Download Operational Flow Chart Prostate Cancer

Transforming Cancer Services Team for London
Operational Flowchart Prostate Cancer Enhanced Follow-up
Patient identified as suitable for primary care follow up using patient
identifier (attachment 1 overleaf)
Patient already
having primary
care follow up
Patient is informed by practice
Letter sent to secondary care urologist to request transfer
(Attachment 2)
No
Secondary care agree that patient
followed up in primary care
according to protocol?
Consultant team
follow-up in
hospital
Yes
Send Living with
Prostate cancer letter
(Attachment 4
overleaf). Use
EMIS/VISION Template
at reviews.
Letter sent from Urology consultant to GP with detailed discharge
advice.
Practice to inform patient about transfer of care.
Patient to receive a copy of discharge/transfer letter
Welcome appointment: Initial 30 minute
appointment for new patients with clinician to
review:

Prostate care plan that patient has
completed

Discuss treatment so far, any side effects
of treatment, discuss support needs and
provide relevant information.
Practice send out “Welcome pack” to patient 4 weeks from
transfer that includes the following:
1.
2.
3.
Welcome pack
Patient survey with TCST addressed envelope
Prostate Care plan
(Attachments 3 overleaf)
PSA test at 6 months with any other required bloods
See advice given by secondary care at point of
discharge outlined in the discharge summary).
If results are abnormal
according to the discharge
advice given by consultant –
refer back to secondary care
via Urgent Referral letter and
route.
Follow up appointment with GP/PN to:
(attachment 4 overleaf)

Discuss the results of blood tests

Carry out consultation using Prostate
Follow-up Template.
LIS claim made quarterly using excel spread sheet.
Attachment 5 overleaf.
Repeat in 6 months (or as stated on transfer of
care letter)
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Transforming Cancer Services Team for London
Attachments
Attachment 1
Attachment 2
Attachment 3
Patient Identifier tool to help find prostate cancer patients that
are suitable for primary care follow-up.
Letter to secondary care requesting transfer of patient for primary
care follow-up. Use one letter per patient. For CUH please address
to Mark Lynch, for any other trust please address to their
consultant urologist/oncologist.

Practice to inform patient if transfer to primary care is
agreed by secondary care consultant

Welcome Letter, Survey and Welcome Appointment to be
sent 4 weeks from receipt of transfer to practice. Survey
to be sent with SAE to : Barbara Gallagher/Sandra Dyer,
Transforming cancer Services Team for London , SE CSU, 1
Lower Marsh, London SE1 7NT.

Attachment 5
Transfer of care
letter to Secondary Care June 2015.dot
Welcome pack documents

