Monday 3rd December 2012
The first part of Sharing good practice, by Noëline Young, National Cancer Survivorship Initiative, Project Manager.
Research shows that people living with and beyond cancer often have ongoing needs following active treatment.1 Studies have also shown that the health and well-being profile of people with cancer is similar to those with other long-term conditions, including diabetes and arthritis.
Effective assessment and care planning to identify people’s concerns and needs can lead to early interventions, diagnosis of consequences of treatment, improved communication and better equity of care. As such, everyone with cancer should be offered a holistic needs assessment (HNA) and a care plan.
The HNA and care plan ensure that people’s physical, emotional and social needs are met in a timely and appropriate way, and that resources are targeted to those who need them most. The information gathered from an HNA can also be shared with the multidisciplinary team (MDT) to improve a person’s management and care, and the data collected can influence commissioning of future services.
The HNA wheel
The HNA and care plan
An HNA should include:
- Physical concerns
Tired/exhausted or fatigued, pain, wound care after surgery, memory or concentration, sexuality.
- Practical concerns
Caring responsibilities, work and education, money or housing, insurance and travel.
- Family/relationship concerns
Partner, children, relatives, friends, other.
- Emotional concerns
Loneliness or isolation, sadness or depression, spiritual or religious concerns.
- Lifestyle or information needs
Support groups, exercise and activity, smoking, alcohol or drugs, sun protection, hobbies.
A care plan should be developed as part of this process. A care plan enables appropriate interventions, including support and information, and signposting or referral to other services if required. The process ensures timely interventions, prevents concerns from escalating and supports self-management.
NCSI goals and test sites
When the National Cancer Survivorship Initiative (NCSI) set out its goals for cancer care in its 2010 vision document,2 it highlighted five ‘key shifts’ necessary to deliver high-quality care and support for people with cancer in England.
The second key shift is to develop holistic assessment, information provision and personalised care planning. This is a move away from a ‘one-size-fits-all’ approach to personalised care planning.
Improving Outcomes: A Strategy for Cancer3 also identifies the need for personalised assessment and care planning for people with cancer. This is in line with other similar developments in chronic disease management.
Testing of assessment and care planning was carried out by 11 test communities within the NHS in England from 2010. Testing covered 19 adult tumour groups.
Sites also tested the Treatment Summary. The test communities mapped their existing services, planned how the assessment and care planning process would take place, agreed tools for assessment, and how to measure and record baseline and further measurements for evaluation. The changes were evaluated and a final report is available at the NCSI website.
In 2011, seven more test sites were appointed to transform care and test a risk stratified care pathway. A risk stratification process helps to identify which care pathway is most suitable for each patient, based on the level of risk associated with the disease, the treatment and the patient’s ability to manage, and therefore what level of professional involvement will be required. Included in that work was assessment and care planning for people affected by cancer at two key points in the care pathway: at or near diagnosis and at the end of treatment.
Assessment and care planning was not evaluated as a separate process, however some interesting data has emerged and is available and in the document, Stratified pathways of care...from concept to innovation.4
Outline of test results
Clinicians said the benefits of undertaking an HNA with patients included: identification of specific problems, greater understanding of the patient, increased competencies and staff satisfaction, and an opportunity to develop a different follow-up process.
Patients had a positive experience of HNA, citing an improvement in their relationship with the clinician and the process being beneficial in eliciting issues, enabling thinking, releasing anxiety and gaining perspective. They said they valued being given contact details and discussing practical issues such as financial benefits.
The test sites identified that simple tools were the most effective. The most popular tools were the Distress Thermometer (DT), the Concerns Check List, and the Sheffield Profile for Assessment and Referral to Care (SPARC). These tools were completed by the patient and then used to facilitate discussion with the healthcare professional.
See the NCSI website for more on assessment tools.
The use of an assessment tool is an important part of HNA as it ensures consistency and stimulates the conversation. However the assessment tool should not become a ‘tick box’ exercise, rather clinicians should focus on exploring and discussing the collected information.
Testing an electronic assessment tool
The NCSI has also piloted touch screen tablets for self-assessment. Appropriate software can analyse the assessment and the data informs the care plan. Visit the NCSI website for more information.
Peer review measure
There has been a peer review measure for the implementation of HNA and care planning since April 2011. The measure states that MDTs should have agreed a list of responsibilities with each of the core nurse specialists of the team. These include:
- contributing to the MDT discussion and assessment/care planning decision
- leading on patient and carer communication issues and coordination of the care pathway for patients referred to the team
- acting as the key worker or responsible for nominating the key worker for the patient
- ensuring that the results of a patient’s HNA are taken into account in the decision making process.
Email Noëline Young, Project Manager, National Cancer Survivorship Initiative, Macmillan Cancer Support.
See the references page for this Sharing good practice.
Continue reading this edition of Sharing good practice
Part two - Secondary care perspective
Dr Alastair Smith, Honorary Consultant Haematologist and Clinical Adviser for Macmillan Cancer Support
Part three - Test site perspective
Louise Smith, Cancer Information Specialist and Centre Manager and Ipswich Project Lead for Survivorship
Part four - Evidence base
Anne Wilkinson, National Improvement Lead, NHS Improvement
Part five - Policy
Relevant policy documents.
Part six - Resources
Part seven - References
References for this Sharing good practice.