Oncology Nurse Led Clinics

Oncology Nurse Led Clinics An economic assessment of Breast Open Access follow up and Uro-Oncology Clinical Nurse Specialist Clinics Understanding the service The Great Western Hospital Foundation Trust provides cancer services primarily to people living in Swindon and North Wiltshire. Predicted activity figures across all tumour sites demonstrates a steady rise in cancer diagnoses (Appendix 1 and 2). The number of people living with cancer is expected to increase from 2 million to 4 million by 2030 [National Cancer Survivorship Initiative (NCSI), 2013]. This means the number of people requiring specialist care and support will increase through the cancer pathway. The NHS Five Year Forward Report (2014) acknowledges, the healthcare system cannot remain in status quo but needs new models of care to support service delivery. The Cancer Clinical Nurse Specialist can help to improve the quality of life for people with cancer. They can also help empower patients to self-manage their conditions leading to reduced costs for health care providers through hospital appointments, emergency admissions and consultant time. The National Cancer Survivorship Initiative (NCSI) in collaboration with NHS England and Macmillan reviewed follow up practice and made recommendations on the stratified cancer pathway. The table below provides suggested pathways. 1

For the purpose of the economic assessment, the Breast and Uro-Oncology nurse led clinics were selected to undertake an economic assessment of the nurse-led clinics against traditional practice. Clinical Nurse Specialists (CNS) provide specialist advice and support for patients diagnosed with cancer acting as key worker in accordance with National Cancer Peer Review requirements. With an aging population and more people being diagnosed with cancer, the teams have developed their service to meet the needs of their patient population. CNSs are at the front-line of cancer care; they are the main point of contact for patients and as a result help to deliver personalised care for each patient according to need and patient choice, which contributes to wider cancer priorities. CNSs play an important role in enabling care to be delivered closer to home and in improving patients ability to self-manage symptoms and side-effects of treatment. The supportive care and information element of the Cancer Clinical Nurse Specialist role should not be underestimated in enhancing the patient experience. This includes providing support for the patient/carer at initial diagnosis, individualised information provision, assisting and supporting with treatment decision making, advice on management of symptoms and side effects, support and assistance with practical issues such as finance, providing emotional and basic (level 2) psychological support, signposting to specialised and support services providing continuity of care. Both during and at the end of treatment the CNS can provide holistic follow-up within a nurse-led clinic. The most recent national cancer strategy 2015-2020 Achieving World Class Outcomes emphasizes the importance of the role of the cancer clinical nurse specialist and is the single most important factor for ensuring a positive patient experience. To support the increasing activity and pressures on traditionally medically led clinics, the CNS team have introduced nurse-led clinics to enhance efficiency in the pathway and patient experience. The team have the appropriate skill and education to provide the nurse-led clinic providing a more holistic assessment and ensuring all questions are answered meeting the patient s needs. This skill is acknowledged by the wider cancer multi-disciplinary teams (MDT) with the MDTs supportive of the clinical development. Whilst no additional CNS were recruited for the delivery of these clinics, the development of clinics would have been difficult if the team had not increased in size to support the increasing patient numbers. It is through improved efficiency in the clinical pathway that the team have been able to include this activity. The following are a summary of nurse led clinics held by the breast clinical nurse specialists. The clinic to be evaluated in the economic assessment is the breast open access follow-up (OAFU). Whilst the tariffs can be provided, it is evident following discussion with the finance team that the elements making up a tariff are not clearly known. With the OAFU clinic a specific tariff was negotiated with the local clinical commissioning group reflecting the time and activity provided in this clinic. 2

