Download Treatment Summary user guide and examples

November 2014
Disclaimer
We have made every effort to ensure that the information we have provided is accurate and will help you
introduce the Treatment Summary into the care and support that you provide. Macmillan Cancer Support
cannot accept liability for any inaccuracy in this information or that of third parties, such as the websites to
which we link.
Thanks
This guide, based on work conducted by the National Cancer Survivorship Initiative (NCSI), a collaboration
with Department of Health, NHS Improvement and Macmillan Cancer Support, has been revised and edited
by Macmillan Cancer Support and its General Practitioner Advisers. We acknowledge and thank them for their
work in developing and testing the Treatment Summary, and Tribal Consulting Limited for evaluating the work
of the test sites.
We also thank the Somerset Cancer Register and InfoFlex CIMS for their work in transforming this concept into
an electronic solution and the NCSI who have been key in the development of this work.
Contents
What is a Treatment Summary?
4
When and how is it used?
4
Why was it developed?
4
Summary of evaluation following testing
5
Style and format
5
Using an electronic solution template
5
Treatment Summary templates and guidance
6
Recommended practice for using the Treatment Summary
6
Tips from health professionals using the Treatment Summary
7
The commissioning process
8
Commissioning intentions
8
Service specifications
8
Quality requirements
9
Quality incentive schemes (CQUINS)
11
Local incentive schemes
12
Local tariffs 12
Reporting requirements
12
Appendix 1: Treatment Summary template
Appendix 2: Structured letter template
Appendix 3: Example of a Treatment Summary
Appendix 4: READ codes to be sent with the Treatment Summary
Appendix 5: Screenshot from the Somerset Cancer Register
Appendix 6: Rationale for data fields included in the Treatment Summary
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Resources available for the Recovery Package
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Treatment Summary:
user guide and templates
This user guide has been produced following
testing and evaluation of the Treatment
Summary, to help you implement the Treatment
Summary in your local hospital Trust/service.
This document outlines what a Treatment
Summary is, what its key components are,
what templates should be considered for
implementation, and what the commissioning
process is.
What is a Treatment Summary?
A Treatment Summary (TS) is a document
produced by secondary and tertiary care cancer
teams, usually following treatment for cancer or
at other subsequent trigger points. It is designed
to be shared with the person living with cancer
and their General Practitioner (GP). A Treatment
Summary describes the treatment that a person
has received, its potential side effects, and signs
and symptoms of recurrence. It will also help
inform the GP Cancer Care Review and enable
the GP’s database and records to be kept up
to date. The Treatment Summary forms a key
part of the Recovery Package¹ – a series of key
interventions which, when delivered together,
can greatly improve outcomes for people living
with and beyond cancer.
Treatment Summaries are useful for:
•
GPs and primary care professionals
•
people living with a diagnosis of cancer
•
secondary care clinicians, particularly those
in A&E and those dealing with unplanned
emergency admissions
•
hospices, day centres and care homes, and
•
oncology staff who would benefit from an
at-a-glance summary.
4
When and how is it used?
A Treatment Summary is designed to be
completed by the hospital clinician at the end of
an episode of treatment. This may be following
surgery, chemotherapy, radiotherapy or adjuvant
therapy. It is then shared with the person living
with cancer and sent to their GP. A Treatment
Summary can be sent with the standard clinic
letter or replace it altogether. It may also be
used when there is a referral from secondary
care to palliative care for symptom control or at
other points in the cancer journey, for example,
following treatment for recurrence. A Treatment
Summary includes details that are relevant to
further management and care, for example,
endocrine or other maintenance treatment and
ongoing surveillance.
Treatment Summaries are as much for people
living with cancer as they are for health
professionals, because these documents can
help people understand more about their
condition. They can also use them to share the
information about their treatment with others,
for example, for travel insurance purposes.
Why was it developed?
The Treatment Summary was developed to
improve communication between primary and
secondary care professionals working with
people living with cancer. It was also conceived
to help GPs update their records and databases
and provide better support for people living with
cancer.
Following a scoping exercise in 2010, GPs
reported that they were receiving lots of
information from secondary care, but they were
lacking a simple summary of their patient’s
Treatment summary: user guide and templates
cancer diagnosis, treatment and ongoing
management plan.
