Asking for feedback on your work is never easy. When Judith Curtis and her colleague Louise Sadler, specialist nurses in breast care at the Friarage Hospital in Northallerton, Yorkshire, took up the Breakthrough Breast Cancer service pledge, they knew they could be opening themselves up for criticism.
Informal feedback from patients on the breast cancer unit had always been fairly positive, Ms Sadler says. But the nurses wanted to gain a true picture of the service they were delivering – and how to improve it. ‘We are lucky that our patients are really supportive and have always given us verbal feedback,’ Ms Sadler says. ‘But we wanted to find out what we could do better.’
She first saw the potential of the pledge at a conference in 2005. It is a tool devised by Breakthrough Breast Cancer to give patients and nurses the chance to work together to improve breast cancer services, setting out core standards that patients should expect such as timely information and sensitive communication. Each hospital produces its own version, with a copy given to patients on diagnosis to show how the unit is improving its standards of care.
In 2007, the Friarage became a pledge site, one of 16 hospitals in England and Wales. The first step was an external audit by the charity, which investigated all aspects of service and care. One hundred patients were given a questionnaire to fill in and 11 were chosen to be interviewed in depth about their experience of care in the unit.
‘It was quite scary,’ says Ms Sadler, who led the pledge with Ms Curtis. ‘We had no knowledge of what was said until a report was sent to us with the results of the audit.’
When the audit came back, it was complimentary – with a few exceptions. The nurses were asked to choose three aspects of the feedback where the breast cancer unit was not meeting the charity’s standards and develop an action plan to meet them, involving patients throughout.
The nurses chose three targets – patient, unit and community, Ms Curtis says.
The first change aimed to improve patients’ experience before they arrived at the hospital. ‘New patients coming to the rapid diagnostic clinic wanted more information before they even attended,’ Ms Sadler says.
A letter calling women in for tests contained only basic information. Most women did not know what to wear, whether they could bring a friend, make notes or, importantly, that they could be in the diagnostic clinic for four hours.
‘Sometimes patients would get quite worked up because they didn’t realise how long they were going to be there,’ Ms Curtis says. ‘Some had childcare problems or didn’t know how much money to pay for parking.’
The two nurses completely revised the letter. ‘We felt that by giving them as much information as possible it would allay some of their anxiety,’ Ms Sadler says. Preparing patients has calmed them and made life easier for receptionists, Ms Curtis adds.
Second on the list was the appearance of the unit. Patients were unhappy with the dark, windowless rooms. ‘We had one or two quite dreary pictures – a tree in the middle of the wilderness. People said we could do with more cheerful decor,’ Ms Sadler says.
The nurses approached another charity, the Healing Art Foundation, which provided them with colourful artwork and ‘moving pictures’ in the mammogram and ultrasound rooms to give patients something to focus on. ‘It doesn’t take the terror away but it’s helped to soften the clinical feel,’ Ms Curtis says.
By far the biggest challenge was improving outreach. The Friarage covers 1,000 square miles, from Darlington to the central Pennines and the North Yorkshire moors. From some villages in the Dales, there is only one bus per day to the nearest town.
The nurses had been running a successful drop-in clinic one morning a week for 10 years. It was growing in popularity: they had seen 500 patients in a six-month period in 2006, helping with any problem they could – including problems with prostheses and enquiries about genetic treatment.
‘We deal with whatever comes through the door. If we can help them we will; if it’s out of our remit we usually know where to point the patient and who to contact,’ Ms Sadler says.
But the audit raised comments from patients in remote areas saying they needed something closer. ‘If you have children, or you’re elderly or you’ve finished exhausting treatment, the last thing you want to do is get on public transport,’ Ms Curtis says.
So the nurses decided to set up a satellite clinic. Getting the hospital management on board was a struggle. Eventually they found a venue – Catterick Garrison, the biggest army base in Europe, which has its own military hospital and a free bus service to it. After negotiation, the nurses secured two rooms and a waiting room, and use of the reception for free, one morning a month.
‘The drop-in clinic was definitely the most challenging aspect,’ Ms Curtis says. ‘You can’t just go out and set up a service. You have to present a business case to show how valuable it is.’ The outreach clinic has helped keep many out of hospital. ‘It is now generating revenue for the hospital,’ Ms Curtis says. ‘Patient power has moved this.’
Sharon Catterick, 45, is one patient. She was diagnosed with breast cancer three years ago and is still undergoing treatment.
‘The army clinic has been very good,’ she says. ‘Instead of going down to Northallerton it’s five minutes up the road. You don’t have to go every month but it’s there if you need reassuring or a chat.’
When the breast cancer unit first contacted her, Ms Catterick received a standard issue letter. On arriving at the diagnostic clinic, she was given a mammogram, then a biopsy and kept for several hours.
‘You don’t realise what’s going to happen until you get there – it’s a shock. I’m sure more information in the letter would help,’ she says.
The nurses worked closely with Breakthrough Breast Cancer throughout. Having the backing of a large charity was invaluable in overcoming hurdles and gaining the interest of patients, Ms Sadler says. Madeleine Davies, an officer for the charity, was in frequent contact, passing on advice from her experience with other units. ‘She’s given suggestions – with the drop-in clinic she said: “Read this article – they’ve done something similar”,’ Ms Curtis says.
Maggie Alexander, the director of policy and campaigns at Breakthrough Breast Cancer, hopes other hospitals will follow the Friarage’s example in making patient-led change.
‘We want to send a message of support out to specialist nurses,’ she says. ‘Translating rhetoric into meaningful change has been very patchy [across the NHS]. But these hospitals have brought about tangible improvements.’
Ms Alexander says the work of the Friarage nurses pre-empted Lord Darzi’s recommendations around the importance of making local care accessible to patients.
‘This is a really good example of that. It goes to show that specialist nurses given the chance to deliver something appropriately and imaginatively in response to patient need can be very successful,’ she says.
In the autumn, an audit by Breakthrough will update the nurses on how patients feel the unit has improved. ‘At the end of the day, the pledge is a gold standard and that’s what we all want to aspire to,’ Ms Curtis says.
The breakthrough breast cancer service pledge