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People with upper gastrointestinal (GI) cancer at Bradford Hospitals have traditionally been seen in busy surgical and gastroenterology clinics for diagnosis and follow-up. Patients were waiting for unacceptable lengths of time and the consultation time was inadequate. The clinical nurse specialists were covering four surgical clinics, gastroenterology clinics and oncology clinics each week, and were finding it impossible to provide an equitable service for all patients.
The consultations felt rushed, with little time for a holistic needs assessment.
In August 2010, the upper GI nursing and dietetic team introduced a new follow-up service to improve this situation. As part of the new service, patients are seen in a nurse and dietetic-led clinic for diagnosis, investigation results and for follow-up after treatment. This provides an opportunity to offer ongoing holistic needs assessment at key points along the care pathway.
The new approach has allowed the team to work as independent, autonomous practitioners, which has increased motivation and created an opportunity to extend our skill base.
The majority of the multidisciplinary team responded positively to the proposal and support was gained from the team’s general manager and lead clinician. There were concerns around changing current practice, so it was agreed that the service would be piloted for six-months.
Careful assessment procedures are adhered to and patients are referred to the consultant as appropriate. Assessment tools are used as a guide for symptom management and medical support is sought in complex or unclear circumstances. The medical team may be contacted when the nurse-led consultations take place or shortly afterwards. Therefore, support from the team has been essential. The nursing team have also trained to become non-medical prescribers to ensure a streamlined service for patients.
A protocol for requesting x-ray images was developed and the team are about to embark on IRMER (radiation protection) training to ensure there are no delays in patient care.
To ensure the sustainability of the service, a competency framework for any new appointments to the nursing team was developed. The following was also needed for the proposal:
- availability of clinic rooms for two clinical nurse specialists and one specialist dietitian
- clinical support
- administrative support (existing)
- clinician time if advice is required.
The team evaluated the service after six months and both the patients and clinicians responded favourably. All patients (100) who had attended the clinic and the three surgical consultants were sent an evaluation questionnaire (excluding duplicates and those deceased).
The patients and clinicians were asked to return the questionnaires to the clinical governance support officer who collated the results. The team received 89 responses from patients and two from clinicians, resulting in a 74% return rate.
Most patients responded favourably to the service, with only 2% preferring a consultant-led service. Neither of the two responding clinicians felt that the service needed to change and 80% of respondents felt the length of their appointment was adequate.
Clinicians commented, ‘I think the support provided in this realm is of immense importance to the quality of care we provide to our patients,’ and, ‘The nurse and dietetic-led clinics for people with upper GI cancer have been excellent. It has freed up a lot of space in busy general clinics. It has also provided patients with a more efficient clinic focussed to their needs.’
Comments from patients included:
- ‘The consultant dealt with the surgical operation while the nurse specialist dealt with aftercare and general well-being. [It was] important [the] consultant [was] involved but for a different function.’
- ‘[I] fully understand that it is not necessary to continue to see a consultant and in some respect the level of care may be considered better. A good team.’
- ‘Waiting times appear to have been cut significantly which is good.’
Holding one follow-up clinic a week has streamlined the workload ensuring an equitable, appropriate service. It has also supported the continued professional development of the team and has led to greater productivity.
Although the cost savings for the clinician-led clinics are minimal, both patient and clinician evaluation has suggested not only acceptance of the new model, but a preference to this way of working. This has highlighted the value of the role of the clinical nurse specialist and dietetic team.
The the team will continue to provide a service responsive to the needs of the upper GI patient group.
- Anna Fletcher, Specialist Dietitian
- Amanda Procter, Lead Upper Gastrointestinal Clinical Nurse Specialist (Email Amanda|)
- Tracey Wilcocks, Upper Gastrointestinal Clinical Nurse Specialist.
Neil Bowman, Gail Conlan, Linda Cutter, Rachel Kelly, Shirley Lyon, Emma Maclellan-Smith, Lisa Riley, Dawn Stephenson and Western West Yorkshire MDT.
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