Summary
The Christie is one of the largest single site cancer centres in Europe treating more than 40,000 patients a year. The specialist supportive care team is an expanding service within the Trust, made up of medical and nursing professionals, with a background of pain and palliative care expertise. In addition to pain and palliative care, services include chaplaincy, psycho-oncology, dietetics, physiotherapy and pharmacy. The team’s enhanced supportive care (ESC) model is a new initiative aimed at patients with advancing progressive cancer and extending the excellent care patients receive at the end of life to include the whole continuum of cancer.
Challenge
Due to advances in cancer treatment, there are now an increasing number of patients, at different stages of their illness, who are ‘living with cancer’. They may be actively receiving anticancer therapies (sometimes over many years), or be ‘off treatment’ – either in remission, cured (‘beyond cancer’), or living with advancing disease. Many will require the help of healthcare professionals who have expertise in managing a range of problems, whether these are associated with the cancer itself, or as a consequence of cancer treatment. ESC has developed through recognition of what specialist palliative care can offer, but also from recognition of the barriers to achieving earlier involvement of palliative care expertise within the cancer treatment continuum. These barriers may be largely due to the perception of palliative care by the public, patients and many health professionals – in particular the association with care at the end of life. The excellent care that is provided for patients who are nearing the end of life needs to be extended to support them much earlier on in the pathway.
Objectives
The first objective was to implement five standards derived from national clinical guidelines, including documented evidence that the patient is identified as having advancing progressive disease and that the patient has been considered for entry on to the local supportive care register though GP communication. The second objective was to develop, deliver and evaluate an education programme around advance care planning (ACP) aimed at professionals working within the identified disease groups. The third objective was to undertake patient and carer interviews and questionnaires to measure the impact of ESC on quality of care and experience.
Solution
To implement enhanced supportive care, a change in culture across palliative care teams and cancer clinicians was needed to provide these services at an earlier stage. Among the measures taken were the undertaking of joint consultations and providing proactive support including advice, directing referrals to palliative care clinics and liaison with community services. A one-day training programme was developed and delivered in collaboration with the school of oncology, training a total of 80 staff. We distributed a questionnaire to a randomly-selected sample of 40 patients and 30 carers in each disease group, informing semi-structured interviews which were conducted on a sample of three patients in each disease group. The patient and carer questionnaires were developed from nationally-recognised quality of life tools.
Results
Palliative care in the UK has traditionally focused on care at the end of people’s lives. At the Christie, we have changed that focus, and helped to improve care for patients at a much earlier stage. This has had a direct impact on their care from initial consultation, through to the end of their lives and has been shown to improve symptom control, quality of life and patient and family satisfaction. Our approach has led to more seamless and better coordinated care. It has ensured a person-centred approach, improved symptom control, and has demonstrated a clear potential for cost reductions. There has been significant improvement against each of the five standards across the three disease groups over the three-year project.
Learnings
To fully implement ESC in the context of the changing landscape of cancer, the team is remodelling the service dividing into inpatient and outpatient teams. In addition the aim is to develop a supportive care unit. The SSCT is using a proactive approach to care, underpinned by the ethos ‘predict and prevent’. Early integration of supportive/palliative care into cancer care benefits patients with advanced progressing disease, and promotes better care in the last days of life. ESC creates opportunities for earlier conversations and planning care. ESC has rebranded and re-packaged existing services that support cancer patients, to better suit the changing landscape of cancer care. It has demonstrated improvements in patient experience, increased referrals to supportive care services and potential cost efficiencies.Evaluation
The Trust was keen to validate the impact of ESC by looking at any potential associated cost benefits to support its wider implementation nationally. It found a reduction in patients dying within 30 days of chemotherapy, which suggests less inappropriate chemotherapy was given. There was also a reduction in the overall delivery of chemotherapy treatments and in emergency admissions against the number of referrals received by the disease group. This implied that the facilitation of ACP conversations empowers patients and addressing symptom control issues earlier may have a role in preventing crisis admissions.
