Download Colorectal Cancer follow Up

NHS DONCASTER
Local Enhanced Service
Colorectal cancer Follow-up in Primary Care. - DRAFT
1. Introduction
All practices are expected to provide essential and those additional services
they are contracted to provide to all their patients. This service specification is
designed to cover an enhanced service for those patients identified by
secondary care clinicians as suitable for provision of follow up of colorectal
cancer in primary care, which is considered to be beyond the scope of
essential or additional services.
No part of this specification by commission omission or implication redefines
essential or additional services.
This specification intends and expects compliance with relevant Care Quality
Commission Standards as appropriate to the service.
2. Background
The 2010/11 review of cancer follow-up practices across the North Trent
Cancer Network revealed that there was wide variation between localities and
individual clinicians regarding how follow-up was delivered, and in some areas
duplication between surgeons and oncologists occurred. The increasing
volume of patients living with and beyond cancer, and the constraints on
financial and service resources is recognised as a major threat to the
sustainability of traditional routine follow-up services.
A new pathway has been developed by the North Trent Cancer Network for all
patients who are registered with a GP in Doncaster who are being treated with
curative intent for Colorectal and Rectal cancer.
In areas where care is co-ordinated and patients are supported to selfmanage their conditions it has been found that unplanned and emergency
admissions to specialist care have been reduced. Further, it has been shown
that where people are well supported with their condition, the number who can
return to work is increased leading to a positive impact on self-esteem,
finances and contribution to society.
A key component of the local Colorectal and Rectal Cancer pathway re design
is the requirement for exit planning and support for patients being discharged
from specialist care. A holistic needs assessment and associated care plan
will be completed for patients at discharge to primary care. This will be at
year 2 for patients suffering from Colorectal cancer and at year 3 for patients
with Rectal cancer. Patients will be provided with a support pack at discharge
which will include:




A treatment summary
A minimum ongoing support checklist
A summary of their holistic needs assessment
An individualised holistic needs care plan
3. Service Aims
The overall aims of the service specification are to:
Provide a community based follow up service for those patients who suffer
from Colorectal or Rectal cancer who are identified by secondary care
clinicians as suitable for follow up in primary care.
The implementation of this specification will result in the following outcome for
Doncaster patients and the Commissioner:




Care closer to home
Increased patient satisfaction
Reduced travel for patients
A potential to reduce expenditure on secondary care services whilst
maximising the use of primary care.
4. Service Criteria and Delivery
This service is specifically for patients suffering from Colorectal or Rectal
cancer who are being treated with curative intent. The follow up will be for a
period of 5 years after treatment and will include the use of carcinoembryonic
antigen (CEA) as a marker of disease progression.
Exclusions
Patients who have metastatic disease at diagnosis, or develop metastatic
disease during their follow-up are not included in the remit of this service.
Providers will be expected to:
1 Receive referrals from DBHFT of patients who are identified as
appropriate for follow up in primary care in accordance with the
principles outlined in the LES
2 Check that all patients have been referred with the following
information:
 Treatment summary
 Minimum Ongoing Support checklist
 Patients holistic needs assessment and associated care plan
(shared care plan)
3 Establish and monitor appropriate recall systems within the practice to
ensure safe and consistent follow up.
4 For patients suffering from colon cancer providers will:
(i)
arrange and review the CEA blood test at 2½, 3½ and 4½
years after treatment and make a decision whether a
specialist opinion is required based upon to following:
- If the CEA has risen – repeat within one month
- If the CEA consecutively rises 3 times refer the patient back to the
consultant led acute service.
(ii)
arrange and review the CEA blood test and provide a
clinical assessment at 3 and 4 years after treatment.
For patients suffering from rectal cancer providers will:
(i)
arrange and review the CEA blood test 3½ and 4½ years
after treatment and make a decision whether a specialist
opinion is required based upon to following:
- If the CEA has risen – repeat within one month
- If the CEA consecutively rises 3 times refer the patient back to the
consultant led acute service.
(ii)
arrange and review the CEA blood test and provide a
clinical assessment at year 4 after treatment.
5 The clinical assessment will include:
 Review of the CEA blood test results and make a decision
whether a specialist opinion is required based upon to following:
- If the CEA has risen – repeat within one month
- If the CEA consecutively rises 3 times refer the patient back to the
consultant led acute service.
 Review of the:
 Minimum Ongoing Support checklist
 Shared care plan
6 When no scheduled clinical assessment with a GP occurs the practise
will feedback the results of the CEA test to the patient in writing as
soon as the result has been reviewed.
7 Record the outcome of the follow up.
8 The practise will refer the patient back to the consultant led acute
service for colonoscopy at year 5 after treatment.
Accreditation and Training
By signing up to the LES the practice is agreeing for a GP to attend either a
TARGET session or post TARGET "Master class ".
5. Data Collection, Record Keeping

The practice will implement appropriate recall systems within the
practice to ensure safe and consistent monitoring.
6. Performance Management

Practices will complete a dataset for each follow up including as a
minimum: patient NHS number, date of follow up and the outcome of
follow up. The dataset will be provided to the commissioner on a
quarterly basis which can be combined with the claim form.

