Primary Care Update

Macmillan’s GP Advisers, with the support of GPs and the wider Macmillan team, produce a quarterly e-newsletter to inform GPs, primary care cancer leads and the wider primary care community.

It includes the latest developments, learning and case studies relating to cancer across primary care.

We would like to thank our amazing Macmillan GP Newsletter team for the continued enthusiasm and dedication that they bring to each edition, thank you Dr Bhushan Rao, Dr Lucy Martin and Dr Vicki Clarke.

Missed last quarter's edition? You can read it here.

Social Prescribing: What does it mean for us?

Primary Care Networks (PCNs) have been forming as part of Primary Care contract arrangements since April 2019. Individual practices will retain their GMS or PMS contract but will work as part of a network of linked practices with 30,000 - 50,000 registered patients between them.

The aim of the PCN is to ‘focus services around local communities and local GP practices to help rebuild and reconnect the primary healthcare team across the area they cover.’ [1] In the first year of formation, PCNs will appoint pharmacists and social prescribers to take on a network role to deliver care to their patients.

But what is a social prescriber? This will be a Link Worker who enables practice staff to aid patients to access a range of non-clinical services in the local area. The role has been successfully used in some areas of the country for some time [2].

NHS England sees this as a central part of the provision of personalised care, enabling patients to have choice and control over the way their care is planned and delivered, while integrating care around the person [3]. This aligns with the Macmillan strategy of ensuring people with cancer get support that is right for them.

In Dudley, West Midlands, practices in the CCG have been working in a PCN format for over five years. Five localities used an integrated approach to form a ‘team around the patient’ model of care delivery. The model is enabled through a regular multi-disciplinary team (MDT) meeting where patients who have increased needs are discussed. This includes people with long-term health conditions, people who are socially isolated and those who frequently attend primary or secondary health care services.

An essential member of the MDT is the social prescribing Link Officer, in Dudley known as Integrated Plus. We talked to Terry Gee, Link Officer for Dudley and Netherton to find out more about this role. Terry has been working in this role for over four years. He has a background working in local youth services, providing information and support to young people with varied backgrounds, including homeless young people and people with learning disabilities. He says his role is ‘all about listening to people and their individual challenges, and helping them to access the support they need.’

Each Link Officer supports around ten surgeries in their local area and works closely with Dudley Council for Voluntary Services (CVS), a local umbrella organisation that brings together services in the voluntary, community, faith and social enterprise sectors. It’s one of 280 CVS nationally. Their philosophy is to provide a holistic approach. They see people in their own homes and provide support in any area of a person’s need, ‘unrestrained by organisational boundaries and cultures.’ [4] The Link Officer is responsible for the caseload and works with a support worker who is responsible for data collection, completing benefits applications and collecting feedback.

The network supports people with many types of interventions, including access to services, advocacy, mobility, domestic support and community or social links. Some examples of these include helping people with access to work schemes, access to benefits, help with navigation of the health and social care system, accessing health services for specific issues (e.g. mental health, drugs and alcohol services), advocacy in benefits tribunals and applications for Personal Independence Payments or Attendance Allowance.

It also helps with access to local transport services for health and social activities, such as accompanying people with low confidence to services or activities, helping people access food banks, the local winter warmth scheme, arranging home adaptations and telecare. Social support can include connecting people with a range of social, leisure and faith-based activities. It can also reconnect people with family and friends, or provide support with peer-to-peer support networks between patients, which were designed and set up by the networks [4].

Terry reports that patients have been able to claim over £536,000 in benefits since the start of the service. He says people who use the service ‘get out more, manage their conditions better, access the support they need, exercise more and eat a more balanced diet.’ He also says GP practices ‘value having a non-clinical service to refer to directly’ as they provide a ‘person-centered, solution focused approach’ to support.