Discharge and clinic letters were often missing
key information in a format that allowed people
to self manage or be fully managed effectively
in the community. This resulted in unnecessary
delays and referrals back to secondary care.
In 2009, a group of Macmillan GP Advisers
identified information that would be helpful
for primary care following treatment and the
Treatment Summary template was designed to
capture this information.
Summary of evaluation
following testing
The Treatment Summary was tested in
secondary care communities across several
tumour groups. It was evaluated through
surveys, telephone interviews and face-to-face
meetings with more than 50 clinicians. An
updated version for wider use was developed
based on feedback and subsequently used in
test sites in 2011 and 2012.
The Treatment Summary has been positively
received in both primary and secondary care.
Eight out of 10 GPs found it useful or very
useful. More than half felt it would make a
difference to the way they managed people
living with a cancer diagnosis and nine out of
10 wanted to see its use continued. The majority
of hospital clinicians recognised the value of
summarising what could be months of treatment
and holistic care into one concise summary.
One clinician said, ‘it made us document and
communicate better’, while another reported
that it was, ‘excellent to be able to access all the
relevant data quickly in a short document’.
People living with cancer found the Treatment
Summary useful because it kept all the
necessary information in one place. Their
Treatment Summary allowed them to share their
information with family members or carers.
They also found it useful if they were admitted
to hospital in an emergency, if they found
themselves in a different hospital or hospice, or
if they were applying for travel insurance.
Style and format
There are three different formats for
the Treatment Summary. Clinicians and
administrative staff can choose the template that
best suits their local practice. The options are:
•
a standard Treatment Summary template
•
a structured letter template, and
•
electronic solutions.
The templates can be adapted to suit local
community or IT systems as long as the
document follows the rationale in Appendix 6.
Using an electronic template
An electronic template can be automatically
populated from the Cancer Information Systems
(CIS) provided by the Somerset Cancer Register
and InfoFlex CIMS Ltd. It can then be added
to the electronic patient record (EPR), making it
quicker and easier for a clinician to complete
following treatment. The template can also be
built into local systems. For further information,
please contact your CIS provider or your local IT
provider.
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Treatment summary: user guide and templates
Treatment Summary templates and
guidance
Recommended practice for using the
Treatment Summary
•
Appendix 1: the standard Treatment
Summary template.
•
•
Appendix 2: the same information in a
structured letter template.
All sections of the Treatment Summary
should be completed, with one copy offered
to the patient and another sent to the GP.
This should happen promptly following any
treatment for cancer.
•
Appendix 3: a completed example template
with prompt notes.
•
•
Appendix 4: GP READ codes to be sent with
a Treatment Summary.
Treatment Summary updates should be
generated at key points, eg following
recurrence, further treatment or transition to
end of life care.
•
Appendix 5: an example screenshot from
the Somerset Cancer Register.
•
•
Appendix 6: a user guide with rationale for
why data has been included. This shows
which fields are essential and which are
desirable (this information is important
if the form is going to be redesigned for
local use).
The Treatment Summary should be used
alongside a Holistic Needs Assessment
and care plan as it will not capture the
same detailed information as the needs
assessment.
•
All members of the multidisciplinary team
involved in a person’s care should have the
opportunity to contribute to their Treatment
Summary.
•
The GP can enter the details onto the
patient’s primary care medical records or
their database and use the information to
inform the Cancer Care Review.
•
If recommended, the GP will make sure
the person is entered onto an appropriate
monitoring or screening programme
and review surveillance systems, eg for
osteoporosis.
The templates were tested in a variety of ways:
•
The majority used the formatted template
provided (Appendix 1).
•
Some used the structured letter template
to make it easier for secretarial staff to
complete from dictation (Appendix 2).
•
Some sent the Treatment Summary
electronically to GPs, while others printed
and posted it.
•
One consultant used the electronic
Treatment Summary instead of routine clinic
letters at all appointments and gave the
patient a copy when they left the clinic.
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Treatment summary: user guide and templates
Tips from health professionals using
the Treatment Summary
•
Involve administrative staff early on when
changing to the Treatment Summary system
and encourage them to suggest the best
ways of implementing it locally.
•
Make sure all members of the medical
records department are familiar with the
Treatment Summary and know where it
should be filed in the medical records.
