Tuesday 16th December 2014
Mac Voice, the magazine for Macmillan professionals: Winter 2014
Nicola Easton and Paul Worrall describe their experience of being among the first sites to test the concept of eHNA
Guy's and St Thomas' NHS Foundation Trust (GSTT)
Setting the scene
Guy's and St Thomas' is one of England's leading cancer centres, treating more people with cancer than any other provider in London. Leading cancer experts are based onsite and work as part of the cancer team. That means joined-up care, all in one place, for an all-round better experience of healthcare. Cancer care is about much more than medical treatment. That's why we do a HNA for everyone who joins our services, to find out what cancer means to them, and what support they need. From psychological support to financial advice, we will work with the person to understand how cancer is affecting them and their family. It was important to us to find a more effective and efficient way of assessing people's holistic needs.
Challenges and solutions
GSTT were accepted as one of the first test sites for eHNA. WiFi was one of the first challenges. We couldn't get the tablets to connect and stay connected without them timing out and requiring a personal password. Using a mobile WiFi device worked; we could connect and stay connected. However, this didn't work in the lower floors or where there was high lead shielding.
Involve the IT department really early. Ask for an IT representative to be the contact for the project and work with your team to solve IT issues and processes. This works best when there is a member of the IT team willing to be 'hands on'. The IT contact can be the main contact with the IG department and can respond to any IG issues.
Further challenges came at the start of the pilot, as tablets were not yet approved for use in the trust. It took some time for the use of iPads for this work to be approved. In addition, the iPads were not a standard procurement item at the time. Testing included making sure that, if an assessment was not completed, the tablet would automatically return to the welcome screen after a certain time. Once iPads were procured through IT, the uptake of eHNA advanced rapidly. Now all clinical teams in all areas have access to an iPad to use for eHNA.
eHNA is offered to people living with cancer in a variety of ways: in clinics by the clinic staff, by a volunteer who assists the person to complete the eHNA, and in some clinics, the doctors identify who needs an eHNA. They are completed in some specific clinics, such as end of treatment clinics, HNA clinics or at radiotherapy review meetings. The care planning discussions may happen at the clinic appointments, at the next appointment, or over the phone after the hospital appointment.
Benefits to people living with cancer
The benefits to people living with cancer have been identified by Sarah Thompson, CNS at GSTT, as:
'Holistic Needs Assessment is an important part of the persons treatment because it allows us as nurses to be able to focus on individual needs and their primary concerns.'
One person I was caring for commented that:
'Having a CNS supporting my treatment made a huge difference. Even now treatment has finished, I still require physical and psychological support, which has been highlighted and demonstrated by the Holistic Needs Assessment.'
The IT project team saw the extra benefit of the tablet and that it could be used for other surveys, for example the Staff, Friends and Family Test. IT ensured that mobile device management software was used to enable more than one survey to be loaded on the iPad.
This also means that the care planning website is on the iPad, so the assessment can be viewed by the clinician without them needing to go to a computer. This is useful in areas with limited access to computers, such as on the wards and certain clinics. You will need IG agreement to view or do care planning on the iPad.
The Deputy Chief Nurse for Cancer is using the data from eHNA within performance review meetings and is reporting results to the cancer locality meeting with the Clinical Commissioning Group. Now that more assessments have been carried out, we can look at the top concerns of people with cancer overall, or by individual tumour groups by using the 'Data Store' function on the care planning website. This helps us to see where there are capacity issues or gaps in services across the different tumour groups, and it will therefore assist in future planning to ensure we have the right type of services to address these concerns.
Quality and Improvement Lead
Cancer Programme, King's Health Partners Integrated Cancer Centre
Guy's and St Thomas' NHS Foundation Trust
University Hospitals Coventry and Warwickshire NHS Trust (UHCW)
Setting the scene
Cancer site specific CNSs are often assigned the role of 'key worker' for people living with cancer and their relatives from the point of diagnosis. As a result, CNSs play a central role in the initial coordination of the care planning process.
University Hospitals Coventry and Warwickshire is a regional cancer centre covering a wide geographical area, including Coventry and Warwickshire. Depending on the type of cancer a person has been diagnosed with, the subsequent treatment plan will determine where they are cared for. As a result, people are often referred to the centre for all or part of their treatment.
At UHCW, five cancer sites (skin, breast, colorectal, neurology, and head and neck) were already using the paper-based concerns checklist and distress thermometer assessment tools for HNA. As these sites were already experienced with undertaking HNAs, they were approached by the Lead Cancer Nurse for UHCW to determine interest in applying to participate in the pilot study. The CNSs already using paper versions saw this as an ideal opportunity to further develop their existing HNA practice.
Following a successful application to be involved in the pilot, a steering group was set up to ascertain how the eHNA would be implemented. The steering group also involved representatives from the IT and governance department, to ensure correct IT and governance procedures were adhered to.
Following initial training for the touch screen tablets and the care planning website, provided by the Macmillan Cancer Support eHNA project team, the cancer sites began using the eHNA in June 2013.
Challenges and solutions
Once the pilot was in progress, regular steering group meetings were held to identify any challenges the sites encountered. The meetings also provided an ideal forum to formulate potential solutions.
Initially it was felt that completion of the eHNA and care plans was more time consuming. To overcome this, specific clinics were developed to ensure there were protected times for individuals to complete the assessment and for the CNSs to produce the care plans. Some CNSs asked people living with cancer to arrive 10 minutes earlier for their clinic appointment to enable completion of the eHNA, and this reduced the time spent in their consultation.
The limitation of language barriers was raised as a concern, but it was felt this was addressed by using the in-house interpretation service.
The colorectal team discussed the option of using the eHNA during community assessments. The option of purchasing a 3G-enabled tablet and the ongoing cost has also been discussed with the IT department. Other technical issues such as the tablets freezing when submitting the assessment were easily resolved via the support team.
Benefits for people living with cancer
The steering group has also discussed the benefits of the eHNA for people living with cancer. Primarily it was felt that the process was person-centred and that consultations were more person-focused rather than being health professional-led. This encourages more in-depth exploration of people's concerns, supporting individualised care. The eHNA has also provided CNSs with the ability to demonstrate a 'before and after' treatment picture for people, enabling them to see an improvement in areas such as treatment-related symptoms.
The eHNA has allowed cancer teams to share the HNA outcomes with other members of the multidisciplinary team, GPs and community teams, creating more focused discussions about the management of care for people living with cancer.
Producing the eHNA not only provides people with individualised care plans, but also benefits the organisation, by ensuring compliance with peer review measures and national projects. It also aids data collection of specific concerns, which in turn supports service development.
Following a successful implementation of the eHNA in the pilot sites, the intention is now to roll out the eHNA to the remaining cancer CNSs across the trust.
Macmillan Head and Neck Clinical Nurse Specialist
University Hospitals, Coventry and Warwickshire NHS Trust