Results have been collected throughout. Attendances at the local Emergency Department have reduced to 17% in this patient group, while inpatient admissions reduced by 15%. In addition, 60% of GP surgeries involved reported a reduced consultation rate both in home visits and surgery consultation. An in-depth review of four of the surgeries involved in the services demonstrated a reduction in cost to the service of around £36,000.

Social prescribing is ideally placed to support patients living with and beyond cancer. Mrs. P is in her 60s, lives alone and is recovering after cancer treatment. At the point of referral to Integrated Plus, treatment had left her frail and she had experienced a number of falls, resulting in stays in hospital and a rehabilitation centre. She had a small package of care but needed more as she could only manage a few steps before needing rest and her house was becoming more difficult for her to clean. She has a daughter, but they were not in touch.

As a result of the social prescribing service, Mrs. P’s package of care was increased to the maximum four visits per day. Help with shopping, reading letters and getting her out of the house in her wheelchair was provided by a local voluntary organisation. When she fell again, a respite bed in a care home was arranged rather than a hospital stay.

Terry says the team works closely with Macmillan’s community nursing team and local Specialist Palliative Care service, with regular referrals from them. Each area of the country will have a different local landscape to integrate with, but this example in Dudley shows that social prescribers are well placed to access and maximise the use of services that are already in place. They work well in the GP setting and appear to be making a real impact on the holistic care of patients living with cancer and other long-term conditions [4, 5].


End of life care quality improvement resources

We have developed resources to help primary care professionals implement end of life quality improvement projects, in response to the 2019/20 GP contract QOF changes.

These resources can be used at practice or network level and have been developed to meet the specifications set out for the 2019/20 QOF Quality Improvement Project.

If you have any questions, please contact us at macdocs@macmillan.org.uk.



Quality toolkit for cancer care in primary care (module 4)

This module builds upon our existing toolkit. It focuses on end of life care quality improvement in the context of the 2019/20 QOF contract.



End of life care network guide

This guide draws insight from our work in end of life care, and the innovative work of Macmillan GPs. The guide provides Network Leads with an introduction to end of life care, resources to support you, and case studies of UK quality improvement initiatives.



Palliative care templates

  • EMIS Web template

We have worked with EMIS Health to develop an updated palliative care template, which enables you to code relevant information directly into the patient notes.

To access the template in EMIS Web, follow this pathway:

Template manager > Templates & Protocols > EMIS Library > Primary Care Templates > History and Exam > Macmillan Cancer templates
  • SystmOne template

We have now built the updated palliative care template in TPP SystmOne. This template is available to all TPP users via the Resource Library.

To access the template, follow this pathway:

System > Resource Library (keyword search is Macmillan)

We are working with GP IT providers to replicate this template in other systems.



Palliative care searches

We have worked with EMIS Web to develop automated palliative care searches. These searches support the use of Module 4 of the Quality Toolkit and enable practices and networks to gather a baseline of current activity. You can run these searches at the start of an end of life care quality improvement initiative, and can then re-run them after implementation, to demonstrate its impact.

To access the searches in EMIS, follow this pathway:

Population reporting > EMIS Library > EMIS Clinical Utilities > Third Sector Partnerships > Macmillan Cancer Support > End of Life Care QI Searches.

We are working with GP IT providers to replicate this template in other systems.



TPP SystmOne searches

To access the searches in TTP SystmOne, follow this pathway:

System > Resource Library (keyword search is Macmillan)

You can download an Access guide [PDF] for all of the templates and searches available within TPP SystmOne.

We would like to thank Greater Nottingham CCG for their support in developing and sharing this work.


Strength in numbers: The brave new world of Primary Care Networks?

GPs have collaborated across practice boundaries for decades, in England and through cluster-working in the UK. Now, with the rollout of Primary Care Networks (PCNs) in England, this way of working will be formalised through a new GP DES, which will establish networks covering populations of between 30,000-50,000 people.