The nurse led clinics for Breast CNS: Clinic Frequency Activity Description Traditionally-led Breast Open Access follow-up clinic Weekly 5 patient slots 1hour each End of treatment summary, Holistic Needs Assessment Signposting to Living Well events Clinical Oncologist Surgeon annually for up to 5 years. Ad-hoc & virtual clinics As required Seroma drainage/surgical clinics Telephone clinics which stop a traditional outpatient appointment Surgeon Oncologist Breast Enhanced recovery clinicpre-operative assessment Weekly 45 minute slots 8 patients Clinic supporting enhanced recovery for breast surgery Surgeon The Uro-Oncology CNS nurse led clinics: The following are a summary of the range of nurse led clinics held by the urooncology clinical nurse specialists. For the focus of the economic evaluation, the prostate biopsy results clinic will be used. Clinic Activity Description Traditionally-led Radiotherapy Follow-up Men reviewed 6 weeks Clinical Oncologist Clinic following radical/palliative radiotherapy to the prostate PSA/Support Clinic Monitoring PSA results in Urologist clinic PSA Telephone Clinic Monitoring stable PSA Urologist results via telephone clinic E-HNA Clinic Holistic Needs Assessment Nurse-led Clinic Andrology Clinic Erectile Dysfunction style Urologist clinic TURBT Clinic Provision of bladder histology results following surgery Urologist Prostate Biopsy result clinic Virtual Provision of prostate biopsy results following MDT discussion Telephone and in person review ad hoc supporting patient need and reducing need for consultant review/admission Urologist Nurse-led 3

Breast OAFU Clinic: In 2012, in line with the NCSI recommendations, the breast MDT with patient involvement, reviewed standard follow up practice for patients following adjuvant breast cancer treatment. Metastatic breast patients are not included in this pathway. Adjuvant follow-up included annual review by the surgical and oncology teams for 5 years. Most patients were discharged at this time but for some psychologically they preferred on going annual review to ensure access to the system if required. With the breast open access follow up clinic (OAFU), following the completion of adjuvant treatment (surgery, chemotherapy & radiotherapy) the patient is referred for an end of treatment summary, holistic needs assessment and signposting to living well events and support groups. The patient is given written information listing treatment to date and advice on symptoms that require rapid access back into the healthcare system. A telephone number is provided to call if required for an urgent appointment in the breast clinic within 2 weeks. This stops the follow up of adjuvant breast cancer patients on an annual basis in both the breast surgical clinics and oncology clinics for up to 5 years. This type of follow up reduces the anxiety associated with routine follow up and empowers the patient to access at time of need with symptoms of concern. Anecdotally recurrence is often diagnosed between routine appointments and results in a person requiring an additional appointment or people waiting with symptoms until the next follow up appointment. Whilst 18 patients have re-accessed the service to date no one was diagnosed with a recurrence. This correlates with national work where the figures are presumed small. Financially the nurse led service is cost effective, meets national guidance and has met the patients needs demonstrated in a patient experience survey and Family & Friends testing. There have been no complaints received nor any incidents reported for this service. One Band 7 CNS conducts the OAFU clinic but two other CNS are also skilled to conduct the clinic to ensure it is not cancelled at times of leave. The nurses have completed the breast care module at the Royal Marsden Hospital. These clinics require suitably trained specialist staff. The nurses do not receive any health care assistant support to run the clinic nor prep the notes. The CNS spends approximately 2 hours per week prepping clinics. The patient pathway facilitator supports the maintenance of the OAFU database, approximately 2 hours/week. For a small cost, a health care assistant supporting the clinic and note preparation would reduce CNS time. It would also provide equality in service provision. Support of medical clinics is a given within the Trust but not supported for nurse clinics providing similar activity. 4

Traditional Medical Follow-up Early Breast Cancer- Surgery, Chemotherapy, Radiotherapy, Hormone treatment as required Open Access Follow-Up CNS led Early Breast Cancer- Surgery, Chemotherapy, Radiotherapy, Hormone treatment as required Traditional follow-up: Annual outpatient appointment with Breast Surgeon (4 OPA) Annual outpatient appointment with Oncologist (4OPA) CNS may also be in attendance at this appointment. Open Access Follow-Up (OAFU) 1 Nurse led appointment (1hour) to complete End of Treatment Summary, Holistic Needs Assessment and signpost to living well/support groups Annually, 230 clinic slots released for both breast surgery and oncology allowing the consultant to see new patient/increasing activity. This will result in increased income for the Trust from new patient tariff. OAFU Tariff 164 5 appointments weekly 164 x5= 820 820 x46 clinics/year= 37720 Annual number of patients: 230 This is about efficiency in the pathway and the release of outpatient appointments for increasing predicted activity and the more complex patient pathway. This will increase service capacity allowing consultants to see more new patients and this comes with a higher tariff. Cost of a 3 hour consultant clinic (usual sessional clinic time- BMA reference cost) 891 230 patients x 8 OPA (1 patient f/u OPA over 4 years) = 1840 appointments released for new patients. It is acknowledged the Trust and nationally we are seeing increasing predicted activity & more complex patient pathways. From 1 year of activity, 920 Breast surgery appointments released over 4 years 920 Breast oncology appointments released over 4 years. A small percentage of patients will reaccess the service. Cost for Breast OAFU clinic 572 654 with HCA support 5

