Into the patient pathway

Macmillan Cancer Support with the National Cancer Survivorship Initiative have developed the concept of health and wellbeing clinics in response to this need.

The clinics provide information and services for patients making the shift from treatment to life after cancer, enabling them to better manage aftercare.

It is envisaged that clinics could replace face-to-face review appointments with a doctor or nurse, while patients continue to receive their surveillance testing in addition to attending a clinic.

Macmillan is working to raise awareness of the clinics’ potential among clinical commissioning groups with a view to CCGs commissioning clinics as part of the services they provide to cancer patients.

The health and wellbeing clinics were piloted in 14 NHS trusts in England, Wales, Scotland and Northern Ireland during 2010-11. Across the 14 pilot sites 87 clinics were held and attended by a total of 764 patients.

One of the trusts which decided to continue clinics based on the positive outcomes for patients and services that were seen under the pilot is the South Eastern Health and Social Care Trust, where work is underway to integrate clinics into the pathway for breast cancer patients. Portsmouth and Barts & the London are two other trusts who are continuing to offer clinics to breast cancer patients.

The South Eastern Trust is simultaneously involved in Northern Ireland’s Transforming Cancer Follow-up Programme which is about developing a new approach to patient follow-up based on risk stratification, and it is hoped that the clinics will play an integral part in this wider process.

It is anticipated that the trust will formally introduce the new risk stratification system this summer. Through a holistic needs assessment conducted six weeks after primary treatment, patients suitable for a self-management approach will be identified and referred to attend the next available health and wellbeing clinic. These patients will be invited to the clinic instead of the traditional review appointment, and will still have their mammography arranged automatically.

The Transforming Cancer Follow-up Programme anticipates that 30 per cent of patients will be risk-stratified into the self-management category and therefore attend a clinic; however this is an initial, conservative estimate and it is likely that the actual proportion will be higher.

The clinics take place in the hospital breast unit and involve a series of presentations followed by opportunities to ask questions, browse stalls manned by local voluntary agencies, and mingle with other patients, families and volunteers over refreshments.

Presentations are given by a surgeon on prognosis and recurrence; radiographer on follow-up mammography; staff grade doctor on side effects of chemotherapy and hormones; and clinical psychologist giving positive messages around goal-setting and looking to the future. There’s also a more general talk on healthy lifestyles covering diet and exercise.

Additional staffing of the clinic is undertaken by a breast care nurse, the information manager and volunteers. Patients are asked to complete a pre-attendance questionnaire relating to physical, psychological and social issues and to identify their top three concerns – of these the fear of recurrence is the stand-out issue for patients, which is why the surgeon’s presentation is an important focus of the clinic.

Both the evaluation of the pilot by the Office for Public Management and the trust’s own ongoing evaluation show that patients find the clinics a highly valuable experience, reassuring them about prognosis and helping address feelings of isolation. Partners of women affected by breast cancer have commented on how eye-opening the clinic has been for them, helping them to understand what their partner is going through and to be better able to support her.

From a clinical perspective, the positive findings from the evaluation have helped to convince senior surgeons and other staff that clinics are a worthwhile use of their time and, importantly, the experience of attending clinics and talking to patients has shown them clearly the benefits and impacts on patients.

From a resources perspective, it is not yet possible to quantify the benefits to the trust in terms of time and cost savings obtainable through patients attending a clinic instead of a review appointment, and through their likely reduction in use of other services such as their GP. However, it is acknowledged that review of breast cancer patients to detect recurrence is not clinically beneficial, and that health and wellbeing clinics can offer a more effective way of addressing the real needs of patients and promoting recovery.

Lucy Smith is a senior researcher at the Office for Public Management lsmith@opm.co.uk