Transcript Macmillan-HNC-Project-Sian-Lewis

Thames Valley review of
rehabilitation services for
patients diagnosed with head
and neck cancer following
treatment
Siân Lewis
Macmillan Clinical Lead Dietitian
24th February 2016
Rehabilitation
• To restore a patient’s roles and functions as far as
possible, and help them to adjust to limitations where
required (Cancer Taskforce 2015)
• Focus is primarily rehabilitation services - dietetics,
nursing, psychology, occupational therapy, restorative
dentistry, SLTs and physiotherapy
- To ensure prudent healthcare and co-production a
multi-disciplinary team approach led by the surgeons
and oncologists is paramount
Project background
2012:
• Concerns were formally raised regarding the overall
current provider capacity to deliver a service to meet
HNC patient’s demands and be compliant with national
guidelines
• Patients felt there was a lack of specialist workforce in
restorative dentistry and AHPs such as dietetics and
SLTs
• SCN approached Macmillan for funding towards a major
scoping project
Achieving world-class cancer outcomes
Cancer Taskforce 2015
How should we improve the QOL of patients after treatment
& at end of life?
• Recommendation 63: The NHS and partners should
drive forward a programme of work to ensure that people
living with and beyond cancer are fully supported and
their needs are met.
• Recommendation 65: NHS England should accelerate
the commissioning of services for patients living with and
beyond cancer, with a view to ensuring that every person
with cancer has access to the elements of the Recovery
Package by 2020
• Recommendation 67: NHS England should pilot stratified
follow-up pathways of care for other tumour types
Cancer of the UAT
NICE 2016
Follow up
• Ensure people with cancer of the upper aerodigestive
tract and their carers have tailored information about the
symptoms of recurrence and late effects of treatment at
the end of curative therapy
• Consider structured, risk-adapted follow-up using
locally-agreed protocols for people who have had
curative treatment for cancer of the upper aerodigestive
tract. Use the follow-up protocols to:
- Help improve QOL, including discussing psychological
issues
- Detect disease recurrence or second primary cancer
Aims & Objectives
Aim:
The main aim of the scoping project is to identify and
understand key areas within the rehabilitation services for
HNC patients where the support and care is not met and
needs enhancement
Aims & Objectives
Objectives:
• Identify the number of HNC patients
• Map current services for HNC patients within the network
• Identify gaps in current service provision
• Identify models for service development to support HNC
patients
•
Identify staff involved with HNC patients and their needs
Incidence of new cases of HNC in
Thames Valley SCN
National Cancer Registration Service 2015
Tumour site
Number of new cases of HNC diagnosed per annum
2011
2012
2013
Lip, tongue & oral
cavity
156
152
148
Salivary glands
24
28
41
Pharynx & tonsil
75
83
89
Nose, ear, sinus &
larynx
86
104
88
Total
341
367
366
CCG
Number of new cases of HNC diagnosed per annum
2011
2012
2013
NHS Aylesbury Vale
34
22
27
NHS Bracknell & Ascot
16
18
14
NHS Chiltern
38
51
37
NHS Milton Keynes
37
36
33
NHS Newbury & District
13
19
22
NHS North & West
Reading
15
16
20
NHS Oxfordshire
97
93
98
NHS Slough
11
15
19
NHS South Reading
13
9
14
NHS Swindon
35
34
36
NHS Windsor, Ascot &
Maidenhead
11
28
21
NHS Wokingham
21
26
25
Total
341
367
366
Methodology
Main activities conducted:
• Mapping of current services within the network and
identification of gaps
• Patient experience using focus and support groups
• Education and training needs of the workforce
• Recommendations
Mapping current services
1.Great Western Hospital
2. Milton Keynes Hospital
3. Churchill Hospital
4. Royal Berkshire Hospital
5. Stoke Mandeville Hospital
6. Wexham Hospital
7. Wycombe Hospital
NHS Milton
Keynes CCG
2
NHS Aylesbury Vale
CCG
5
NHS Oxfordshire CCG
3
7
NHS Chiltern CCG
NHS Swindon
CCG
1
NHS Winsdor , Ascot
& Maidenhead CCG
NHS Newbury &
District CCG
6 NHS Slough CCG
NHS South
Reading CCG
NHS North &
West Reading
CCG
4
NHS
NHS Bracknell
Wokingham CCG& Ascot CCG
7.3 Appendix 3: HNC care referral pattern Berkshire, Buckinghamshire, Oxfordshire, Swindon
Copyright © Thames Valley Cancer Network 2012
Key:
BHT (SMH):
BHT (WGH):
HWP:
MKFT:
ORH:
RBFT
GWHFT
Key:
Stoke Mandeville Hospital – Buckinghamshire Healthcare NHS Trust
Wycombe General Hospital - Buckinghamshire Healthcare NHS Trust
Heatherwood & Wexham Park Hospitals NHS Foundation Trust
Milton Keynes NHS Foundation Trust
Oxford University Hospitals NHS Trust
Royal Berkshire NHS Foundation Trust
Great Western Trust / Swindon and Marlborough Hospitals NHS Foundation Trust