Key benefits of this innovation For those using the service: Enhanced patient experience Patient pathway meeting NCSI guidance supporting Living Well & National cancer strategies. Fewer appointments at the hospital, possibly reduction of 4 years follow-up. Psychological benefit allowing patient to move forward, live well & selfmanage. Holistic patient assessment To the healthcare system: Efficiency in pathway Enhanced tariff Release consultant time to see new patients improving access to service & receiving enhanced activity Cost effective service- right band/right skill New patient tariff from increasing activity and OPAs released for Consultant activity Quality service To the wider health and social care system: Appropriate tariff for OAFU clinic Release of consultant time to new or more complex patients. Increasing activity figures- support clinical demand. Key costs of this innovation: The set up and running costs are listed in more detail in Appendix 3 and 4 Set up costs Direct 6043 Indirect Nil Total 6043 Weekly Running costs 572 654 with HCA support Training costs Breast Marsden Module 970 Nurse-led clinics conference 175 It should be acknowledged that these costs are listed in the set-up costs but the CNS requires this training for the specialist role. 6

Demand for this clinic is outstripping supply. The clinic currently has a 6 month waitlist which does not meet national recommendations. A further clinic is required. Uro-Oncology Clinics: The uro-oncology clinical nurse specialists have established numerous nurse-led clinics to support patient need and increasing patient numbers. The clinics have ensured timeliness of access to treatment for patients with urological cancers within national treatment target times. The prostate cancer biopsy clinic improves efficiency in the patient pathway, particularly and will be the focus of this economic assessment. The CNS provides the diagnosis and treatment options following multi-disciplinary team (MDT) discussion and arranges onward referral to appropriate team (urology or oncology). This is releasing consultant Urologist capacity to see more complex and new patients which brings additional revenue at a higher tariff. The CNS supports the patient decisionmaking to determine which clinic the patient returns (surgical or oncology). On average this improves the patient pathway and experience reducing timed pathway by 14 days. Cancer patients will be on a timed pathway subject to 31 & 62 day targets. The CNS clinic will on average release 2 outpatient consultant appointments improving capacity with the consultant clinics for the increasing activity and the more complex patient. The three nurse specialists can support any of the clinics to ensure cover throughout the year and at times of leave. The nurses do not receive any health care assistant support to run the clinic nor prep the notes. The CNS spends approximately 4 hours per week prepping all clinics that could be undertaken by a band 2 health care assistant. The prostate biopsy clinic takes up to one hour to prep. The tariffs have not been included for the uro-oncology clinics but following discussion with the finance team the breakdown of the tariff is not known. No specific tariffs have been negotiated for these clinics. 7

Weekly Clinic Timetable Clinic Day No of patients Length of appointments Radiotherapy Follow-up Clinic Monday PM 4 30 minutes Total: 120 mins PSA/Support Clinic PSA Telephone Clinic Tuesday PM 5 10 minutes Total: 50 mins Tuesday PM 12 10 minutes Total: 120 mins E-HNA Clinic Andrology Clinic TURBT Clinic Wednesday PM Weeks 1 & 3 Thursday PM Weeks 2 & 4 Friday AM week 1 & 3 PM week 2 & 4 5 th Friday if needed 3 45 minutes Total: 135 mins 4 45 minutes Total: 180 mins 5 20 minutes Total: 100 minutes Prostate Biopsy result clinic Friday AM week 2 & 4 PM week 1 & 3 5 th Friday if needed 5 30 minutes Total: 150 minutes This does not include virtual activity. 8