This will prevent any Treatment Summaries
from being filed in the wrong place or
inappropriately removed from the medical
records.
•
•
If the Treatment Summary template
is redesigned to fit with other hospital
documents, check that data inclusions or
fields are not removed as they may be
useful to other people (see the rationale for
data fields in Appendix 6).
Think about providing a prompt list
for clinicians to use as they dictate the
information for the Treatment Summary
in clinic.
•
Consider creating a template letter with
headings to make it easier to fill in.
•
Get into the habit of completing a
Treatment Summary at the end of an
episode of treatment. Add a reference in the
clinic notes that you have completed it and
file a copy in the medical records.
•
Provide the standard GP READ codes
attached to whichever Treatment Summary
format has been used or issued to GP
practices separately.
•
Test the system with a few clinicians then
review and amend the process if necessary
before its full implementation.
•
Attach the template or prompt list to the
front of the case notes before a person
is seen in the clinic to help encourage its
completion.
•
Pre-populate the entries wherever possible
(either electronically or by hand), eg the
common signs and symptoms of recurrence
and treatment toxicities. Different tumour
groups may require different pre-populated
entries.
•
Consider creating a separate list of signs
and symptoms and key contacts for complex
tumour groups to cut and paste from.
•
If the Treatment Summary template is set
up on a local electronic database, it may
be possible to add common side effects,
signs and symptoms of recurrence and
medications as drop-down menus or
electronic versions.
•
Use the Treatment Summaries available
on InfoFlex CIMS or the Somerset Cancer
Register where possible, as these will
self-populate much of the detail from the
multidisciplinary team meetings.
•
Share testing and experiences with
colleagues in order to encourage more
people to use the Treatment Summary.
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Treatment summary: user guide and templates
The commissioning process
Service specifications
The inclusion of Treatment Summaries in
NHS contracts
This is where commissioners document
the service they expect to commission. The
development of this document should involve
a collaborative approach between the CCG
and the provider to define the expectations of
the service.
The inclusion of Treatment Summaries in NHS
contracts could occur through a number of
different levers.
The publication Living with and beyond cancer:
Taking action to improve outcomes1 promotes the
importance of increasing the number of people
with a care plan and a Treatment Summary.
In terms of the NHS Outcomes Framework
2014/20152, Treatment Summary
implementation would form part of Domain 2:
Enhancing the quality of life of people with longterm conditions.
Commissioning intentions
Commissioning intentions represent the means
to communicate the intentions of clinical
commissioning groups (CCGs) for the following
year. They set out how things will be different
and what the impact on providers will be. The
commissioning intentions process ensures that
resources are focused on realising the CCGs’
mission and goals.
Service specifications can be developed to
describe services in different ways. This may
be by care pathway, by individual service or by
individual service user. Where agreed pathways
(such as use of the Treatment Summary) need
to be captured within the contract, a service
specification can be used to identify this
expectation.
A service specification provides a brief
description of the services being commissioned
and will include information on:
•
the population’s needs
•
the scope of the service to be provided
•
appropriate national and local clinical
standards, such as NICE care pathways,
and
•
key service outcomes, eg the expectation
that all patients will receive a Treatment
Summary.
An example of the inclusion of Treatment
Summaries in commissioning intentions could
be, ‘All newly diagnosed cancer patients will
receive a Treatment Summary.’
1 National Cancer Survivorship Initiative (2013) Living with and beyond cancer:
Taking action to improve outcomes.
2 Department of Health (2013) NHS Outcomes Framework 2014/2015.
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Treatment summary: user guide and templates
Quality requirements
Included in the quality requirements will be the:
Within the contract document there is a section
on quality requirements where commissioners
will include quality indicators that would be
expected to be achieved. It is best to work
this up collaboratively with the provider, and
potentially include financial rewards or penalties.
•
quality indicator
•
threshold
•
method of measurement, and
•
consequences of non-achievement.
An example for Treatment Summaries is shown below in Table 1.
