A WHOLE SYSTEM REDESIGN THE DEVELOPMENT OF CANCER

-A WHOLE SYSTEM REDESIGN THE DEVELOPMENT OF CANCER NAVIGATOR SERVICE & REMODELLING OF CANCER CNS WORKFORCE DIANE DUNN TRUST LEAD CANCER NURSE IMPERIAL COLLEGE HEALTHCARE NHS TRUST

EVIDENCE OF NEED – WHY DID WE NEED TO DO THIS ? Poor patient experience – as highlighted by successive National Cancer Patient Survey results, particularly the ability of patients to contact their CNS time inappropriately taken up with routine admin/non specialist tasks reducing the time and attention available for clinical work and innovation

EXPECTED OUTCOMES To improve patient experience by: Ensuring that patients receive a timely response to their queries and have a positive seamless experience of accessing cancer services, support and information Freeing up CNS time to focus on appropriate patient support, clinical care and innovation

THE CONTEXT Cancer Navigators were developed as part of a Whole System Redesign partnership between Imperial College NHS Healthcare Trust and Macmillan Cancer Support The programme work-streams include: � CNS development � Cancer Navigator Service � Schwartz Rounds � Values Based Standard (VBS) � Living With and Beyond Cancer

WHAT IS THE CANCER NAVIGATOR SERVICE? Macmillan Cancer Navigators is an enhanced phone based service for cancer patients, their family/carers and primary care services The Navigators triage all calls from cancer patients, and using a PRAG system are authorised to action calls or to refer to more appropriate person primarily CNS

DESIGN AND INDUCTION FOR NAVIGATORS To create competent staff and raise the VALUE of the team Orientation and training is essential for each Navigator: � Attendance/observation of MDTS & relevant departments & services � Radiology diagnostics & treatment areas � ensures visualisation of service & increased understanding of service & treatment to reassure patients Ability to book/check appointments � - to enhance understanding of role & function ensures speedy response to patients Instigation of PRAG rated triage assessment sheets * Designed to speciality needs with CNS teams Key manger / leader initiatives Establishment of regular team meeting 1 to 1 s for each team member Monthly ‘Supervision Sessions’ whole team to attend Promotion of service CNS to inform patients about the service remit Navigator information leaflet

Breast Example of PRAG*: Clinical / Symptomatic calls(navigators) PURPLE – Emergency – call 999 RED – bleep CNS: immediate action • Chest pain • Haemorrhaging (bleeding) • Seizures • Breathlessness • Symptomatic issues requiring immediate action, e. g. sudden change in: • Bowel habit • Vomiting • Pain • Swallowing • Leg pain / swelling • Wound issues – fluid retention (seroma) • Neurological deterioration • Alarming immediate frightening symptoms – e. g. loss of sight • Rigors or high temperature • Retention of urine • Psychological issues (patient or carer) • Extreme Distress • Extreme Anxiety • Uncontrollable crying • Extreme aggressive or assertive behaviour AMBER – action to next available CNS telephone clinic • Symptom issues non-urgent will book for CNS clinic next working day or alternatively advise to see their GP. • Carers’ non-urgent call • MDT/other departments internal and external calls requesting CNS input • Phoning with expectation Outpatient (patient received significant news) new diagnosis and recurrence • Patient requesting results or clinical information • Requesting investigations • Family issues GREEN – admin calls or actions from Post MDT • Appointment enquiries • Information needs (excluding clinical issues and symptoms), transport etc. • Benefits issues – signpost • MDT / other departments internal and external. Info only • Prosthesis clinic bookings

NEW WAYS OF DELIVERING SPECIALIST NURSING CARE With an aim to improve patient experience now and in the future by maximizing use of Cancer Nurse Specialist’s knowledge and skills How ? – what was put in place ? � Clear nursing leadership and accountability � Key Performance Indicators for CNS team � Effective MDT working in accordance with SOP � Clear training and career progression � Specialised and focused practitioners � Sustainable working model in place

RESTRUCTURED CANCER CNS TEAM The demands on nurses to effectively work with patients and assure a good patient experience is paramount to the successes of our service provision at ICHT Reorganisation of the Cancer Clinical Nurse Specialist (CNS) team undertaken � unified structure with effective leadership/team leads, opportunity for career progression For CNSs to deliver improved care and services to patients quality contacts with patients was needed. New initiatives developed in: � � � CNS led services and clinics, Holistic Needs Assessment(HNA) undertaken – HNA and information clinics established Open Access Follow Up (OAFU) - reduced OPD attendance in place in Breast, Prostate, LGI and developing in Gynaecology Projects linked to Health and Wellbeing and Living With and Beyond Cancer established Enhanced Recovery /Rehabilitation Service Additionally support for: Schwartz rounds, Health & Wellbeing events and integration with Cancer Recovery packages for patients

EVIDENCE OF IMPACT Improvement in score of National Cancer Patient Experience Survey- most notably a 23% increase in the ability of patients to easily contact their CNS Multiple CNS led innovations including: � Development of nurse-led OPD & telephone clinics across tumour sites � Innovative prehabilitation programmes Nurse-led assessments with introduction of highly specialised treatments � Redesigned patient pathways � Development of Open Access Follow Up

NAVIGATOR CALLS

NCPES : IMPROVEMENT IN CNS RELATED QUESTIONS

NCPES : IMPROVEMENT IN CNS RELATEDQUESTIONS

EXAMPLES OF WIDER IMPACTS: INNOVATIONS, INITIATIVES � � � & IMPROVEMENTS PREPARE for surgery programme: Venetia Wynter-Blyth - Lead CNS, UGI. ‘ Nursing Standard Nurse of the Year’ - 2016 Physical activity Remove bad habits Eat well Psychological wellbeing Ask about medications Respiratory exercises Enhanced recovery The PREPARE programme is a pioneering and innovative quality improvement initiative currently being piloted within Imperial College NHS Trust Oesophago-Gastric (OG) Cancer Service. � PREPARE represents a shift away from the traditional pre-operative assessment and delivers a more holistic and proactive approach to peri-operative management. The programme delivers a personalised, multi-professional programme of support intended to place the patient in the best possible position for their surgery and post-operative recovery � Urology Redesign: Jo Sethi - Lead CNS, Urology � Supporting patients on 2 week wait pathways for suspected cancers, through diagnostics, into follow up alongside supporting patients with benign urology and stone disease. � The one stop service has received excellent feedback from patients who receive investigations and consultations on the same day. The service has been developed and has established multiple Nurse Led Clinics which enhance and improve patient experience and satisfaction. • Nurse led Clinics, and virtual clinics • Open Access Follow Up for prostate Cancer � Hyperthermic Intraoperative Peritoneal Chemotherapy (HIPEC): LGI colorectal CNS-led initiative Development and introduction of HPIEC with pre + post treatment CNS led clinics & support sessions with patients. 1 st centre in London to offer this service.

LEARNING Renewal is central to success On-going communication between navigators and CNS teams particularly is essential e. g. each attending the others team meetings Team Leader to manage the day to day activities Banding is such that there is likely to be a regular turnover of staff as staff seek professional advancement or perhaps face roles Clinical Supervision is critical Review of what does/doesn’t fall in the various role remits is important