This development comes with new investment of up to £1.8 billion by 2023/24, allowing GPs to manage their growing workload with greater support from extended multi-disciplinary teams. With practices closing on an unprecedented scale, the innovation and professional collaboration inherent in the model are welcome ambitions.

Also welcome is the alignment of Macmillan’s strategic focus on personalised cancer care and support, and the priorities of PCNs. Early diagnosis and personalised care are set out in national specifications to be delivered from April 2020. End of life care will also be prioritised as part of quality improvements within QOF. This alignment creates new potential for Macmillan to utilise our 200 strong UK-wide GP community to ensure that PCNs can hit the ground running, providing person-centred care for people living with cancer.

Practices will be reimbursed for employing a wide variety of new roles (initially pharmacists and new social prescribing link workers, as well as physician associates, physiotherapists and community paramedics from 2020/21). These new roles have huge potential for us to increase our multidisciplinary team working across primary and community care, and gives us the opportunity to test a different way of working to better support people living with cancer.

The increased focus on Social Prescribers will enable practices to take a more holistic approach to supporting people within the community, whether we’re providing financial, emotional or practical support. In addition, the opportunity for each PCN to employ a pharmacist to work across the network allows us to build on models we’ve already seen working well in many practices, while building on the strengths of key primary and community roles in a more connected way.

There will no doubt be challenges to this way of working. The media has exploited teething troubles such as contracting difficulties and potential mismatches between network areas and Clinical Commissioning Group (CCG) boundaries. Current workforce challenges may also act as a barrier to recruitment. However, this is a genuine opportunity to work with PCNs to transform the quality of care for people living with cancer.

Download Investment and evolution: A five-year framework for GP contract reform to implement The NHS Long Term Plan [PDF]

Download Universal Personalised Care: implementing the Comprehensive Model [PDF]



Patient perspective: Macmillan’s Online Community

I was diagnosed with endometrium cancer (womb cancer) in June 2017. Macmillan became a lifeline with its services like the Support Line, but more so the Online Community. Being able to chat to other individuals going through the same experience [and asking] questions of professionals was totally invaluable.

When you’re diagnosed, you’re overwhelmed. Questions seem to swirl around your head. Some [questions] get asked time and time again, and you soon realise why having a service out there to support patients, their families, friends and carers is so well regarded. People speak of Macmillan with genuine gratitude and the Online Community brings people together.

People have found friendship at a time when they are vulnerable. It’s not simply answering the question that’s important, it’s the fact that no matter how scared you are, the [Online Community’s] Experts do everything they can to help and explain.

Often the simplest of answers has the biggest impact. Knowing what you feel is normal and that you’re not alone, having the treatment explained, being told what each scan is, what it’s looking for and what to expect is invaluable. Sometimes it’s easier to ask those burning questions anonymously, through Ask an Expert, then to ask your specialist.

When I became a Community Champion, it was a real privilege to use my experience to help others. The Community’s been a combination of giving and getting support during the most difficult and scary time of my life. Over the last two years, I’ve gone through a wave of emotions. I had to first overcome the diagnosis, the shock and the denial of what I’d been told. I then had to recover from surgery. I believed I’d ‘gotten through it’, but I never expected to end up with so many different health issues.

At the same time, a good friend was diagnosed with terminal cancer. He was told he had twelve months to live. His death devastated me, and again I turned to the Online Community, its experts and members. I’ve struggled emotionally of late, yet I’ve more trust and respect for the Community. I feel I can ask questions with no judgment, and that takes some of the strain off my shoulders.

Macmillan is always trying to improve its services, so they can reach more people, but it’s important to remember that each person Macmillan supports is one less person left in the dark, or isolated and alone. It’s a privilege to be part of the Community and team that works towards this goal.

By Sarah (GBear)


Topical highlights

Travel and health

Do you advise people with cancer planning to travel abroad? The National Travel Health Network and Centre (NaTHNaC) is a Public Health England commissioned service that offers support for health professionals who advise travellers with complex needs. This includes people with cancer, who may be planning to travel, before, during or after treatment.