Prostate Biopsy Results Clinic Traditional medical follow-up Consultant first appointment- Assessment Uro-Oncology CNS follow-up Consultant first appointment- Assessment TRUS Biopsy- Radiology TRUS Biopsy-Radiology MDT Discussion MDT discussion Results provided with Consultant and CNS MRI arranged as required MDT discussion following MRI Results provided by CNS MRI arranged as required MDT discussion following MRI Results OPA & treatment discussion by Consultant & CNS Results OPA & treatment discussion by CNS Surgical or Oncology OPA Cost for a 3 hour consultant clinic 891 (BMA reference costs) Surgical or Oncology OPA Cost for a CNS clinic 138 With HCA support 158 & release of 2 consultant appointments 9

Suspected Prostate Cancer Patient Pathway- Timed pathway comparison Appointment Schedule Previous Pathway Number of days New Pathway Number of days Doctor CNS Assessment OPA 11.8.15 Consultant 20.10.15 Consultant TRUS Bx 20.8.15 9 27.10.15 7 Results OPA 11.9.15 Consultant & CNS 22 13.11.15 CNS 17 MRI 21.9.15 10 25.11.15 12 Results OPA & Treatment discussion 9.10.15 Consultant & CNS 18 59 days 4.12.15 CNS (some consultants may continue with this element of the pathway) 8 45 days Oncology OPA 16.11.15 Consultant & CNS 38 11/1/16 Oncology OPA 38 Total Days Doctor 97 days CNS 83 days Not only did the CNS pathway save 14 days from time of referral to appointment with an oncologist, it also released two consultant appointments on the pathway. This is significant when considering patient numbers expected in the future. This would improve consultant clinic capacity and allow the doctor to see more complex or new patients. New patient appointments receive a higher tariff to follow up. To provide the clinics two of the CNS have completed the Royal Marsden Hospital Uro- Oncology module and attended the nurse-led clinic study day. Both staff are undertaking Master s programme. These clinics need suitably trained specialist staff. Key benefits of this innovation For those using the service: Enhanced patient experience Expedite patient pathway- reducing cancer diagnostic pathway for prostate cancer by 14 days & stopping 2 Urologist appointments. Holistic patient assessment 10

To the healthcare system: Two consultant appointments released Efficiency in pathway and possible reduction in cancer breaches. Patient pathway subject to 31 and 62 days cancer target. Release consultant time to see new or more complex patients improving access to service Cost effective service- right band/right skill New patient tariff from increasing activity and OPAs released for Consultant activity Quality of service To the wider health and social care system: Appropriate tariff Release of consultant time to new or more complex patients. Increasing activity figures - support clinical demand. Key costs of this innovation: The set-up and running costs for this clinic are listed in more detail in Appendix 3 and 4. Set-up Costs Direct 1106 Indirect Nil Total 1106 Weekly running costs With HCA support 138 158 There is a potential for further savings by a health care assistant supporting the clinic and prepping notes. This would release 2 hours of a band 7 CNS time for clinical activity. Training costs GU Marsden module 970 Nurse-led clinics conference 175 This training is required as part of the specialist role and not specifically just for this clinic. 11

Conclusion: The running for each of the clinics incurs similar costs except for the difference in staffing costs and HCA support to the clinic. The weekly running costs have been compared with only the differences listed as per the running templates in Appendix 4. Where costs have been the same, they have not been included. Summary of clinic set-up and running costs Clinic type Traditional Medically led Consultant clinic Prostate Biopsy Clinic- Uro- Oncology CNS Breast OAFU clinic Breast CNS Cost for 3 hour clinic Set up costs 1106 6043 Weekly running costs 891 138 572 With HCA support: Not supported currently 158 Saving: 24.69 & release 2 hours CNS time for clinical activity 654 This would potentially release 1 hour of CNS time to see an additional patient. Additional benefits Release 2 consultant appointments for new activity at a higher tariff. Reduction in follow-up appointments for possibly 4 years. Annual appointment with surgeon and oncologist cease. This releases consultant appointments for new activity at a higher tariff. Enhanced tariff for nurse-led clinic 12

