Leading change

A general practice nurse (GPN) at Lancaster Medical Practice addressed unwarranted variation relating to cancer care reviews through introducing a group consultation model at the surgery. This new approach has led to better outcomes for patients, better experiences for patients and staff, and better 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. Advancements in treatments mean that there are more individuals than ever before that 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, cancer is not just a disease of secondary care, and colleagues in primary and community care provide significant support for people with cancer. Primary care colleagues are often the key point of contact for someone with cancer. They will be involved at key transition points, such as when patients move within and between health and care settings or they experience significant changes in their condition.

The GPN at Lancaster Medical Practice recognised unwarranted variation in her surgery in cancer care reviews. Some were held face to face and others over the phone, there was variety and inconsistency in frequency, and at times patients may not have been aware it was a cancer care review. The GPN saw an opportunity to improve the quality of practice within this area of work.

What to change

Prior to implementing the change, standard practice at the surgery was that patients would have a one-off cancer care review within 6 months of their cancer diagnosis. Some patients had specific appointments for a cancer care review, whereas others may have had the review at the same time as another appointment with their General Practitioner (GP) or GPN.

As part of The GP Five Year Forward View there is a drive in primary care to:

• Broaden the workforce to reduce demand for GP time and connect the patient directly with the most appropriate professional;
• Introduce new consultation types including new communication methods for some consultations, such as phone and email, improving continuity and convenience for the patient and reducing clinical contact time;
• Maximize the use of appointment slots and improve continuity by reducing ‘Did Not Attends’ (DNAs). Changes may include redesigning the appointment system, encouraging patients to write appointment cards themselves, issuing appointment reminders by text message, and making it quick for patients to cancel or rearrange an appointment;
• Introduce new ways of working which enable staff to work smarter not harder.

At Lancaster Medical Practice, the GPN was already providing chronic disease management, cervical cytology, immunisations, travel advice, injections, dressings and a range of other services to those using the surgery. Following training in Group Consultations, the GPN felt there may be a better way of delivering care to ensure a holistic approach for cancer patients, ensuring their wider needs were also met in a personalised approach.

Group consultations (also known as shared medical appointments, group clinics and group appointments) are one to one medical appointments delivered by a clinician within a group setting. They are not an addition to routine one-to-one appointments but rather replace routine one to one appointments where appropriate. This means a GP or nurse practitioner can see up to 12 patients for extended appointments. This potentially doubles productivity and access to routine care and follow up appointments as well as opening the doors for peer support between patients with similar conditions.

How to change

Following completion of an accredited education programme on group consultations, the practice nurse established a gynaecological cancer group consultation at the surgery as a trial. Patients with similar cancers who were living with and beyond cancer were invited to attend. An explanation as to the purpose and design of the consultation was provided for their information. Using the Cancer Macmillan Holistic Needs Assessment (HSN) , the practice nurse assesses and supports each individual who attends the group, to address any concerns they may have, identify referrals/tests they may need, share their experiences and provide peer support within a confidential and safe space. Due to the success of the initial trial, a further group consultation session was arranged to roll-out the offer of support, review progress and identify new needs as well as ensuring previous concerns had been addressed.

The success of this trial prompted conversations between the practice nurse and a local uro-oncologist, which led to the development of an integrated prostate cancer event. This event saw a cancer nurse specialist share health and wellbeing information and included a practice nurse group consultation combined with a consultant follow up. In addition to peer support and clinical review, health and well-being information (including healthy eating and exercise) was shared and further groups/events are being planned.

Adding value

Better outcomes – The immediate impact of the change is identified by an observed reduction in concerns on the holistic needs assessment and patient experience questionnaire audits. At baseline, 66% of patients at the initial gynaecological group consultation reported at least one area of concern. On average, those patients reported 8.3 specific concerns (4 physical, 2.5 emotional and 1.8 lifestyle and information). At follow-up, 66% of patients no longer had concerns; the 33% that did have concerns reported an average of 4 physical, 1 lifestyle and information and 2 emotional concerns. The total number of concerns at baseline was 33 and at follow-up it reduced to 14, a reduction of 58%. The average self-assessed ‘overall level of concern’ was 3 at baseline and 2.2 at follow up, a reduction of 27%.

Long term, it is hoped that healthy lifestyle behaviours have been adopted by patients, which will be measured through an audit of clinical biometrics including cholesterol levels, sugar levels and Body Mass Index (BMI). It will also be possible to measure absence of complications, such as re-occurrence and chronic disease related to lifestyle.

Better experience – Patient and family feedback has been extremely positive, for both the gynaecological group consultation and the prostate cancer event. These had an overall average score of 9.4/10 (where 10 is the best experience). The increased level of support and information provided has been well received; many patients did not realise how prostate cancer and treatments can have a broader impact on their whole body, e.g. impact on bone health. Since implementing the standardised approach, patient experience and staff job satisfaction has improved and team working has been more evident. Patients also felt that the group consultations could have worked for their initial primary care review following diagnosis. Patient feedback to date includes:

• “Marvellous support, information, care and now have a better understanding, particularly of bone health”
• “I feel so much better. It was perfect support at the time it was needed”
• “No information gets wasted so very helpful”

Staff also responded positively to delivering the group consultations and feedback includes:

• “I gained valuable knowledge of different partners’ work and roles”
• “Open relaxed atmosphere”
• “Good networking”

Better use of resources – The new approach has led to consistency in cancer care reviews and information given to patients about cancer and the impact on their health. 25% capacity saving has been achieved and time spent consulting has had greater impact and service improvements can be seen now that all information and peer support is provided.

Challenges and lessons learnt for implementation

It can be challenging when working with a large team from different backgrounds but it is worth it.

There is reinforced learning in recognising the need to improve practice and lead on change for the benefit of patients and communities even when this change is outside of your comfort zone.

Speaking with stakeholders will support successful improvements to be implemented on a broader scale to reduce unwarranted variation.

Due to the success of the programme, the practice nurse and practice manager won the ‘Most Innovative Group Consultation’ award from Health Education England (HEE) at the North-West Group Consultation Celebration Event in October 2017, and in November 2017 won the ‘Supporting Families and Carers’ award at the NHS England Regional General Practice Nursing Conference.

Find out more

For more information contact:

• Emma Hodgson, General Practice Nurse, Lancaster Medical Practice, emma.hodgson@gp-P81002.nhs.uk