The practice will also report the following to the commissioner on an
annual basis.
 Activity: total number of patients followed up & number of follow
ups
 Patients referred to secondary care.
7. Payment Mechanism
Per patient follow up fees:


GP follow up appointment
CEA test (only)
£38.26
£16.43
It is acknowledged that some GP practices use acute phlebotomy services
and therefore an amendment will be needed to the LES prices for those
practices.
8. Notice periods
The LES will be subject to annual review and can be cancelled with three
months notice by NHS Doncaster or the contractor.
9. Agreement Term
The term of the agreement is from 1st #### 2012
Schedules
Schedule 1
Colorectal Cancer Follow-Up Pathway
Imaging Follow Up
Clinical Follow Up
Colonoscopy Follow Up
CNS in attendance when histology
given/CNS to see if stoma or other
problems.
HNA assessment tool offered to
patient
2 - 6 weeks
OP appointment
•CEA
Patient
Clinically
Unwell: refer to
consultant team
or MDT
3 or 6 months (depending on
patient need) Nurse Led OP
appointment
•CEA
9 months
CT Scan (abdomen, chest,
Pelvis)
Support Pathway
Completion
Colonoscopy within 6 months
(if not done
pre- operatively )
9 or 12 months (depending on
patient need)
•CEA only
HNA review with CNS
CNS to attend to provide support if
CT shows recurrence
Abnormality management
Abnormal CT:
refer to MDT or
discuss with
consultant team
18 months
Nurse led OP appointment
(depending on patient need)
•CEA only
CEA Rise:
Repeat within 1
month
24 months
CT scan (abdomen, chest, pelvis)
3 consecutive
CEA rises: CT
scan, MRI (if
NAD), ?PET
Colon
24 months
Exit planning and discharge pack
OP appointment
•CEA only
6 monthly – 5 yrs GP led..
Include fast track to Cons
Surgeon.
All Rectal Cancers
To be seen at 3 yrs
Normal CT – HNA form given
and discussed with patient
3 yrs
OP Appointment
*CEA
Abnormal
Colonoscopy:
Refer to
consultant team/
MDT, repeat
colonoscopy
•CEA
GP Led
6 monthly
5 Years
•CEA
Abnormal CT – CNS to attend to
provide support.
HNA form given and discussed
with patient.
5 year colonoscopy
Discharge to colonoscopic
surveillance:
•5 yearly until age 75
Rectal – 37 months HNA form
given
Schedule 2
Colorectal Cancer Follow-Up: Patient Triage
Patient Concerns/Clinical Issues
Pain– Lymphoedema- Symptoms- Prosthesis- Emotional- Psychological- Financial- Support
Patient contacts GP or CNS
(locality decision)
Patient signposted
to appropriate
agencies
Patient self refers to
appropriate Info Support to
address their needs
Triage
Clinical Issue Colorectal/Rectal Cancer
-Refer to relevant clinic or
other agencies
Clinical Issue - Non
Colorectal/Rectal Cancer
-Primary care management
- Onwards referral
Financial
problems:
- Benefits
Advice
Emotional
Problems:
- Support Centre
- GP
Clinical Issue
- GP or
CNS (locality
decision)
Schedule 3
Minimum Ongoing Support Information
Colorectal/Rectal Follow-up
For inclusion:
- Pro-forma checklist
- Treatment summary
- Shared Care Plan
- Information on Late Effects
- Information on Recurrence
- Fast Track Access
- Signposting
- Information on Health & Wellbeing Information about the Next
appointment
Checklist
Has the patient received:
A copy of their Shared Care Plan
Treatment summary
Verbal and Written Information on Late Effects
Verbal and Written Information on Recurrence
Verbal and Written Information on Lymphoedema
Verbal and Written Information on how to gain Fast Track Access
Verbal and Written Information on Health & Wellbeing
Verbal and Written Information about the Next appointment
Information on supportive services
Where to go if need clinical advice or support