The biggest impact from the nurse-led clinics is to the patient having a reduced timed pathway to treatment and also to the Consultants who will see the release of sessions each week for new & more complex patients. The Trust also benefits from additional revenue from the consultants seeing more new patients at a higher tariff. Feedback from patient survey s and from family & friends testing for nurse-led clinics has been very positive with all comments positively acknowledging the holistic and comprehensive assessment supporting shared decision-making. Whilst comparison of outcomes demonstrates more patients are reviewed in the medical clinic, the medical clinic will see a wider variety of specialty patients including non-cancer and cancer patients. For patients with a cancer diagnosis, the feedback to date suggests, that the outcomes from a nurse-led clinic experience is equivalent with having health care needs met but with more quality time having concerns listened to and supported. The patients in nurse-led clinics are reviewed earlier in the pathway in comparison to a medical pathway. No complaints or incidents have been noted in these clinics suggesting outcomes for both types of clinics are similar and worthy of comparison. The economic assessment has demonstrated the value of nurse-led clinics providing a service positively evaluated by patients that is value for money. Clinical teams also value the support of nurse led clinics and the time this releases for more complex patients and new patients. Clinical Nurse Specialist clinics improve quality of the service, release capacity in medical clinics and generate income via tariff. Recommendations: Where additional clinics are required; Trusts to recognise value of nurse led clinic and not default to further medical services. For this economic assessment to be repeated across all oncology clinical nurse specialist clinics An additional OAFU clinic be resourced to meet patient demand allowing appropriate capacity Health care assistant support provided for all nurse led clinics to improve efficiency and ensure right staff with right skill doing the job. 13

References 1. National Cancer Survivorship Initiative (2013) Living with and beyond cancer: Taking action to improve outcomes, London. 2. Royal College of Nursing (2010) Clinical nurse specialists: adding value to care. An executive summary. London. 3. http://alisonleary.co.uk/docs/rcn%20study%20adding%20value%20to%20 Care%20the%20work%20of%20the%20CNS..pdf (Accessed 25November 2015) 4. https://www.rcn.org.uk/employment-and-pay/nhs-pay-scales-2015-16 (Accessed 13 December 2015) 5. http://bma.org.uk/support-at-work/pay-fees-allowances/payscales/consultants-pay-england (Accessed 13 December 2015) 6. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file /300549/Annex_4A_Additional_info_on_currencies_with_national_prices.pdf (Accessed 13 December 2015) 7. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file /214902/PbR-Guidance-2013-14.pdf (Accessed 13 December 2015) 8. https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf (Accessed 28 January 2016) 9. http://www.cancerresearchuk.org/sites/default/files/achieving_worldclass_cancer_outcomes_-_a_strategy_for_england_2015-2020.pdf (Accessed 30th January 2016) 10. http://www.bma.org.uk/support-at-work/pay-fees-allowances/fees/feefinder/fee-finder-government-agreed-fees-consultants (Accessed 30th January 2016) 11. https://www.rcn.org.uk/employment-and-pay/nhs-pay-scales-2015-16 (Accessed 30th January 2016) January 2016 This case study was completed by Lyndel Moore, Cancer Nurse Consultant, Trust End of Life Lead Nurse at The Great Western Hospital Foundation Trust in January 2016. Lyndel successfully completed a collaborative learning programme designed to empower nurses to understand, generate and use economic evidence to continuously transform care. The programme was delivered by the Royal College of Nursing and the Office for Public Management, funded by the Burdett Trust for Nursing and endorsed by the Institute of Leadership and Management. You can contact Lyndel by email lyndel.moore@gwh.nhs.uk. 14

Appendix 1 The following table provides indicative figures for cancer diagnoses locally for the next twenty years. This is then broken into predictive figures for the two main Clinical Commissioning Groups (CCGs)- Swindon and Wiltshire, however patients may also attend from Berkshire, Oxfordshire, Gloucestershire and Avon. Table 1 : Forecast increase in cancer diagnosis for GWH 15

