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Care for cancer patients


22 April 2016

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The battle against cancer is unfortunately on-going and the role of GPs and community nurses is invaluable when supporting patients. But there are always opportunities to drive improvements in cancer services

The battle against cancer is unfortunately on-going and the role of GPs and community nurses is invaluable when supporting patients. But there are always opportunities to drive improvements in cancer services

From April 2016 more than half of clinical commissioning groups (CCGs) will take on delegated responsibility for commissioning primary care services from NHS England. This follows the first tranche of CCGs adopting this new way of working in April 2015. NHS England has made it clear that this is the direction of travel for the future.
 While this poses a myriad of challenges, CCGs – whether they have opted for greater involvement or joint commissioning, but particularly for delegated responsibility – now have significant opportunities to drive forward improvements in primary care services as a consequence.

People affected by cancer
For cancer, this is critical. Cancer has historically been seen as a disease that only requires hospital-based care. However, the evidence shows that significant support is provided in primary care, and not just for the obvious need to ensure cancer is diagnosed early. Across the whole cancer pathway, from prevention through to those living with cancer and until the end of life, primary care plays a pivotal role. GPs and their primary care colleagues are often the main point of contact for someone with cancer – involved at key transition points, such as when people move within and between health and care settings or they experience significant changes in their condition.
And the story of cancer is changing. Both incidence and prevalence of cancer is rising; Macmillan’s projections show the cancer population will rise from 2.5 million in 2015 to 4 million by 2030 in the UK, with the number of people living more than five years increasing from 1.6 million to 2.7 million. Many of these people are living with cancer and the long-term consequences of their cancer diagnosis and treatment. In addition, more than two-in-three people with cancer are living with one or more other long-term conditions.  
That is why, a year on since the new primary care commissioning arrangements were first introduced, and as the next wave of 52 CCGs take on delegated responsibility, Macmillan Cancer Support has published the second in its series of top tips guides for commissioners, Improving Cancer Services through Primary Care Commissioning (see Resources). This includes practical suggestions and examples of commissioning levers CCGs have used to drive forward improvements in early diagnosis, supporting people living with and beyond cancer, and at the end of life. It also includes examples and suggestions of how CCGs can facilitate better patient experience and engagement, education around cancer and support for carers in primary care.

The role of commissioning
By driving forward improvements to cancer services in primary care, CCGs can spearhead progress in patient outcomes and experience across the pathway. This should be a key component of local sustainability and transformation plans (STPs), which the 44 footprints are tasked with developing.  NHS England’s Planning Guidance asks the local health and care system to set out “how [they] will deliver a transformation in cancer prevention, diagnosis, treatment and aftercare in line with the cancer taskforce report”.  The Cancer Strategy for England includes 96 recommendations to deliver its six strategic priorities:
1 Prevention and public health.
2 Earlier diagnosis.
3 Patient experience.
4 Living with and beyond cancer.
5 Investing in modern, high quality services.
6 Overhauling processes for commissioning, accountability and provision.
Macmillan is working with some local areas to support their local cancer strategy as part of the STPs process and can offer advice and support for addressing the strategic priorities outlined in the taskforce report.
Through commissioning primary care CCGs have an opportunity to re-evaluate how services for people with cancer are delivered. This could include a focus on cancer priorities in the local primary care strategy; reviewing and revising contracts to focus on identified improvement areas; working closely with primary care colleagues to support them to deliver improvements; using local incentive schemes or local enhanced services and alternatives to the quality and outcomes framework (QOF); and supporting relevant training opportunities for primary care colleagues.

Examples of best practice
A new indicator in the 2016/17 Quality Premium encourages CCGs to drive more diagnoses of cancer at stages one and two. Macmillan’s guide includes examples such as South Tyneside CCG, which is promoting an annual screening reminder and auditing notes of patients diagnosed with cancer who were not put on the two-week wait referral pathway, as well as using a cancer risk assessment tool to help identify at-risk patients.
Primary care has an integral role in supporting people after they have finished their cancer treatment. Many people are left to manage the consequences of cancer, both the physical and psychological, on their own and can rely heavily on primary care. The Nuffield Trust showed that 15 months after diagnosis, cancer patients have 50% more visits to their GP than expected. The top tips guide gives examples of CCGs testing extended follow-up appointments to conduct cancer care reviews. Brighton and Hove CCG has commissioned a local charity to pilot a scheme to support people living with and beyond cancer to access physical activity. Evidence shows that physical activity can help people recover physical function, reduce the risk of cancer recurrence and mortality and reduce the risk of developing other long-term conditions, as well as helping people to maintain their independence and wellbeing.
Supporting people at the end of their life is very important to good patient and carer experience. CCGs can support the use of advance care planning in primary care and should, as appropriate, review their community-based palliative and end of life care services. Examples in Macmillan’s guide of what commissioners are doing in this area include Dudley CCG who used a local incentive scheme to improve the practice Gold Standards Framework register, as there is a strong correlation between this and patients being able to die outside of hospital if they so choose.  
The top tips guide also gives practical suggestions and examples of what commissioners are doing in other areas, for example incentive schemes for GPs and practice nurses to attend cancer training courses; using peer educators to explore issues around patient experience and user involvement; and integrated work across acute trust and primary care to provide early support and access to services for carers.

Beth Capper, commissioning support programme lead at Macmillan Cancer Support.

Resources
Improving Cancer Services through Primary Care Commissioning –
macmillan.org.uk/_images/toptipsforcomissioners improvingcancerservices_tcm9-274367.pdf

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