Quality requirement
Implementation of
Treatment Summaries
by March 2015
Threshold
Method of
measurement
50% of patients to have Measurement is by the
a Treatment Summary number of new patients
receiving first treatment
within the quarter, as
50% of all new patients
reported by the cancer
to have a Treatment
waiting times, who
Summary provided
have had a Treatment
Summary
Consequences of
breach
Action plan produced
by providers with risks
and risk mitigation
identified
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Treatment summary: user guide and templates
Service development and improvement plans
The service development and improvement plan
(SDIP) is a mandated plan that is closely aligned
to local CCG commissioning plans. These plans
may be included in the contract, and the best
improvement plans include actions for both the
provider and the CCG. In the case of Treatment
Summaries, this might include a commitment
to educate GPs about the Treatment Summary
and the Cancer Care Review, as well as a
requirement that the provider implements the
Treatment Summary rollout for all tumour sites.
SDIPs can be used to support implementation of
Treatment Summaries.
An example of a SDIP to support Treatment
Summary implementation is illustrated below
in Table 2. Actions are often divided in the four
quarters of the financial year where Quarter 1
(Q1) is April to June, Quarter 2 (Q2) is July
to September, Quarter 3 (Q3) is October to
December and Quarter 4 (Q4) is January
to March.
Table 2: An example of a service development and improvement plan for
Treatment Summaries
Clinical area
Actions
Timescales
Benefits
Cancer: Work in
collaboration with the
CCG and strategic
clinical network
colleagues to be
an early adopter of
cancer Treatment
Summary initiative
Actively contribute
to strategic clinical
network activity
By end of Q1
Create local awareness
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Work with the CCG
By end of Q2
and cancer network
leads on developing an
implementation plan
for commencement
in Quarter 3 based
on outputs from
network events
Rollout cancer
Treatment Summaries
for three tumour
types, ie skin, lung
and bladder
Commencement date
Work with
commissioners in
developing a rollout
implementation
plan for all cancer
specialities.
By end of Q4
Enhanced experience
of cancer survival
for patients
Better communication
with GPs and
primary care
Learning through
implementation
and developing
sustainability measures
Early implementer
status and reputational
benefit for Trust
Treatment summary: user guide and templates
Quality incentive schemes (CQUINS)
Table 3: An example of a Treatment Summary CQUIN
Milestones
Rules for achievement of
Date milestones Example milestone
milestone including evidence
to be reported weighting (% of CQUIN
to be supplied to commissioner
scheme available)
Quarter 1
Develop local project plan
for the implementation of
Treatment Summaries
By mid date
0.45%
Quarter 2
25% of eligible patients with
colorectal and breast cancer will
be supplied with a Treatment
Summary, as will their GP
By mid date
0.45%
Quarter 3
50% of patients with colorectal
By mid-date
and breast cancer will be supplied
with a Treatment Summary, as will
their GP
0.45%
Quarter 4
75% of patients with colorectal
By mid date
and breast cancer will be supplied
with a Treatment Summary, as will
their GP
0.45%
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Treatment summary: user guide and templates
Local incentive schemes
There is also a section for local incentive
schemes that create additional risk-share
agreements for other improvements which
don’t fit anywhere else in the contract. They
might include all-or-nothing incentives between
providers that specify they have to work together
on something to gain any financial benefits.
Local tariffs
This is where you can develop innovative ways
of paying for services which do not fit under
national definitions. A good example of this
would be non-face-to-face consultations where
a Holisitic Needs Assessment is completed, eg
over the phone. These may be conducted by a
Clinical Nurse Specialist or a Band 4 care coordinator, rather than being charged the normal
price for a consultant follow up.
Reporting requirements
This is where the CCG may stipulate that
they want specific regular reports from the
providers that help inform their commissioning
but do not have a specific target attached to
them. For cancer, that might mean an activity
report around numbers of patients on remote
monitoring by CCG or a regular action plan
shared off the back of peer review and patient
experience surveys.
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To find out more about the
Treatment Summary, please email
[email protected]
Treatment summary: user guide and templates
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Appendix 1: Treatment Summary
template
<Insert GP’s contact details> <Insert Trust logo>
<Address>
Dear Dr <insert GP’s name>
Re: <insert patient name, address, date of birth and record number>
Your patient has had the following diagnosis and treatment for cancer and received a summary and ongoing
management plan as outlined below. They have been offered/received a copy of this summary.
