it will benefit men?The NCSI demonstrated that such an approach can bring improved patient outcomes, cash savings and improved productivity. Evidence from the pilots confirmed that as the proportion of patients eligible for supported self-management grows, the amount of outpatient resources that can be released to deal with more complex cases or future demand also increases.

Empowering patients to manage their own health by providing information and education, including ensuring patients are aware of how and when to re-access the service and have relevant signposting information.

A more streamlined, straightforward pathway for men to follow from diagnosis, through treatment and follow-up.

Providing a more holistic approach to ensure that not only medical needs are met, but also ensuring emotional, practical and financial needs are met as well.

Any learnings or discoveries so far?We have a better understanding of the importance and value that patients place on the Holistic Needs Assessments (HNAs) and living well days and courses.

Preliminary data analysis shows that attendance at living well course reduces depression and anxiety levels, increases patient activation and improves quality of life (full statistical analysis currently being conducted).

We found that patients were enthusiastic to be placed on the remote monitoring system, and that this system and the patient tracker were easy to use.

Biggest challenge?Change of personnel in the lifespan of the project. This lead to short staffing in CNS team and delays in recruitment.

We also found it challenging to engage members of the multidisciplinary team with proposed changes to pathway.

We have worked on overcoming the challenge of engaging members of the multidisciplinary team by arranging smaller weekly team meetings with lead cancer consultant in order to gain their support in integrating this with the rest of the team. We have also ensured lots of training sessions for staff members on use of equipment such as the psa tracker and eHNA tablet, and involved as many professionals as possible in the provision of living well days.

Monitoring and evaluationThe following psychometric data is being collected at assessment (start of living well course), reassessment (end of course) and follow-up (3 months after course):•Quality of Life Adult Cancer Survivors – QLACS

as recommended by NCSI•Hospital Anxiety and Depression Scale (HADS)•Patient Activation Measure (PAM) - measure of

confidence self-managing condition (adapted version).

Data is currently in the process of being comprehensively analysed. However, some basic preliminary analysis has been undertaken. Paired-samples t-tests were conducted to compare total QLACS scores, HADS anxiety scores, HADS depression scores, and PAM scores, at assessment and reassessment stages. Current results suggest there were significant differences between all groups tested, indicating an improvement in scores across all psychometric questionnaires following attendance at a living well course.

Costings of the new pathway are a work in progress at present. We are aiming to establish costs of ‘old’ and ‘new’ pathways in next 6 months.

Sustainability plansThe overall aim for the Trust is to move to a position in which a new treatment and follow up pathway, for men with prostate cancer, is embedded within normal practice on a cost neutral basis.

NBT is leading nationally on survivorship initiatives and the Trust Board is committed to sustaining and further developing the survivorship programme in partnership with a range of health care providers.

The hope is that cost and efficiency savings arising from the project will support the re-alignment of staffing resources. In addition, evaluations of the pilot will be used to inform future discussions with local CCGs in order to secure investment where necessary to sustain and further develop the survivorship and self-management models of care in partnership with a range of healthcare providers and organisations.

Additionally a longer term goal is for the expansion of similar services across other cancer tumour sites.

How to find out moreChristine Millard, Clinical Nurse Specialist, Cancer Services, Beaufort House, Southmead Hospital, Bristol, BS10 5NB Christine.millard@nbt.nhs.uk

Carol Chapman, Lead Cancer Nurse, Cancer Services, Beaufort House, Southmead Hospital, Bristol, BS10 5NB

Elisabeth Summers, Assistant Psychologist, Sherston Building, Southmead Hospital, Bristol, BS10 5NB Elisabeth.summers@nbt.nhs.uk

Dr. Nick Ambler, Service Lead, Consultant Clinical Psychologist, Sherston Building, Southmead Hospital, Nicholas.ambler@nbt.nhs.uk

To find out more about the Prostate Cancer UK professionals support programme visit prostatecanceruk.org/professional-support

Any references or acknowledgments?National Cancer Survivorship Initiative (DoH)

Prostate Cancer UK is a registered charity in England and Wales (1005541) and in Scotland (SC039332). Registered company 2653887.

North Bristol NHS Trust Prostate Cancer Survivorship Project

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Quotes

It (the course) has changed my sleeping pattern, it has changed my response to my fatigue…I can be more active now.

I was hearing things that I needed to know to help me make those changes.

I now feel confident about who to talk to if I have any problems not just with my health but in all areas of life.