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Providing cancer care at home

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A trust has set up a pioneering oncology service. Victoria Hoban finds out more.

Today, more and more people in the UK survive cancer due to groundbreaking developments in diagnosis and treatment.

Treatment will typically be given in the acute setting but this is not the experience for many patients at Mid Staffordshire
NHS Foundation Trust.

In December 2006 the trust set up a pioneering outreach oncology service in partnership with Healthcare at Home (HAH), a national company that offers acute medical and medical oncology patients the choice of homecare as an extension to their hospital-based care.

‘One lady had such a difficult time visiting hospital for treatment that she would vomit in the car park. Her two small children had to go and live with their grandparents,’ recalls NHS service development manager for HAH, Sarah Barnhill. ‘She had really been through it and was then told she needed an infusion of anti-virus medication three times a week for a year.’

But instead of continuing to attend hospital, thanks to the outreach service, she was able to have this ongoing treatment in the comfort of her own home, meaning her children could come back and live with her.

The service at the trust has so far administered 630 chemotherapy treatments to patients in their own homes and waiting times on the nurse-led chemotherapy and haematology unit at Stafford Hospital have dropped from three weeks to five days.

‘Cancer is now a more chronic disease and some patients can undergo years of chemotherapy. This has created capacity issues,’ explains Sarah, who is also a former cancer nurse specialist.

‘Trusts are under increasing pressure to provide a new generation of non-cytotoxic drugs that often require long infusions,
and a lot of hospital units are struggling to offer such treatments to several hundred patients at a time.’

The Cancer Reform Strategy, published by the Department of Health last December, states that services must be extended to cope with the increasing numbers of people surviving cancer, and care must be provided in the most suitable environment – which may not necessarily be hospital, says Sarah.

‘There has been a gradual shift of some more continuous treatments away from hospital and into the home. Some patients love to go to hospital as that’s where they feel comfortable. But many don’t want to be confronted by their diagnosis every week. Having treatment at home enables them to get away from that,’ she says.

HAH used to only offer services to patients with private medical insurance but due to a new openness within the health service to working with the independent sector, trusts are now able to buy in HAH’s expertise.

Patients remain under the care of the hospital but receive their treatment in the community from one of the permanent full-time specialist nurses working for HAH. ‘We are not a nursing agency – we operate more like district nurses,’ explains Sarah. ‘Each nurse has a caseload of oncology patients who schedules their care, liaises with consultants over their treatment plans, and administers chemotherapy and other drugs.’

HAH has a central manufacturing unit and dispensing pharmacy with regional refrigeration units where chemotherapy is collected by HAH nurses. Alternatively, trusts can continue to prepare and provide chemotherapy medication themselves, as is the case at Stafford Hospital.

After years of experience, HAH is able to provide around 90 different drug regimens. Their nurses have a minimum of five years’ post-registration experience, undergo a strict three-month competency programme and complete University of Birmingham’s chemotherapy course before unsupervised practice. They then have regular clinical supervision and compulsory training updates.
HAH now provides services for 40 trusts around the UK – and working with the health service has thrown up new challenges. ‘The biggest hurdle is winning the hearts and minds of professionals who have never given treatment in that way,’ says Sarah. ‘Although we have been doing it for years, it is a new concept for most trust staff.’

At Mid Stafffordshire, the service began with a three-year pilot with the trust’s breast cancer and colorectal cancer patients.

‘There were a few sceptics initially but we worked with a few oncologists to gain approval for the pilot,’ says Tracey Beetman, Macmillan lead cancer nurse and matron at the trust’s nurse-led haematology and oncology unit.

Now, however, all oncology patients at the trust who fulfil a certain criteria are offered the option of home treatment. In addition to having a home telephone, and the absence of conditions such as unstable angina, the most vital qualifying factor is patient consent.

‘We offer the option of home care at the pre-assessment clinic,’ says Tracey. ‘Most patients tend to opt for hospital treatment at first but once they know what their treatment is all about, they can swap.’

Safety is paramount in any treatment plan decision, stresses Sarah. ‘Patients might have the first four or five days of their treatment in hospital. We don’t want people having anaphylactic reactions at home.’

About 10 new patients a month now take up the option of home care and patient feedback has been excellent. ‘Some patients have said it literally saved their life,’ says Sarah. ‘When you are faced with a diagnosis of cancer, the first thing that happens is every element of control is taken away from you. This service allows them to get it back.

‘For the nurses, once the infusion is up and running, you can concentrate solely on what the patient is saying. You can see the photos on the mantelpiece and really understand the effect their condition is having on them,’ she adds.

‘One patient was needle-phobic,’ recalls Tracey. ‘Being treated at home meant he could stay out of the way until the last minute, then lie on his chaise-longue, have his treatment and go straight to bed afterwards – something we simply can’t offer at the unit.’

She adds that trust staff have also benefited. ‘It does increase paperwork slightly but the advantages of freeing up capacity is immense.

‘We can see the waiting list come down, which is very rewarding. We are still very busy but are able to run a few more pre-assessment clinics and see more staff access training for new services.’

Similar outreach services are now being set up for haematology and general medical patients. Strong partnership working between the trust and HAH, spearheaded by Tracey and Sarah, has been vital and this has required negotiation and trust building.

Team communication is strengthened by an electronic patient record system, Artemis, whereby HAH nurses send information instantly via a PDA (personal digital assistant) to clinicians or hospital nurses.

‘A few trusts have tried and failed to set up a similar service on their own. An outreach oncology service is not something you can provide by having hospital nurses “popping out” to the community,’ Sarah believes. ‘You need a fully built-up, robust, 24-hour, permanent team.

‘The real strength lies in having partners who can provide a familiar day-by-day service that can change the way cancer patients are treated for the better.’

Providing an outreach oncology service

  • Access the expertise and experience of existing services. Build partnerships gradually, tailoring the service to the needs of the unit and patients

  • Pilot the service first to build trust of colleagues and patients. Use audits to monitor success and ask patients to share their experiences with those considering homecare

  • Ensure continuity of care and patient choice. Develop identical protocols for home and hospital care, prioritising safety and patient choice – homecare may not be right for everyone

  • Maintain accountability. Homecare patients are still under the supervision of the trust. Keep updated on their progress using personal digital assistant (PDA) technology and meet regularly with homecare staff

  • Keep staff training up to date. Make sure that all staff are fully aware of the service and offer training updates for homecare staff on new clinical trials, protocols or drug regimens at
    the trust

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