chemotherapy
surgery
radiotherapy
out of network surgery
out of network chemo/radiotherapy
HWPFT
MDT
Northwick Park or Mount Vernon – for surgery
Mount Vernon for chemo/radiotherapy
NOC
Oxfor d
Nuffield Orthopaedic Centre in Oxford for sarcoma surgery
May receive
referrals from
anywhere
Nuffield Orthopaedic Centre in Oxford for sarcoma surgery
Thyroid
BHT
M DT
Oxford for Upper aerodigestive tract & thyroid surgery
Oxford for chemo/radiotherapy
OUH
Oxford for Upper aerodigestive tract surgery
SMDT
RBFT
M DT
Oxford for Upper Aerodigestive Tract
Oxford for chemo/radiotherapy
MKFT
GWHFT
MDT
MDT
GWT for thyroid
Northampton & occasionally also to Kettering for surgery
Northampton for chemo/radiotherapy
Occasionally to Salisbury for surgery
Occasionally Southampton for radiotherapy
Lymphoedema
Therapists
Acute
Community
Total
WTE
1.1
1.8
2.9
NCAT workforce mapping tool
WTE by professional group, showing break down by pathway stages
25
Pal & EoL
Survivorship
20
WTE
Treatment
Diagnosis
15
Pre Diagnosis
10
5
0
Diet
Lymph
OT
Physio
SaLT
Main findings
• Limited access to MDT post treatment
• HNA not being completed due to time constraints
• Variation in services across the network
• Data activity supports development of pay band 4 role
General Practitioners:
• Rehabilitation services should be provided by cancer
centres/ units
- Skills & expertise
- Access to members of MDT
• End of Treatment summary could be used as education
tool
• Use of modern technology
- Internet
- Mobile phones
- Videoconferencing
Patient experiences
Findings
• High praise from patients and their carers for the care
they had received during their treatment
• Lack of access or delays with referrals to some
rehabilitation services such as SLT, physiotherapy,
dentistry and psychology - some patients accessed
services privately
• Lack of restorative dental services - lack of dental staff,
waiting times for treatment and location of services
• Local support groups seem invaluable - provided
additional psychological and emotional support
• Laryngectomy patients report some difficulty in
accessing SLT services - standard approach in
prosthesis replacement across the network
• Need to be provided with more information regarding
side effects of treatment and specific HNC services
• Some patients felt that an EOT meeting which included a
holistic assessment and provision of information specific
to them would be beneficial
• H & WB events were valued - carers felt that they were
included
• Patients valued texting service - ease of communication
with CNS during periods of speech difficulties
• Milton Keynes:
- Highly valued the support and care provided by SLT
and community dietitians
- Significant lack of co-ordinated services, access to
rehabilitative services and communication
Education & training needs of
workforce
Findings
• Overall response rate for the questionnaire was 78%
• Highest response rate was by dietitian and SLTs, lowest
was OT
• Majority of education was in the form of self-directed
learning
• 69% felt that their education and training needs not met
• Top three priorities:
- Opportunities to work across network
- HNC specific training
- Improved psychology, counselling and communication
training
Recommendations
Hub and Spoke Model
Version A
• One team providing after care services:
- Attached to hub and hosted by OUH
- Regular rehabilitation OPCs to spokes
• Team would consist of:
- Care coordinator
- CNS
- Dietitian
- SLT
- Musculoskeletal physiotherapist
Version B
• Increase in workforce at each spoke:
- CNS
- Dietitians
- SLT
- Access to musculoskeletal physiotherapist
• AHP rehabilitation clinic in conjunction with local medical
review
Version C
• Hybrid of version A and B
• Three community teams each covering two localities
- Locality Team 1: OUH and GWHT
- Locality Team 2: RBH and FHFT
- Locality Team 3: BHT and MKH
- Access to musculoskeletal physiotherapist
• Each team would consist of a CNS, Dietitian, SLT and
access to musculoskeletal physiotherapist
• AHP rehabilitation clinic in conjunction with local medical
review and local H&WB events
Summary
• Patients should be offered stratified follow-up pathways
• Development of local specialist HNC teams
• Increase rehabilitation staff at cancer units
• Development of the pay band 4 role within cancer
centres
• Increase restorative dentistry services
• Better access to physiotherapy, lymphoedema and OT
services
• Develop and implement a programme of new learning
opportunities and ensure protected time
Acknowledgements
• Steering group
• Kim Bowles
• Nick Crowson-Towers
• Dr. Richard Fisher
• Sam Penney
• Helen Petley
• Mr. Priy Silva
• Allan Warnock
• All staff and patients who helped and contributed to the
project