Diagnosis:
Date of diagnosis:
Organ/Staging:
Local/Distant:
Summary of treatment and relevant dates:
Treatment aim:
Possible treatment toxicities and/or late effects:
Advise entry onto primary care palliative or
supportive care register:
Yes/No
DS 1500 application completed:
Yes/No
Prescription charge exemption arranged:
Yes/No
Alert symptoms that require referral back to specialist team:
Contacts for re-referrals or queries:
In hours:
Out of hours:
Secondary care ongoing management plan:
(tests, appointments etc)
Other service referrals made: (delete or add)
District nurse
AHP
Social worker
Dietician
Clinical Nurse Specialist
Psychologist
Benefits/Advice service
Other
Recommended GP actions in addition to GP Cancer Care Review: (e.g. ongoing medication, osteoporosis and
cardiac screening)
Summary of information given to the patient about their cancer and future progress:
Additional information, including issues relating to lifestyle and support needs:
Completing clinician:
Signature:
Date:
Please take this document with you to your GP practice appointment where your diagnosis and cancer care will be
reviewed with you.
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Treatment summary: user guide and templates
Appendix 2: Suggested structured letter
template (refer to rationale in appendix 6)
Date: <insert date>
Dear Dr <insert GP’s name>
Re: <insert patient’s name>
Your patient has had the following diagnosis and treatment for cancer and received a summary and ongoing management
plan as outlined below. They have been offered/received a copy of this summary.
Diagnosis:
Date of diagnosis:
Staging:
Summary of treatment and relevant dates:
Treatment aim:
Possible treatment toxicities and/or late effects:
Alert symptoms that require referral back to specialist team:
Secondary care ongoing management plan: (tests, appointments)
Recommended GP actions: (e.g. medication, osteoporosis/cardiac screening)
Summary of information given to the person living with cancer:
Additional information including issues related to lifestyle, physical activity and support:
Advise entry onto primary care palliative or supportive care register: (Yes/No)
DS1500 application completed: (Yes/No/N/A)
Prescription charge exemption arranged: (Yes/No)
Contact for re-referral or any queries:
In hours:
Out of hours:
Yours sincerely
<insert clinician’s signature>
<Insert clinician’s name>
CC: <Insert patient name>
Please take this document with you to your GP practice appointment where your diagnosis and cancer care will be reviewed
with you.
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Appendix 3: Completed Treatment
Summary example
Dear Dr Jones
Re: John Smith, 3 Park Road, Doncaster DN4 DEF DoB: 10.10.10 NHS No: 123456
Your patient has had the following diagnosis and treatment for cancer and received a summary and ongoing
management plan as outlined below. They have been offered/received a copy of this summary.
Diagnosis:
Date of diagnosis:
Organ/Staging: Dukes T2
Colorectal cancer
10.02.10
Local/Distant: No
Summary of treatment and relevant dates:
Treatment aim:
Surgery – Resection (March 10) and reversal of stoma (Sept 10)
Radiotherapy – May–June 2010
Curative
Possible treatment toxicities and/or late effects:
Advise entry onto primary care palliative or
supportive care register: No
Diarrhoea following pelvic radiotherapy
DS 1500 application completed: No
Prescription charge exemption arranged: Yes
Alert symptoms that require referral back to specialist team: Contacts for re-referrals or queries:
• Diarrhoea for more than two weeks not relieved by loperamide/
In hours: 01234 567890 (CNS team)
codeine
• Blood or mucus per rectum
Out of hours: 01234 987654 (oncology ward)
• Further change in bowel function
• Abdominal pain that persists for longer than four weeks and
does not respond to simple analgesia
Secondary care ongoing management plan:
(tests, appointments etc)
•
•
•
•
Referrals made to other services:
Next OP Review – Jan 2011
CEA next due in Jan 2011 then annually until 2015
CT scan (abdo and chest) next due Sept 2011
Colonoscopy repeat next due Sept 2015
Community dietician
Benefits/Advice service
Recommended GP actions in addition to GP Cancer Care Review: (e.g. ongoing medication, osteoporosis and
cardiac screening)
Please review dose of XXXXX in two months if symptoms of XXXX resolved reduce to 4mg daily
Summary of information to the patient and/or their carer:
John Smith and his wife have been informed that the cancer in his colon was non-invasive and that he has received
surgery and radiotherapy with curative intent. He is aware however that it may recur in the future and we have briefly
discussed the further treatment available should this be required. He is fully aware of the symptoms of recurrence and what
to do should any occur.
