Published: 04/07/2002, Volume II2, No. 5812 Page 26 27
An assessment system for cancer services in general practice has highlighted the need for better registers and more effective communication with hospitals.
David Lyon reports
Cancer is a major cause of mortality and the evidence suggests that the outcome for patients in the UK is worse than in the rest of western Europe. The NHS Cancer Plan attempts to address the problems in combination with the guidelines for urgent referral of patients with suspected cancer and out-of-hours palliative care.
1,2,3 Primary care has a crucial role in identifying and referring suspect cases, in supporting the patient and their families through investigation and treatment and, where appropriate, into palliative and terminal care.
4North West regional office, supported by Macmillan Cancer Relief, has developed an appraisal process to assess cancer care in the primary care setting. The objective is to encourage good practice through health promotion, prevention, screening, early identification and referral of suspect cases to improve palliative care and practice-based learning.
The process is designed to facilitate clinical governance. It went live in 1999, celebrating success and identifying development needs for individual practices and the primary care trust as a whole. It enables primary care to be actively involved in cancer networks and commission with an informed voice.
Primary care representatives have developed the appraisal criteria. Clinicians and allied health professionals were involved and the criteria and have been modified by piloting.
They include: systems for diagnosis, including one-day access to a GP for patients worried they have cancer; referral and test result arrangements;
identification of a key contact in secondary care;
protocols for follow-up and palliative care;
arrangements for respite care; access to bereavement counselling; development of a practice cancer register; professional development for members of the practice team; access to allied health professionals.
No practice can successfully fulfil all the criteria, so there is an opportunity to learn and to develop their cancer care practice.
The project team has a full-time audit clerk, who has a background in primary care, and a former Macmillan nurse. They cover a large area that takes in Merseyside and Cheshire, Greater Manchester, Lancashire and Cumbria. The team contacts the PCTs and offers to visit up to six practices in the trust's area. These should include a single-handed practice.
The team has a one-hour meeting with the practice and as many members of staff as possible.
The assessing team goes through the list of criteria and scores the practice on each one. They then write a report for the practice, with some comments. The assessors go on to prepare a collective report for the PCT, identifying problem areas and development needs.
So far, 120 practices have been assessed and the team has been warmly welcomed.Most practices have scored more than 50 per cent on the criteria, but widespread problems exist with the establishment of cancer registers (reported by 80 per cent of practices), communication difficulties with hospitals and problems in establishing patients' family history.
Good practice identified includes personal medical services schemes' employment of designated nurses to support patients through the whole 'cancer journey' and PCTs arranging for hospital specialists to go into general practices to improve communication.
We have found that the greatest improvements have been made when the primary care organisation has become involved and produced a development programme for all practices.
An analysis of the first 10 primary care organisation reports, involving 60 practices, has shown there was no difference in the number of development needs identified between an organisation in which many practices have undergone appraisal and those where only four have taken part.
Consequently we recommend that cancer leads appraise between four and six practices only, provided there is a range of practice type.
The practice receives a confidential report celebrating success and highlighting development needs, and a summary report is sent to the PCT.
Some development needs can be addressed by the practice. For example:
call and re-call systems to ensure that defaulters of the breast-screening programme are followed up;
the use of the 'status of change'model to identify those most likely to succeed at lifestyle change;
5 the identification of a key worker in primary care for each patient with cancer.
Others need a collective approach by the PCT - for example, access to investigations may be a problem, communication from secondary/tertiary care might be slow or practice staff may be unsure of the fax numbers for urgent two-week referrals.
The reviewers have been impressed by examples of good practice:
A consortium of primary care organisations has established a monthly multiprofessional educational forum to secure protected time to disseminate good clinical practices.
In partnership with local practices, a community centre run by nurse practitioners is providing excellent smoking cessation counselling, nicotine replacement therapy and Zyban.The centre takes the opportunity for health education, including breast and testicular examination.
A local procedure highlights to all members of the primary healthcare team the phase that the patient with cancer has reached.
Some practices have several years' computerised patient records and others are now computerising, making it easier to access cancer patients' care plans and facilitate audit. Some practices are also introducing a cancer register.
Many areas provide 24-hour nursing care for cancer patients, maintaining them in their home environment where they want to be.
Some practices hold regular multiprofessional educational patient review meetings.
Some practices are introducing patientheld records.
A number of common development needs are emerging:
Documentation nrecording family history and referral;
recording dialogue and the wishes of the patient;
recording consultations and treatment by all primary healthcare team members and secondary care;
Communication nbetween care settings;
written patient information.
Education nsignificant event audit;
multidisciplinary team learning and development;
access to information;
A national form for urgent referral has been developed but most units preferred to design their own.As the cancer networks become more established and better linked with primary care via the cancer leads, this problem could be rationalised. The networks will also help address the follow-up guidelines for patients undergoing treatment and 24-hour services in the community for palliative care.
The cancer plan indicates that a national group will explore patient information, but as yet this has not been convened.
Clinicians' 'protected time' is an issue for clinical governance and professional development, and although minimal resources have been identified PCTs will have the responsibility to resolve this funding problem.
The appraisal process and reports can be used as a baseline assessment for cancer leads and help inform commissioning and participation in the cancer networks. It is a way of galvanising primary care to assess and address services it provides for patients with cancer. It helps establish shared team learning, continued professional development and ultimately to deliver the cancer plan.Most important, the appraisal process is a way of improving patient care.
Dr David Lyon is a GP adviser to the primary care cancer appraisal team, based in the North West regional cancer modernisation team.
1Department of Health.
The NHS cancer plan. DoH, 2000.
2Department of Health.
Referral guidelines for suspected cancer. DoH, 2000.
3 Thomas K. In the community: continuing care of the dying at home.
Macmillan Cancer Relief, March 2001.
4 Expert Advisory Group on Cancer. A policy framework for commissioning cancer services: a report to the chief medical officers of England and Wales (The CalmanHine Report). DoH, 1995.
5 Prochaska J, DiClemente C. Stages and processes of self-change of smoking: toward an integrative model of change. J of Consulting and Clinical Psychology 1993; 51(3): 390-395.
A system of assessing cancer care in general practice has been well received by practice teams.
The most common problems concern development of a cancer register, communication with hospitals and lack of written information for patients.
Greatest progress has been made when the primary care organisation has produced a development plan.