Cancer commissioning: a survivor's guide

As healthcare managers, we are told to look at our services through the eyes of the patient. While most of us will depend on the NHS some time in our lives, thankfully just a fraction will experience treatment for cancer.

I have been treated successfully twice for Hodgkin’s lymphoma in the past five years, requiring both standard chemotherapy and a bone marrow transplant. The clinical care on both occasions has been world class and a credit to the clinicians and managers involved.

However, my second treatment at University College London Hospitals Foundation Trust raised some interesting thoughts that could help health managers and commissioners overcome some of the quality and financial pressures affecting cancer care.

‘I firmly believe that without the support services, I would have required significantly increased resources from the clinical team’

At UCLH, the majority of haematology cancers are treated within ambulatory care, where patients receive chemotherapy as a day case and stay in a hotel room overnight. This type of pathway has been such a success that the trust and its charitable partners have recently invested in a purpose-built hotel as a more permanent solution to utilising commercial hotel capacity.

It is clear ambulatory care delivers a significant direct cost saving and reduction in length of stay. However, I also feel there are significant additional commissioner and patient benefits that are worthy of note.

The NHS is under significant pressure to deliver care closer to home and my experience of the above pathway demonstrated to me that commissioners and providers should partner with local hotels to test and trial ambulatory suitable cancer pathways, as there is often significant unease about discharging or allowing patients to remain at home, due to unsuitable facilities or location.

Greater use of ambulatory pathways for chemotherapy would allow commissioners to maximise the efficiency and patient volumes of existing facilities, while still providing ward-based care where appropriate.

Competitve advantage

As a cancer patient, the ambulatory care model allowed me to take increased responsibility for my condition. It increased my level of empowerment and confidence in self-care, so that I did not have to regain these skills before discharge.

While not suitable for all patient groups, the model could allow the NHS to meet rising patient expectations, especially those that demand higher standards of food and comfort and that require cancer care, now increasingly seen as a long term condition, to be delivered around the patient’s lifestyle. 

Finally under patient choice, the use of such a pathway can give a provider a competitive advantage in attracting patients, in comparison to the majority of providers that use traditional inpatient treatment settings.

The second lesson I feel can be imparted from my experience is the importance of a single and effective key point of contact in all cancer pathways. National Institute for Health and Clinical Excellence guidance stipulates that all patients are allocated key workers to provide information and advice and this role is generally carried out by specialist nurses.

‘The ease of contact of the key worker avoided two potential admissions, simply by providing telephone advice’

As finances become more constrained, I predict that the value of the clinical nurse specialist will be given more scrutiny, given the post holders’ high salary banding. I would argue that the role of the key worker and clinical nurse specialist is paramount to safe, effective and cost-efficient care, as it allows the integration of the handoffs between various departments and reduces complaints and errors.

For commissioners, the capability of key workers to make clinical decisions and coordinate treatment is likely to avoid non-elective admissions, which are a costly burden on the health economy. In my case, the ease of contact of the key worker avoided two potential admissions, simply by providing telephone advice to help me better manage my condition and this is highly significant when replicated across the health economy. In short, any dilution of the role should clearly be avoided.

The final message that I would like to discuss is the significant but underutilised, role of the third sector in the delivery of cancer services. At UCLH, most cancers are treated within the University College Hospital Macmillan Cancer Centre, a state of the art facility.

Gain confidence

Although Macmillan and other charities were heavily involved in the funding of the building, it is the pastoral and emotional support such as counselling, treatment information and complementary therapies provided by the Macmillan Support and Information Centre – a partnership between Macmillan and UCLH – that is worthy of note.

During my treatment, I also made contact with the Lymphoma Association which was invaluable in providing a “buddy” patient, so I could learn from the experience of others. This, combined with support from the NHS and third sector, allowed me and my family to become informed about my condition, gain confidence to articulate our needs to the clinical team and reduce significantly the stress inherent in the situation.

‘I hope by sharing my experience, fellow commissioners will take on board the potential of the ambulatory care model’

At the Macmillan Cancer Centre, the seamless nature of the partnership allows clinical staff to make referrals to the support and information service, where it is felt additional help for patients or carers would be beneficial. Although staff are employed by the NHS and UCLH, the service became possible through funding from Macmillan and will rely on fundraising and its volunteer support in future to survive and prosper.

Third sector integration

I firmly believe that without the support services, I would have required significantly increased resources from the clinical team, and suffered a slower recovery. As both of these occurrences are costly to the health economy, commissioners should seek to test the integration of the third sector when procuring or improving cancer pathways and should ensure that pastoral or supportive care is a high priority in service redesign.

I hope that by sharing my experience, fellow commissioners will take on board the potential of the ambulatory care model in terms of patient satisfaction and ability to release savings for the health economy. I also hope that we can continue to advocate for the role of key worker within cancer pathways and underline the importance of third sector organisations within an integrated patient pathway.

Together these innovations can both help us improve the productivity of clinician to patient time, avoid unnecessary non-elective admissions and deliver the world class cancer care that we all wish to provide.

Charles O’Hanlon is associate director for delivery at Newham CCG