Additional information relating to lifestyle and support needs:
I have advised him to quit smoking and referred to smoking cessation clinic.
He is keen to join local colorectal support group and plans to attend next session in November.
Completing clinician: Charles Goodenough
Signature:
Date: 30.10.10
Please take this document with you to your GP practice appointment where your diagnosis and cancer care will be
reviewed with you.
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Appendix 4: GP read codes for
common cancers (For GP use only)
Please include with the Treatment Summary to the GP. Note: This is an aide memoir for common cancer related
codes, not all will apply to this patient. Other GP READ codes are available if required. (Note: the codes are case
and symbol sensitive so always ensure codes are transcribed exactly as below)
Systmone
(5 digit codes)
Treatment
All other systems
Version 3 five byte codes
Treatment
Palliative radiotherapy
5149.
Radiotherapy tumour
palliation
5149.
Curative radiotherapy
XalpH
Radiotherapy
7M371
Chemotherapy
x71bL
Chemotherapy
8BAD.
Radiotherapy
Xa8S1
Treatment aim
Treatment aim
Curative procedure
Xallm
Curative treatment
8BJ0.
Palliative procedure
XaiL3
Palliative treatment
8BJ1.
Actions recommended to
the GP:
Actions recommended to
the GP
Tumour marker monitoring
Xalqg
Tumour marker monitoring
8A9..
PSA
Xalqh
PSA
43Z2.
Osteoporosis monitoring
XalSd
Osteoporosis monitoring
66a..
Referral for specialist opinion Xalst
Advised to apply for free
prescriptions
9D05
Entitled to free prescription
6616.
Cancer Care Review
Xalyc
Cancer Care Review
8BAV.
Palliative Care Review
XalG1
Palliative Care Plan Review
8CM3.
Information to patient:
Information to patient:
DS1500 form claim
XaCDx
DS1500 completed
9EB5.
Benefits counselling
6743.
Benefits counselling
6743.
Cancer information offered
XalmL
Cancer information offered
677H.
Cancer diagnosis discussed
XalpL
Cancer diagnosis discussed
8CL0.
Aware of diagnosis
XaQly
Unaware of prognosis
XaVzE
Carer aware of diagnosis
XaVzA
Miscellaneous:
On GSF Palliative Care
Framework
XaJv2
On GSF Palliative Care
Framework
8CM1.
GP OOH service notified
Xaltp
GP OOH service notified
9e0..
Carers details
9180.
Carers details
9180.
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Appendix 5: Screenshot from
Somerset Cancer Register
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Appendix 6: Rationale for data fields
included in the Treatment Summary
Field
Why include this?
Essential (E) or
Desirable (D)
Diagnosis
• Important for the GP and patient to know the type and location of
cancer and the likely source of secondary recurrence.
E
Organ staging/local or
distant spread (grade)
• Information about staging and spread provides insight into prognosis
and risk of recurrence.
D
Date of diagnosis
• Shows how long the person has known their diagnosis.
• Shows the time period between referral from primary care and
diagnosis – helps identify where delays can be minimised in future.
• Important data for monitoring treatment outcomes in relation to
survivorship.
• Helps plan the date of a GP Cancer Care Review.
E
Summary of treatment
and relevant dates
• To understand the range and order of treatment/s and the likely
sequence of treatment effects.
• Essential to inform future treatment choice if further disease occurs.
• Important information for people wishing to take out insurance or a
mortgage.
E
Treatment aim
• Shows whether treatment intended is curative, palliative or for symptom
relief – helping the GP understand the aims of treatment and to refer
back to secondary care or other services appropriately.
• Supports the GP to anticipate future care needs.
E
Possible treatment
toxicities and/or late
effects of treatment
• People undergoing some cancer treatments may be more prone to
toxicity and late effects of treatment such as osteoporosis or heart
disease. Including risks here will help ensure the patient is entered onto
appropriate ongoing surveillance programmes by the GP practice (see
Quality Outcome Framework (QOF).
• Signs and symptoms addressed earlier may improve quality of life
and treatment outcomes from side effects or late consequences of
treatment.
• Suggested or preferred treatment associated with toxicities and late
effects can be initiated without the patient needing to be referred back
to the specialist.
• Raises awareness of common late effects and reduces delays to further
investigation and treatment. This may also impact on survival rates as
symptoms are picked up sooner.
