An outreach chemotherapy van is part of a new approach to improving care delivery in the community, says Alison Moore.

Moving services closer to patients has been an aim of successive governments. Planned changes to the NHS are likely to speed up this shift of care.

But there are patient safety implications to moving services away from an acute hospital setting with its crash teams, resuscitation facilities and access to highly trained staff. There may be longer term implications for safety related to the skill set of staff working in different settings and their access to training and development.

All of these issues had to be faced when East Kent Hospitals University Foundation Trust decided to explore an outreach service for chemotherapy. This is now being provided in community hospitals and health clinics across the area – saving many patients a long trip into Canterbury. 

But setting up the service involved risk assessing every element – which drugs could be delivered in a community setting; which patients could be treated safely; what back-up was available in an emergency; which staff had the skills to work away from the main site; and even where the van containing drugs and equipment is parked.

Inevitably this has limited what can be done – some patients and treatments can still only be provided at the main unit, and at one site staff rejected a proposed room as being too isolated and difficult to reach in an emergency.

Matron Tracy Anderson says there is an ongoing process of risk assessment, which has led to changes. Patients who require monoclonal therapy, for example, can now be considered for community treatment provided they have had their first treatment in the chemotherapy unit and have not reacted adversely. Initially, they still had to have the treatment in the main hospital.

Safety first

But a big change has been the decision to rotate staff rather than assign them to the mobile team permanently.

“We realised that the staff were becoming quite de-skilled quite quickly,” says Ms Anderson.

Because only a limited range of chemotherapy treatments was being provided in the community, those nurses were not getting up to date experience of the full range of treatments offered in Canterbury. It was also becoming difficult to cope with sickness and leave because not enough nurses had experience of the outreach clinic. And working only in pairs the mobile nurses could feel isolated.

A new rota allocates nurses to a fixed day a week providing outreach services – so patients usually see the same nurse but the nurses also get experience back in Canterbury.

Ms Anderson says risk assessment “was a huge task and continues to be a huge task”. Patient safety will need to come first when moves into the community are considered – and some patients will always require an acute setting.

NHS Alliance chair Michael Dixon says there will need to be discussions between primary and secondary care over which patients can be treated appropriately in a less intensive setting. Secondary care often has a “no risk” approach.

“If you have a headache in hospital you get an MRI scan,” he points out.

That may be difficult to replicate in the community and severely limit what services are provided closer to home. 

GP Paresh Dawda, who teaches on patient safety at the NHS Institute for Innovation and Improvement, says risks will differ according to what services are moved into the community – although he agrees that human resource issues, such as isolation and de-skilling, will need to be considered.

The institute is developing tools and techniques to allow both commissioners and providers to build reliable processes to identify patient safety issues. This includes assessing services and identifying areas of risk.

But could there be a trade-off between a slightly higher risk and convenience? Some patients already choose to have treatment in a setting where back-up in the event of an emergency is not as extensive as in an acute setting. Women opt for midwife-led birth centres knowing there is no consultant on site and that an emergency may result in an ambulance transfer. GPs carry out minor surgery without a crash team in the next room.

The issues may not just be how to minimise the risks involved but how to explain the remaining risks to patients, and assist them in making an informed choice over where they are treated.