Appendix 2: Table 2 : Swindon CCG forecast new diagnoses at GWH NUMBER OF PATIENTS DIAGNOSED 2015 2016 2017 2018 2019 2020 2026 BLADDER 30 31 31 31 32 32 35 BREAST 167 169 171 172 174 176 186 CERVIX 7 7 7 7 7 7 7 CNS 15 15 15 15 15 16 16 COLON 92 94 96 98 100 101 113 ENDOMETRIUM 27 27 28 28 29 29 32 HEAD AND NECK 29 29 30 30 31 31 35 HODGKIN LYMPHOMA 6 6 6 6 6 6 6 KIDNEY 28 29 30 30 31 32 37 LEUKAEMIA 25 26 26 26 26 27 28 LUNG 114 116 117 119 121 123 136 MELANOMA 41 42 43 44 46 47 57 MYELOMA 13 14 14 14 14 14 15 NHL 33 33 34 34 35 35 39 OESOPHAGUS 29 29 30 30 31 31 34 OTHER TUMOURS 110 112 114 115 117 119 130 OVARY 23 23 23 23 23 23 23 PANCREAS 25 26 26 27 27 28 31 PROSTATE 116 119 122 125 128 131 150 RECTUM 27 28 28 29 29 30 33 SARCOMA 6 6 6 6 6 6 6 STOMACH 23 23 23 23 24 24 25 TESTIS 8 8 8 8 8 8 8 TOTAL 995 1010 1026 1042 1058 1075 1182 Table 3 : Wiltshire CCG forecast new diagnoses at GWH NUMBER OF PATIENTS DIAGNOSED 2013 2014 2015 2016 2017 2018 2019 2020 2026 BLADDER 30 30 31 31 32 32 33 33 36 BREAST 162 163 165 167 168 170 172 173 184 CERVIX 9 9 9 9 9 9 9 9 9 CNS 13 13 13 13 13 14 14 14 14 COLON 83 85 86 88 89 91 93 94 106 ENDOMETRIUM 21 22 22 22 23 23 24 24 26 HEAD AND NECK 23 24 24 25 25 26 26 27 30 HODGKIN LYMPHOMA 5 5 5 5 5 5 5 5 6 KIDNEY 24 25 25 26 26 27 28 29 33 LEUKAEMIA 24 25 25 25 25 25 26 26 27 LUNG 90 92 93 95 96 98 100 101 112 MELANOMA 45 47 48 50 51 53 54 56 68 MYELOMA 16 16 16 17 17 17 17 17 19 NHL 36 36 37 37 38 38 39 40 43 OESOPHAGUS 20 20 21 21 21 22 22 22 24 OTHER TUMOURS 47 48 48 49 50 51 51 52 57 OVARY 17 17 17 17 17 17 17 17 17 PANCREAS 21 22 22 23 23 23 24 24 27 PROSTATE 131 134 137 140 144 147 150 154 176 RECTUM 33 34 34 35 35 36 37 37 41 SARCOMA 6 6 6 6 6 6 6 6 6 STOMACH 15 15 16 16 16 16 16 16 17 TESTIS 5 5 5 5 5 5 5 5 5 TOTAL 878 892 906 921 936 951 966 982 1,083 16

Appendix 3 Set Up Costs: Uro-Oncology CNS clinic Set Up costs-direct costs 2015 Identify Additionality Apportion Full costs Real terms 1CNS Band yes Yes- 8hrs 8hours 18.36 Yes 2.5% 7- time to set of CNS x 8= 146.88 inflation up clinics & time + 22.5%on (1 year) writing protocol, discussing with MDT costs = 169.38 Agenda for change- mid 173 (2015) point payscales (2014) 2 Band 6 Yes Yes- 4 hours each= Yes 2.5% CNS (PCUK apportion 8 8hours total inflation funded x 1)- hours 15.37 (1 year) time to set up clinics, reading x8= 122.96 + oncosts 22.5% = 153.63 (2015) policy, 149.89 discussing with MDT Agenda for change- mid point payscales (2014) Training staff No- required No Each CNS: No within role 970 Royal Marsden Module 175 Nurseled clinic conference MDT approval of protocols for follow-up yes yes 760 1 hour 207 BMA Consultant hourly rate: + on costs Yes 2.5% inflation (1 year) 779 17

22.5%= 253.57 Urologist, Medical Oncologist, clinical oncologist Indirect costs Telephone Patient information Premises IT support/ computer Secretarial support From existing resource From existing resource In kind from Estates In kind from corporate From existing resource Total: 1106 18

