Leading change

Nurses in the Urology Unit at The Royal Marsden NHS Foundation Trust led the development and implementation of a new prostate cancer follow-up pathway. This pathway has significantly improved patient outcomes, experience and use of resources locally.

Where to look

There are over 2.5 million people living with cancer in the UK and by 2030 this number is expected to have risen to 4 million (Macmillan, 2016). This report suggests this is due to rising cancer incidence as well as people living longer after having a cancer diagnosis. Advances in treatment options and success means more individuals than ever before are living with and beyond cancer. The Cancer Macmillan Holistic Needs Assessment (HNA) demonstrates improved outcomes through holistic care which supports patient needs and educates patients to make the best choices for their health. Increasingly, colleagues in primary and community care provide significant support for people with cancer.

The Urology Unit at The Royal Marsden provides specialist care to diagnose and treat patients, providing diagnostic services for people with prostate, testicular, kidney and bladder cancer symptoms. Treating prostate, kidney, bladder and testicular cancer, the Urology Unit provides care and treatment on all aspects of genetic predisposition, targeted screening, treatment and care, improving patient survival, quality of life, and their experience in living with, and beyond, cancer.

What to change

In 2016 there were 1781 prostate cancer patients treated at the Trust, however nurses identified evidence of unwarranted variation whereby patients being discharged from hospital care following curative treatment for localised prostate cancers was not standardised as a pathway. The increasing number of referrals led nurses to look at the way in which clinics were held and the way in which patients were being discharged from hospital care despite the success of their treatment.

How to change

The nursing leads collaborated with physiotherapy and dietetic colleagues to establish a patient reference group which would work to define a new pathway for patients. Considering relevant research literature, the group developed ‘urology stratified care pathways’ which aimed to support an individualised approach to follow-up care. These new pathways include pre-treatment preparation through pre-treatment education seminars focusing on self-management of side effects and coping strategies, opportunity for re-assessment, care planning and supported self-management, which supports patients with previous possible unmet needs and safely reduced what was identified as often unnecessary secondary care use.

The pathways support multidisciplinary teams (MDT) to develop personalised treatment plans for each patient, improving their experience and quality of care. Up to 35 specialists join the weekly MDT meetings, including clinical nurse specialists, surgeons, medical oncologists, radiotherapists, pathologists, radiologists and allied health professionals, using the pathways and associated care plans to maximise the delivery of high quality evidence based practice.

Pre-treatment preparation is now offered to men undergoing radiotherapy, radical prostatectomy, active surveillance and brachytherapy, which includes supported self-management techniques. Survivorship clinics have been set up with structured review and supported transfer-of-care to General Practice (GP) at two years post treatment, with clear trigger points for re-referral. Health and wellbeing events have also been introduced to improve the follow-up services further.

Adding value

Better outcomes – The number of patients treated in 2017/18 has risen to 2300, which is a 30% increase in patients treated in clinic since the implementation of the pathway. The number of follow-up visits remained constant and patient attendance is good at around 92% across the board. Evaluations also show that 85% of patients transitioned through the survivorship clinic back to primary care follow-up and a recovery package was initiated in all cases which is in-line with evidence based practice. Clinic utilisation has increased by 44%.

Better experience – Individuals are now offered increased choice as to how they wish to be cared for. For example, in 2017/18 28% of patients were supported through a survivorship telephone follow-up clinic, which meant patients did not need to travel and disruption to day-to-day life was minimised. In the same year the number of patients discharged back to their GP was 318, which is transformational since the beginning of the programme. The pathway is also facilitating patients to move into survivorship-care earlier due to earlier discharge with appropriate support. The early adoption of a ‘recovery package’ has optimised patient experience and reduced variation. The new approach to cancer care has been well received by those on the pathway.

Better use of resources – As the pathway supports effective decision making, this has supported patients to access care and treatment earlier in their care journey, leading to reduced delays in accessing services as well as timely discharges with a continued focus on follow-up and supportive care in their communities. The pathway supports the prevention of unnecessary readmission to hospital, with follow-ups taking place in primary care, closer to home and by practitioners who manage their overall care and not just cancer care. Due to streamlined services, clinical teams now have increased clinical capacity to manage new patients and treatment outcomes.

Challenges and lessons learnt for implementation

It is important to ask patients what matters to them to ensure a good service is being provided. The views of patients are sought on an ongoing basis and changes made to the service to reflect these.

The leadership skills demonstrated in developing the pathway can be extended to other areas such as physiotherapy and dietetics.

For more information contact

Netty Kinsella
Uro-Oncology Nurse Consultant
Royal Marsden NHS Foundation Trust
Netty.Kinsella@rmh.nhs.uk