E
Advise entry onto
palliative or supportive
care register
• Including the patient on the palliative care register ensures that the out
of hours (OOH) teams are made aware that a patient is nearing end of
life, and they and their carers may need more support.
• The register is shared with all relevant OOH doctors, as well as
staff from the ambulance service, community district nursing teams,
Macmillan support team, social care and hospice, as appropriate.
Patients can then receive the support, information and benefits they
need.
E
Key contact in hours for
advice and re-access
• To ensure the person living with a cancer diagnosis, GPs and primary
care team know who and when to contact should they have queries or
concerns.
• The contact should be able to triage enquiries and initiate action.
E
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Treatment summary: user guide and templates
DS 1500 status (benefit
that a patient can claim
at the last six months of
life)
• If a DS 1500 hasn’t already been completed, this will prompt the GP to
arrange this.
Prescription exemption
• If a prescription exemption hasn’t been completed, this will prompt
the GP to arrange one. All cancer patients are entitled to have their
prescription charges waived for any cancer treatment or drug they
need.
E
Alert symptoms that
require referral back to
specialist team
• This should only include the symptoms where immediate re-referral
to a secondary care specialist is required (e.g. acute breathlessness
requiring a pleural tap) not the expected side effects of treatment that
can be managed by the GP or community team.
• People living with cancer will have a better understanding of the
symptoms that they should be concerned about and that should prompt
them to contact the specialist team.
E
Contact for re-referrals
or queries in and out of
hours
• Confirms contact details for the patient or GP for advice on care or
treatment or to arrange an urgent review. The OOH contact could be a
ward, the acute oncology team or the relevant on call team.
E
Secondary care ongoing
management plan
• Include any planned outpatient reviews and surveillance tests dates
(or approximate timescales) – this provides a framework for GPs. If
indicated here, further tests can be scheduled before the outpatient
visits.
• People living with cancer will be better informed about follow up plans
and what to expect.
• It is reassuring for people living with cancer to see the planned care,
surveillance and support – then they know what to expect and when.
E
Referrals to other services • Helps avoid duplication of referral if the patient visits the GP between
appointments and is unsure of who is involved in their care.
• Particularly useful with social care referrals and when the person is
known to other agencies.
• Can help to reinforce the importance of attending appointments with
other agencies.
• Useful to also include details related to third sector support and centres
such as a Maggie’s Cancer Caring Centre, if available.
D
Recommended GP
actions including
medication etc
E
20
• To provide clarity about expectations in terms of the person’s ongoing
care and how they can support them.
• Provides prompts, e.g. to add the patient to routine screening
programmes to help mitigate late effects of treatment.
• The person living with cancer will be more empowered to approach the
GP if they need further advice and support.
• A specific request can be given to the GP to ensure continuity of care
and avoid ambiguity.
• Provides the GP with guidance and advice on which drugs, if any, need
stopping and when. Also whether any adjustment is needed between
follow up appointments or following discharge.
• May avoid inappropriate prescriptions, overdose or misuse. Particularly
important if the GP is going to continue to prescribe long term, ie
endocrine manipulation.
• People living with cancer will also know what to expect from their GP.
Treatment summary: user guide and templates
Cancer Care Register
• This reminder helps ensure the patient is entered onto the register
and that they are formally reviewed by the GP within six months of
diagnosis. This is a requirement for the QOF for all general practices.
D
Summary of information
provided to patient on
diagnosis and prognosis
• Sharing information on what has been discussed with the patient and
their carer, and any written information provided, improves the quality
and openness of the discussion that the GP can have with people living
with cancer.
E
Additional information to
people living with cancer
• Confirms which lifestyle information and advice has been given
or signposted to, including details of local support groups and
psychosocial support, complementary therapies, returning to work
advice etc.
D
READ Codes
• It is the GP’s responsibility to assign the appropriate codes and enter
them on their systems. GP READ codes are similar to hospital HRG
codes and are used to identify diagnosis, tests and treatments. Both are
complex systems and must be input manually.
• Including the READ codes in the TS prompts and encourages GPs
to accurately code patients. This helps improve safety in terms of
surveillance, disease tracking and audit.
• Please note: Codes may differ depending on the GP IT system used.
