Download What Happens When Cancer Treatments Are

Storyboard Entry Form 2014
Main author: Carlene Jones
Email: [email protected]
Telephone: 07896938472
Follow the detailed instructions in this template for writing your
storyboard. Add your information in each section below and save this
completed storyboard document. Please not amend this template.
Follow the instructions in the Information Guide for Authors to submit
your storyboard.
The word limit is 1100 words including references. Your storyboard will
not be accepted if you exceed the word limit.
1. Storyboard title: a clear concise title which describes the work
Macmillan 121 Pilot :
What Happens When Cancer Treatments Are Completed?
2. Brief outline of context: where this improvement work was done;
what sort of unit/department; what staff/client groups were involved
In 2013 Aneurin Bevan University Health Board (ABUHB) successfully won a bid to be
involved in a national Pilot funded by Macmillan to investigate the needs of cancer patients
upon completion of treatments and discharged to their GP.
By 2020 it is estimated that nearly half (47%) of the population in the United Kingdom will
receive a cancer diagnosis, however almost 38% will not die as a result of their cancer.
Of this 38% evidence demonstrates that many survivors of cancer have unmet needs at the
end of their treatments whilst others struggle with consequences of treatment which could
otherwise be managed or avoided (National Cancer Survivorship Initiative – NCSI - 2013).
Within Wales alone it is estimated that by 2030 there will be approximately 250,000 people
living beyond their cancer and as a result the pathway for patients with a cancer diagnosis is
changing.
3. Brief outline of problem: statement of problem; how you set out to
tackle it; how it affected patient/client care
 Perceptions of cancer tend to be stereotypical with the initial thoughts of patients
commonly reported as being focussed around fear of the unknown and possible end
of life scenarios.
 Macmillan is working towards changing these perceptions by identifying and
addressing the needs of cancer survivors.
 In partnership with Macmillan, ABUHB is introducing the ‘Recovery Package’
(NCSI) to improve the standards of care cancer patients receive following their
discharge from Secondary Care
 The Macmillan 121 support pilot will develop robust community/ primary care
aftercare pathways for patients living with or beyond their cancer.
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 Cancer patients statistically attend their GP surgeries with greater frequency than
their non cancer counterparts- interaction with the Pilot will lead to a reduction in
attendance at the GP’s.
4. Assessment of problem and analysis of its causes: quantified
problem; staff involvement; assessment of the cause of problem;
solutions/changes needed to make improvements.
 There is a gap in service provision for cancer patients across Gwent, patients have
stated that they feel in ‘limbo’ following cancer treatments and do not know where to
turn for help.
 Patients have identified that they did not want to become involved with voluntary
palliative care organisations because of the perceived stigma attached to this.
 This has resulting in many patients struggling with unmet needs – either health or
social which are not addressed upon discharge from Secondary Care.
 Staffs have been recruited into four unique roles to investigate the needs of cancer
survivors all of which are currently based within Primary/ Community Sectors.
 The Recovery Package will be implemented across Pilot areas to improve
communication between clinicians and patients resulting in an improvement in the
standards of post treatment care
5. Strategy for change: how the proposed change was implemented;
clear client or staff group described; explain how you disseminated the
results of the analysis and plans for change to the groups involved
with/affected by the planned change; include a timetable for change
 The expectation was that the majority of referrals would be from professionals,
however this has not been the case; therefore the team have invited potentially
suitable patients to use the service. This approach has proven successful with the net
result being the service becoming ‘patient led’.
 Post referral patients are offered a 1:1 consultation during which a Holistic Needs
Assessment is undertaken, patients then prioritise their main areas of concern and a
care plan formulated accordingly. In this way a sense of empowerment is promoted
and a self management approach is fostered with the patient taking the lead.
 The Pilot team act as ‘care co-ordinators’ for patient’s assisting with the facilitation
of sign posting to other services i.e. financial assessment, psychological services or
negotiating direct access back into Secondary Care or the GP if the need arises.
6. Measurement of improvement: details of how the effects of the
planned changes were measured
 This unique study funded by Macmillan is part of a national Pilot encompassing 16
sites across the UK with ABUHB hosting the only site in South Wales.
 There is no data from ABUHB regarding the services for cancer survivors locally as
these roles are in their infancy. However qualitative feedback from patients
highlights;
‘first time anyone’s talked to me about how I feel’
‘ It’s nice to be treated as a person not an illness’
I didn’t know if I was supposed to feel like this and didn’t want to bother the hospital or
GP because they are too busy’
‘ I wish this service had been available to me at the end of my treatment, I really needed
it then’
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7. Effects of changes: statement of the effects of the change; how far
these changes resolve the problem that triggered the work; how this
improved patient/client care; the problems encountered with the process
of changes or with the changes
 Staff have the ability to perform Holistic Needs Assessments to inform the
development of individualised care plans which has resulted in a truly holistic
approach to the needs of patients living with and beyond their cancer.
 There is a direct correlation between the experiences of individuals with other Long
Term Conditions and those with cancer
 Patients have actively self-referred themselves into this service which may indicate
that there is little insight into the needs of this cohort of patients.
 Patient feedback has indicated that the offer of help and support post treatment is
welcomed with some reporting that they wished such a service had been available
when they had completed their treatments.
8. Lessons learnt: statement of lessons learnt from the work; what
would be done differently next time
Macmillan has used its own data collection processes and has developed a patient
questionnaire which is returned directly to Macmillan. It would be beneficial if some of this
patient experience data could be shared at a local level enabling the team to understand ‘what
is working and what isn’t’ much earlier in the project. Therefore the development of a local
patient experience questionnaire in co-production with Macmillan, ABUHB and patients
would be beneficial.
This service is currently being provided over two specific geographical areas within separate
localities in ABUHB, this has been sited by many professionals as a barrier to the Pilot due to
confusion about the eligibility of patients prior to referral. In hindsight one whole locality
should have been included as this would have minimised this risk.
The specific tumour sites covered also limits the overall impact of the Pilot and therefore a
proposal has been made to open the Pilot to cover all tumour sites in 2014.
9. Message for others: statement of the main message you would like
to convey to others, based on the experience described
With the incidence of cancer diagnoses on the increase and some patients experiencing better
outcomes than in the past, the perception of cancer needs to change with health care
professionals using a Long Term Conditions/ Self Management Model to empower patients to
return to the ‘normal’ life that they desire following their cancer treatments.
A short period of rehabilitation/ support following discharge from Secondary Care can have a
huge impact in assisting this cohort of patients to return to a life that is meaningful to both
them and their families.
The NHS Wales Awards are organised by the 1000
Lives Improvement Service in Public Health Wales.
www.1000livesi.wales.nhs.uk
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