Newsletter Spring 2017

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Maud Charles
5 years ago
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Nowadays many people who are diagnosed with cancer are living with their disease as a long term condition and they need support out in their communities.

That s how we can help save lives. Cancer is changing, society is changing and the NHS is changing.

The media tell us we re in crisis. We agree, and we tell each other we re in crisis. Our patients worry because we re in crisis. But what do we mean and what are we going to do about it?

1 Newsletter Spring 2017 Primary Care's important role in cancer services I m a GP, with a practice in Ebbw Vale and for the last few years I ve been involved with initiatives that look at the role of primary care in cancer services. Ten years ago not many people would consider primary care to play a major role to play in cancer services but the disease has changed. Nowadays many people who are diagnosed with cancer are living with their disease as a long term condition and they need support out in their communities. As well as providing long term support we also have a part to play in securing an early diagnosis for our patients and making sure they start their treatment plan as quickly as possible. That s how we can help save lives. Cancer is changing, society is changing and the NHS is changing. We are all aware of the increasing pressures facing the NHS and I m reminded of the pressures on a daily basis at my own practice, within my wider Health Board and by regular headlines in the media. The media tell us we re in crisis. We agree, and we tell each other we re in crisis. Our patients worry because we re in crisis. But what do we mean and what are we going to do about it? A crisis is a time of intense difficulty when important decisions need to be made. If these decisions are not handled correctly the crisis can turn into a catastrophe. Decisions we make now will have great and long lasting impacts. Money is short so we need different tools to respond to our crisis situation. Stoic philosophers believe that we become wiser by adversity. During times of relative prosperity we get on with our work, we look after our patients, addressing problems as they arise, solving our issues, moving on. When times are good we don t choose to stop, take a good look and consider new ways of solving problems. But when the pressure s on and we have no choice, this is often the time of new ideas, innovation, collective momentum and an appetite for change. I ve been working with a team of GPs and Nurses on the Macmillan Framework for Cancer in Primary Care programme for the last 12 months. During this time I ve met many like minded colleagues from primary, secondary and tertiary care who all have the same goals in mind. We want to make it very clear to all primary care professionals that they have an important role to play in delivering cancer services to the people of Wales.

We want to tackle those long established challenges of better integrating cancer services, and communication, between primary and secondary care.

The Cancer Delivery Plan for Wales 2016 to 2020 talks about the importance of post treatment support and helping people to feel better supported once their acute treatment ends.

2 We want to tackle those long established challenges of better integrating cancer services, and communication, between primary and secondary care. It makes sense, it s do-able and from what I m seeing we ve now got a very real opportunity to make it happen. We re also backed up by policy. The Cancer Delivery Plan for Wales 2016 to 2020 talks about the importance of post treatment support and helping people to feel better supported once their acute treatment ends. It recognises the important role of primary care to provide this support in the community and the importance of making sure that we all signpost our patients to the network of support that exists locally, whether it s through our practice, from patient self-help groups or third sector support. As part of the Macmillan Framework for Cancer in Primary Care we are starting to build a Framework of cancer resources for primary care. The Framework will be available online to all primary care professionals and you can use it in whatever way you find useful for you and your practice. Its content will be assessed and evaluated by an expert panel but we will consistently ask you what you find useful and what you don t. Your feedback and input will help to shape the Framework in the long term. The Framework will cover all aspects of cancer services and is designed to be a valuable go-to resource for any primary care professional who needs information, resources, advice or anything else to help them provide the best cancer service for their patient. We will be working on it with you, taking your advice on what you find useful and what you don t. You ll be able to engage through a variety of channels, from online through to arranging to meet up with one of the team. The Framework will go live in the Autumn of this year. Dr Clifford Jones Lead GP for Wales, Macmillan Framework for Cancer in Primary Care programme Vague Symptom Diagnosis Service project The Vague Symptom Diagnosis Service project has been set up to help diagnose cancer at an earlier stage, with the aim of improving treatment and even curing the disease in some cases. Diagnosis Centres in Denmark have helped to take Denmark from the lower end of the cancer survival league to catching up with the best performing European countries.

GP, Dr Heather Wilkes, is working with specialist colleagues in Abertawe Bro Morgannwg University Health Board to develop a Vague Symptom Diagnosis Service based on the Denmark model.

years depending on outcomes and funding. It will open on the 6 th of June, 2017.

3 GP, Dr Heather Wilkes, is working with specialist colleagues in Abertawe Bro Morgannwg University Health Board to develop a Vague Symptom Diagnosis Service based on the Denmark model. A Rapid Diagnosis Centre (RDC) project group has been set up at Neath Port Talbot Hospital to pilot a RDC clinic service for three GP Clusters in Neath Port Talbot, running from six months to two years depending on outcomes and funding. It will open on the 6 th of June, The project group is developing a pathway and testing whether the model of direct GP access to rapid diagnostics within the clinic setting, as seen in Denmark, can work in Wales. Prostate cancer follow up pathway Every year, approximately 400 patients are diagnosed with prostate cancer in Hywel Dda University Health Board. This equates to an average of 57 patients for each of the seven GP clusters in the area. Those patients who are stable two years after radical prostatectomy could be offered support closer to their own homes. Dr Savita Shanbhag, our GP Lead for Hywel Dda, is part of a team working on a pilot project in GP clusters where nurses provide ongoing care for patients with prostate cancer in the community. The hope is that the partnership between the Urology Cancer Multi Disciplinary Team and primary care clusters will enable prostate cancer patients to receive holistic care in a community setting. The transition from acute treatment to living with cancer in the longer term Around four out of ten people in Wales will be diagnosed with cancer in their lifetime, and the incidence rate is increasing. For many people cancer is now a chronic condition that requires long term care. We know that the transition from acute treatment back to primary care is an area of particular vulnerability with patients telling us they feel like they ve fallen off a cliff at this point and don t know where to turn to for support and advice.