A wealth of travel health information can be found on the their website, Travel Health Pro, including destination-specific advice and targeted factsheets, such as those on immunosuppression, medicines and travel and travelling with additional needs.

The service has a dedicated pre-travel advice line for health professionals. You can call 0845 602 6712 to discuss an individual case, and opening times can be found on the website.

Macmillan also has travel insurance guidance for people living with cancer. You can also download a free information booklet.



Breast cancer risk calculator

A recent article in the Guardian outlines the potential use of an online calculator, devised by scientists, to determine an individual’s personal risk of breast cancer.

Cancer Research UK scientists have developed a calculator tool, which takes into account both genetic and family history data, including other personal and lifestyle factors, such as weight, age at menopause, alcohol consumption and use of HRT. The tool also includes 300 genes.

The tool combines more elements than any previous prediction tool. It is hoped that this method will be effective in identifying women with different levels of risk, not just those who are at high risk.

A large proportion of breast cancers are diagnosed in women at increased risk. The tool aims to identify these women, improving both early diagnosis and breast cancer survival.

The tool has the potential to allow mammogram screening to be more accurately targeted. Not all women participate in the national screening programme, for a variety of reasons. If the tool is successful, it will allow an individual to make an informed decision about whether or not to be screened, following a risk assessment with their GP.

The next step is piloting the tool in Primary Care.



Alcohol and cancer risk

There is now a high level of public understanding about the risks of smoking. In comparison, the public generally perceive alcohol as less harmful, particularly in terms of cancer, despite indisputable evidence that drinking alcohol increases the risk of seven different cancer types (CRUK). In a recent survey of 2100 adults, only 13% named cancer as a health risk of hazardous drinking [1].

How we convey alcohol-risk to our patients remains a challenge. A recent study looked to address this, by answering the question ‘Purely in terms of cancer risk, how many cigarettes are there in a bottle of wine?’ [2].

The study compared the increase in absolute cancer risk attributed to moderate levels of alcohol with the risks of low levels of smoking, creating a ‘cigarette-equivalent of population cancer harm’.

It concluded that one bottle of wine per week is associated with an increased absolute lifetime risk of alcohol-related cancers in women (driven by breast cancer), equivalent to the increased risk associated with ten cigarettes per week.

The risks for men were equivalent to five cigarettes per week. These findings may be useful in communicating to our patients that drinking a moderate amount of alcohol poses a significant health risk, particularly in women.



Red meat link to cancer risk

A recent article in the Guardian refers to data provided by the UK Biobank research project, published in the International Journal of Epidemiology.

The study shows that people eating on average around 76g of red and processed meat daily (in line with current UK recommendations) have a 20% increased risk of developing bowel cancer compared to those who eat on average 21g per day.

One in 15 men and 1 in 18 women born after 1960 in the UK will be diagnosed with bowel cancer in their lifetime. This study found that the risk rose by 19% with every 25g of processed meat (approximately one rasher of bacon or slice of ham) eaten per day and 18% with every 50g of red meat (e.g. a thick slice of roast beef or lamb chop).

Professor Tim Key, co-author of the study concludes, ‘Our results strongly suggest that people who eat red and processed meat four or more times a week have a higher risk of developing bowel cancer than those who eat red and processed meat less than twice a week.’


The Staffordshire Cancer Local Improvement Scheme

The six Staffordshire Clinical Commissioning Groups have recently offered their local practices a Local Improvement Scheme (LIS) to enhance the care delivered to patients diagnosed with cancer.

The scheme was developed to address variations in the skill mix of practice staff (and thus the variation in the Cancer Care Reviews) and to encourage practices to proactively review their cancer registers. This was inspired by the strategy in England to achieve world class cancer outcomes.