D
Include a copy of the
READ codes with the
TS. You may chose to
send local GP practices
a laminated copy of the
READ Codes in advance
to save sending each
time.
21
Useful resources for the
Recovery Package
Treatment Summary – Mac Voice sharing
good practice
A tool to improve communication between
cancer services and primary care. This guide
to the Treatment Summary outlines why
it is important and how it improves care.
be.macmillan.org.uk
(Order code: MAC14582)
The Recovery Package – Mac Voice sharing
good practice
The Recovery Package is a series of key
interventions which, when delivered together,
can greatly improve outcomes for people living
with and beyond cancer. This document outlines
the interventions, the evidence and how it
improves care.
be.macmillan.org.uk
(Order code: MAC5772_0614_SGP)
Assessment and care planning for people
with cancer
This booklet for patients outlines the process of
assessment and care planning, what to expect
and what they can prepare for.
be.macmillan.org.uk
(Order code: MAC12957)
Assessment and care planning folder
This pack contains two triplicate pads for the
assessment and the care plan, sufficient for
100 assessments. This enables the user to
give a copy to the patient, a copy to the GP
or audit, and place a copy in the medical
records. Replacement pads are also available.
be.macmillan.org.uk
(Order code: MAC13689)
22
The Macmillan Organiser
The Macmillan Organiser is designed for
the patient to help them keep track of their
treatment, make notes, and find the information
and support they may need. It enables people
to record useful information to help them self
manage and contains useful assessment tools
such as the concerns checklist and mood and
food diaries.
be.macmillan.org.uk
(Order code: MAC13281)
What to do after cancer treatment ends:
10 top tips
This leaflet helps patients get the support they
need to lead as healthy and active a life as
possible following cancer treatment.
be.macmillan.org.uk
(Order code: MAC13615)
After cancer treatment: a guide for
professionals
This short guide is intended to accompany the
Macmillan booklet What to do after cancer
treatments ends: 10 top tips. It explains why
each of the 10 patient tips is important and
provides practical ideas and suggestions for how
healthcare professionals can support patients in
their recovery from cancer.
be.macmillan.org.uk
(Order code: MAC14302)
Physical activity and cancer treatment
This booklet is written for people living with or
after cancer who want to know more about the
benefits of being physically active. It includes
practical advice and useful organisations.
be.macmillan.org.uk
(Order code: MAC12515)
Treatment summary: user guide and templates
Get active, feel good exercise DVD
In this exercise to music DVD, cancer and fitness
expert Dr Anna Campbell, guides you through
three exercise plans to complete at home.
A booklet comes complete with the DVD.
be.macmillan.org.uk
(Order code: MAC14016)
To find out more about the
Recovery Package, please visit
macmillan.org.uk/recoverypackage
or email the team at
[email protected]
Health and Wellbeing clinics
This booklet provides a guide to Health and
Wellbeing clinics for health professionals and
includes case studies from pilot sites.
be.macmillan.org.uk
(Order code: MAC13349)
Work Support Route Guide English Version
A signposting resource for health and social care
professionals. It supports them in guiding people
living with cancer who are in employment, on
long-term sick leave, self-employed or out of
work and want to discuss work options.
be.macmillan.org.uk
(Order code: MAC13538_ENG. Celtic nation
versions also available.)
Video content
We have produced a selection of videos about
the Recovery Package, all of which you can
find on our YouTube channel. These cover the
following subjects:
• The Treatment Summary
• Electronic Holistic Needs Assessment
• Holistic Needs Assessment and Care
Planning
•
Training for Holistic Needs Assessment and
Care Planning
23
When someone has cancer, they don’t just worry about
what will happen to their body, they worry about what will
happen to their life. At Macmillan, we know how a cancer
diagnosis can affect everything and we’re here to support
people through.
From help with money worries and advice about work, to
someone who’ll listen if someone just wants to talk, we’ll be
there. We’ll help people make the choices they need to take
back control, so they can start to feel like themselves again.
No one should face cancer alone. For support,
information or a chat, call us free on 0808 808 00 00
(Monday to Friday, 9am–8pm) or visit macmillan.org.uk
Macmillan Cancer Support, registered charity in England and Wales (261017),
Scotland (SC039907) and the Isle of Man (604). MAC13894_1014
Printed using sustainable material. Please recycle.