Attachment 4
Patient Identifier
tool.pdf
Welcome Letter to
prostate cancer patient July 2015.doc
Survey One Word
2003.doc
Welcome Appointment to be arranged with patient
Holistic Care Plan to be used in Welcome Appointment
and be reviewed in subsequent follow-up appointment.
This can be integrated into VISION/EMIS web.
Living with prostate cancer letter (for existing patients). Send out
when recalling for PSA blood and review.
Prostate Cancer
Care Plan July 2015.doc
Letter to Existing
patients July 2015.doc
Urgent re-referral/ Advice only letter to Secondary Care.
Urgent follow up
letter June 2015.doc
Advice only template
June 2015.doc
Attachment 6
Guides to upload the Prostate Cancer follow-up consultation
templates for EMIS or Vision clinical systems.
Importing_an_EMIS
web template .pdf
Vision instructions for
downloading and importing PSA Guideline.
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Transforming Cancer Services Team for London
Attachment 7
CCG Reporting Spread sheet for remuneration.
LIS reporting tool.xls
Attachment 8
Maintain Prostate Cancer Register to mitigate and reduce risk of
patients lost to follow up/ or delayed PSA and follow up.
Prostate cancer
Register.xls
Attachment 9
CPD accredited educational resources suitable for GPs, practice
and primary care nurses and Allied Health Professionals.
Final July 2014
Prostate_Cancer_Education_resources.d
Primary_Care_Nurse
s_Tool_ pdf
http://prostatecanceruk.org/croydontoolkit
Attachment 10
Primary care Follow up protocol. Designed to assist primary care
where there is a lack of guidance in their discharge summary
(historical discharges). This does not replace individualised
discharge advice. Please note that secondary care
recommendations for DEXA for patients on hormone treatment or
Sigmoidoscopy post radiotherapy/brachytherapy there are no
commissioned pathways currently.
Follow up in
protocol primary care V1 April 2015.pdf
Frequently asked Questions
You may find the following answers to frequently asked questions useful.
1. What is the Enhanced Prostate Cancer LIS?
This is a Local Incentive Scheme (LI) which provides an incentive for primary care to provide follow up to stable patients
with prostate cancer or those who are on a watchful waiting pathway.
2. What is the difference between watchful waiting and active surveillance?
Watchful waiting is offered to patients when radical (curative) treatment would not be appropriate due to their comorbidities or whose cancer may never cause problems during their lifetime. Any treatment offered will be to control the
cancer as opposed to a cure. Watchful waiting will normally be provided in primary care (NICE CG 175 2014).
Active surveillance is also an approach that delays treatment, the aim of any treatment will be curative however. It is
suitable for some men with localised prostate cancer. It is always carried out in secondary care as it involves prostate
biopsies and MRI scans as well as regular PSA testing and interpretation.
3. How to upload the EMIS/Vision template
There are guides available on how to upload for both systems (Attachment 6 above.)
4. What is a Prostate Cancer Care Plan?
This has been developed to help patients identify their needs relating to the side effects of treatment and the
consequences of their disease and to help structure appointments. It is intended to be used at the welcome appointment
and for patients coming back for review who have not had the opportunity to discuss their supportive needs before. It
was adapted from a validated tool designed to assess the holistic needs of patients with cancer whilst in secondary care.
It will be tested as part of the evaluation of the primary care prostate cancer project. The project team welcomes
comments on the use of this tool (contact details at end of this document).
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Transforming Cancer Services Team for London
5. What is the Prostate Cancer Disease Register?
This is a register of all the patients in one practice who have prostate cancer. This provides a record of who is having
primary care follow up and also of those who may be suitable in the future. It also provides details of when PSA tests and
reviews are due.
6. Which read codes should I use to identify patients within primary care?
The patient identifier tool (Attachment 1) provides the read codes and process required to identify suitable patients for
the LIS
7. How can I learn more about prostate cancer, side effects of treatment and consequences of the disease?
The project team recommends the completion of the modules identified in the attached guide (Attachment 9).
In addition Prostate Cancer UK provides a wide range of resources aimed at health care professionals on their website:
http://prostatecanceruk.org/for-health-professionals
The project team has also developed a tool kit to enable primary care nurses and allied health professionals provide care
to this patient group. This has been developed with the support of Prostate Cancer UK and Macmillan Cancer Support.
This is available here: http://prostatecanceruk.org/croydon-toolkit
8. As a busy practice our GPs are already inundated and we fear that we will struggle with the number of extra patients
and appointments.
After visiting nearly all the practices in Croydon we know that on average each practice will be accommodating between
1 and 8 patients per month depending on the number of patients you have. The transfer from secondary care will be a
slow trickle so you will not have patients flooding into your practice. Practice Nurses and Allied Health Professionals are
ideally placed to conduct Welcome Appointments and follow up care. Support is available from the project ream until
September 2015.
9. Where can I find out more about primary care management of patients discharged from secondary care after
treatment?
The follow up protocol (attachment 10) has been developed to help clinicians in safely managing this patient group. We
know that, historically, discharge information from secondary care was not always comprehensive and that guidance
around follow up changes when new evidence emerges. The protocol is designed as an addition to any individualised
discharge advice and has been endorsed by secondary care clinicians. Advice on dexa scanning for the hormone therapy
patients and Sigmoidoscopy post radiotherapy/brachytherapy is based on local guidance from secondary care, currently
there is no commissioned pathway for these.
Contact details for Project Team: Sandra Dyer, Nurse Lead: [email protected] and Dr Jaimin Patel, GP Lead:
[email protected]. Project support available until 30.9.15
To help the project team evaluate the process and tools developed for the project
please complete the following on line survey after completing a consultation with
patients: https://www.surveymonkey.com/r/3YJL5ZX (please complete once
only, survey open until 30/9/15)
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