The LIS

The three pillars on which the LIS is based are:

A) Training practice staff, including doctors, nurse and other key practice staff by introducing the concept of 'practice cancer champion'.

B) Upskilling practice nurses to deliver Cancer Care Reviews and introduce the concept of 'Cancer as a chronic disease', as for many people cancer survival now means living with a chronic and complex condition [1].

Encouraging practices to review their cancer registers, including routes of diagnoses and performing significant event analysis (now known as Learning Event Analysis) around cancer diagnoses where appropriate. This would apply to, patients being diagnosed with cancer through the emergency routes for example, as these patients tend to have poorer outcomes [2].



The process

The team (Macmillan facilitators and commissioners at the CCG) started having discussions in the first couple of months of 2018 to get a LIS in place where it can enhance care delivered to patients diagnosed with cancer.

Once funding was obtained the team took the LIS to the primary care teams in the Staffordshire CCGs. The LIS was then debated and discussed in multiple meetings such as the Membership Engagement Groups (MEGS) or their equivalents in different parts of Staffordshire. The Local Medical Committee LMC was also approached and their views sought on the LIS.

Taking into account the feedback received at these meetings, the final version of the LIS was prepared and formally offered to the practices in January 2019, with full support and engagement from all partners.



Where things are now

The LIS was launched first in Northern Staffordshire with an educational workshop, which was well attended. Since then about 50% of the practices in the region have signed up to the LIS. Practices signed up to the LIS have identified a cancer champion, who has attended the training event organised by the Macmillan facilitators. Practice nurses who will be delivering the enhanced cancer care review will be attending training in the near future. Practices have started reviewing their cancer profiles and completed relevant audits of their cancer diagnoses.



The future

We envisage practices making it a priority to reflect on their cancer registers and run SEAs/LEAs on emergency diagnoses of cancers. Practice nurses and other relevant practice staff are well trained to support people living with and beyond a diagnosis of cancer. The challenge remains to help practices who have not signed to the LIS to provide the same standard of care to their patients too.

References

Social prescribing: Primary Care Networks

  1. The PCN Handbook, British Medical Association, 2019
  2. https://www.kingsfund.org.uk/publications/social-prescribing
  3. Social Prescribing and Community Based Support, NHSE 2019, https://www.england.nhs.uk/wp-content/uploads/2019/01/social-prescribing-community-based-support-summary-guide.pdf
  4. Dudley CVS ‘Integrated Plus Impact Evaluation 2014 - 2018’ (unpublished) 2017 version available at https://integratedplusblog.com/2017/09/07/integrated-plus-social-and-economic-impact-evaluation-report-1st-september-2014-18th-july-2017
  5. Understanding the effectiveness and mechanisms of a social prescribing service: a mixed method analysis, Woodall et al. BMC Health Services Research (2018) 18:604 https://doi.org/10.1186/s12913-018-3437-7

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Topical highlights

Alcohol and cancer risk

  1. Public awareness of the link between alcohol and cancer in England in 2015: a population-based survey. Buykx P, Li J, Gavens L, Lovatt M, Gornes de Matos E, Holmes, J et al. BMC Public Health. 2016:16-1194.
  2. A comparison of gender-linked population cancer risks between alcohol and tobacco: how many cigarettes are there in a bottle of wine? Theresa J Hydes, Robyn Burton, Hazel Inskip, Mark A Bellis and Nick Sheron. BMC Public Health. 2019:19-316.

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The Staffordshire Cancer Local Improvement Scheme

  1. Phillips, Jane & Currow, David. (2010). Cancer as a chronic disease. Collegian (Royal College of Nursing, Australia). 17. 47-50. 10.1016/j.colegn.2010.04.007.
  2. McPhail S, Elliss-Brookes L, Shelton J, et al. Emergency presentation of cancer and short-term mortality. Br J Cancer. 2013;109(8):2027–2034. doi:10.1038/bjc.2013.569

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Missed last quarter's edition? You can read it here.