Juliet Norwood, our Regional Lead Nurse in South East Wales is part of a team working on a pilot project to improve the patient experience during this transition from acute treatment.

4 Juliet Norwood, our Regional Lead Nurse in South East Wales is part of a team working on a pilot project to improve the patient experience during this transition from acute treatment. The project aims to ensure that all newly diagnosed cancer patients in a GP Practice are offered a cancer link worker, a Holistic Needs Assessment and a co-produced care plan by the Practice Nurse within six months of their diagnosis. This will help them navigate the complex cancer journey and feel supported throughout as they transition from acute to primary care and start to live with the consequences of their cancer and its treatment in the long term. Standardising format of letters Velindre consultants Every day GPs receive a significant amount of mail about a variety of patients. Currently a lot of this correspondence is lengthy and not always as relevant as it could be, leading to requests from secondary care being accidentally overlooked. Dr Elise Lang, our GP Lead for Velindre NHS Trust is part of a team who is reviewing, simplifying and standardising the format of information being sent to GPs from Velindre. The team is simplifying the process for creating one treatment plan for the patient that is then used by all clinicians involved in their care, whether they re based in primary or secondary care. This allows for a more unified approach to the patient s care. Primary Care Support to Velindre Transforming Cancer Services Education Programme Velindre s Transforming Cancer Services Education Programme (TCS) hopes to deliver a world leading research and education centre for all those involved in cancer care. Dr Elise Lang, our GP Lead for Velindre NHS Trust is facilitating ways of providing primary care support and advice to the TCS programme. Specifically Dr Lang is working with the programme to look at how patients can receive the best possible medical care and support at home and in the community.

As part of the programme Macmillan Cancer Support is providing a network of GPs in each health board to help identify problems and improve cancer care from referral to diagnosis, through treatment to

5 As part of the programme Macmillan Cancer Support is providing a network of GPs in each health board to help identify problems and improve cancer care from referral to diagnosis, through treatment to survivorship issues in the longer term. Powys Primary Care Holistic Needs Model In 2014, 954 people in Powys were diagnosed with cancer. Powys Health Board is unique as it does not have any specialist cancer nurses in the community. For people in Powys once they are discharged from their acute treatment in hospitals the specialist cancer nurses are unable to continue providing care because of geographical distances and caseload capacity. Our Lead Nurse for Wales, Sue Llewelyn, is working in partnership with Wales Cancer Network and Powys Teaching Health Board on a project that aims to provide cancer patients in Powys with locally based Community Cancer Nurse who will work closely with primary care, facilitating education and support for practice nurses, district nurses, community Resource Teams, therapies to enable them to undertake an effective cancer care review, incorporating assessment of holistic needs of the person affected by cancer. The role will support a holistic person centred approach through a personal Holistic Needs Assessments and an individual care plan for each patient. The Community Cancer Nurse pilot will signpost patients to services that are available to them locally and explore new ways of working to improve cancer services for patients in Powys. This project is currently being piloted in selected clusters. How to Contact us: All Wales GP Lead: Dr Clifford Jones Clifford.jones@wales.nhs.uk GP Lead Aneurin Bevan: Dr Mary Craig Mary.craig@wales.nhs.uk GP Lead Abertawe Bro Morgannwg: Dr Heather Wilkes Heather.wilkes@wales.nhs.uk

6 GP Lead Betsi Cadwaladr: Dr Hayley Crumpton GP Lead Cardiff & Vale: Dr Rachel Lee GP Lead Cwm Taf: Dr Sriram Rao GP Lead Hywel Dda: Dr Savita Shanbhag Lead for Powys: Dr Karen Gulley, Medical Director GP Lead Velindre: Dr Elise Lang All Wales Nurse Lead: Susan Llewelyn East Wales Regional Nurse Lead: Juliet Norwood North Wales Regional Nurse Lead: Emma Groves West Wales Regional Nurse Lead: Hayley Phillips

106,717 people accessed mental health. 192,192 access A&E. 1,011,942 patient contacts with community staff. 2,245,439 patient contacts

106,717 people accessed mental health. 192,192 access A&E. 1,011,942 patient contacts with community staff. 2,245,439 patient contacts Employs 15,285 2,245,439 patient contacts 192,192 Assisted 91,360 Dispensed 13,598,605 prescription items** 38,107 1,011,942 patient contacts with Across 11 clusters, 540,850 people are registered with