There is a migration of services from the hospital into the community. The enhanced recovery programme and open-access cancer follow-up are just two initiatives that aim to relocate care
Even more treatments could be delivered in the community; in the US, clinics are opening in shopping centres where longer and later opening hours can be offered. To date these have been successful, offering health screening and immunisation, with future plans to help manage long-term conditions.
This trend seems to be being adopted in the UK, as shown by the Clatterbridge Cancer Centre, which has set up a mobile chemotherapy unit in a Tesco car park. With capacity to treat 25 patients a day, the aim is to make the service more accessible. There does seem to be some logic behind these innovations and they provide an insight into the design of services in future.
Some opportunities for more care to be provided in the community are occurring because the methods of drug delivery are changing. For example, a drug used to treat breast cancer, trastuzumab, traditionally given intravenously over 30-90 minutes, will soon be available as a five-minute subcutaneous injection that can be given at home. This illustrates an evolving healthcare system but we must ensure plans are in place to help implement these strategies.
If more care is to be delivered in the community, hospital-based nurses must find a way to arch over both environments or a slick way to hand over to community-based colleagues.
There will also almost certainly also be implications for the family and friends of those undergoing treatment. There is significant stress for all when a family member is having treatment and the vulnerability of carers should be assessed if we want them to support our care pathways. While we assume most relatives would be eager to help care for a relative, there are boundary issues and there needs to be agreement from the patient and relative.
So what of the future? Will this slicker service come at a cost? What if something goes wrong in the home setting - a relative fails to report something, for example? Could a negligence case result? Also, if we are demanding more from carers, will this result in relatives requesting more carers’ leave? The country is in a fragile financial situation and if extra leave is granted on any significant scale, there may be uncertainty as to whether individual businesses can buffer or absorb this.
There are also issues regarding the overall responsibility for the patient - will it still lie with the hospital-based physician who operated on the patient or prescribed the drugs they are receiving, or would the GP become accountable?
The move of treatment to the community seems appropriate, contemporary and inevitable but we must ensure we have robust feedback mechanisms as well as a risk-assessed strategy, investigating implications and consequences. We should also ensure we continue to do the best by our patients and that we do not overburden carers and family members.
Victoria Harmer is team leader/clinical nurse specialist, Breast Care Unit, Imperial College Healthcare Trust.
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