Breast OAFU clinic Set Up costs-direct costs Identify Additionality Apportion Full costs Real terms 2012 OAFU Working Group- Medical Oncologist, Surgeon, Cancer Manager, CNS, patient representative, Lead Cancer Nurse 1 Band 7 CNS time to set up clinics, writing policy, writing patient information, setting up new process discussing with MDT yes 8 hours 8hours 1 hour 207 BMA Consultant hourly rate x 2 Consultants = 3312 +22.5%= 4057 CNS8hours 18.36 x 8= 146.88 + 22.5%on costs = 169.38 Band 8 NHS AFC mid-point manager & Lead nurse 25.55 x 2= 51.10 x8= 408.80 +22.5% oncosts= 500.78 Patient Representativevoluntary Yes 37.5hrs 1 week 37.5 hours total 18.36 x37.5hrs= 688.5 0+ oncosts 22.5% = 843.41 Agenda for change- mid point payscales Yes 2.5% inflatio n (4 year) 4372 2012 187 553 Yes 2.5% inflatio n (4 year) 931 19

Training staff No required No Each CNS: No for role Royal Marsden module 970 Indirect costs Premises In kind from Estates IT support/ In kind from computer corporate Telephone In kind from corporate Secretarial From existing support resource Total: 6043 20

Appendix 4 Running Costs per week: Uro-Oncology CNS Running costs-direct costs Identify Additionality Apportion Full costs Real terms Uro- Oncology CNS Band 7 5 hours yes 5hours 18.36 x5= 91.80 + 22.5%on costs = 112.45 Agenda for changemid point payscales 2.5% inflation- 1 year 115 (2015) CNS 1hours 1hours 2.5% Prepping 18.36 + inflation- and 22.5%on 1 year supporting clinic costs = 22.49 Agenda for 23 (2015) change- mid point payscales HCA Band 2 supporting clinic & prepping notes (not provided nor funded currently) 2 hours 8.29 x 2= 16.58 +22.5%= 20.31 Potentia l saving if HCA support s clinic : 24.69 & release 2 hours CNS time 21

Indirect costs (Add rows as required, and indicate year) Premises Computer/te lephone Patient information Secretarial Support In kind In kind charity In kind Total Weekly running cost: 138 158 With HCA support Potential saving if HCA supports clinic : 24.69 & release 2 hours CNS time for clinical activity 22

Breast OAFU Running Costs-Direct costs Identify Additionality Apportion Full costs Real terms Breast CNS (Band 7) Breast MDT Coordinator (Band 4) OAFU MDT Patient Pathway coordinator (Band 4) Updating OAFU database Breast Medical Oncologist (for OAFU MDT) HCA Band 2 supporting clinic & prepping notes (not provided nor funded currently) 10 hours/week yes 10hours 18.36 x10= 183.60 + 22.5%on costs = 224.91 Agenda for change- mid point payscales 1 hours/week yes 10.66 +22.5%= 13.05 Agenda for change- mid point payscales 2 hours/week yes 10.66 x2= 21.32 +22.5%= 26.11 Agenda for change- mid point payscales 1hours/week yes 1 hour 207 BMA Consultant hourly rate +22.5%= 253.57 8 hours 8.29 x 8= 66.32 +22.5%= 81.24 (4 years inflation 2.5%) 248.25 14.41 28.82 279.90 23

Indirect costs (Add rows as required, and indicate year) Premises Computer/telephone database Patient information In kind In kind In kind charity Total weekly running costs= 571.38 24

Urology Consultant Clinic Running costs-direct costs 2015 Identify Additionality Apportion Full costs Real terms Oncology CNS Band 7 3 hours yes 3 hours 18.36 x3= 55 + 22.5%on costs = 67.50 Agenda for changemid point payscales 2.5% inflation- 1 year 69 2015 Urologist 3 hours yes 3 hour 207 BMA Consultant hourly rate +22.5%= 760 780 HCA Band 2 supporting clinic & prepping notes 4 hours 8.29 x 4= 33.16 +22.5%= 40.62 41.63 Indirect costs (Add rows as required, and indicate year) Premises Computer/telephone Patient information Secretarial Support In kind In kind Charity In kind Total Weekly running cost: 891 25

Appendix 5 Pathways to Outcomes: Input Direct costs- Skilled Breast Care Clinical Nurse Specialist to provide Breast OAFU clinic Breast MDT discussion Service provided in outpatient setting 1 day/ week Clinic room Telephone service for assessment and rapid re-access of service if required Telephone line Computer to record Holistic Needs Assessment (HNA)and End of treatment summary Patient information on service and Living well information IT to access PAS and cancer services system Admin staff to upload to IT system & send to GP No direct funding of service Indirect Costs Hospital accommodation/ overheads for clinic room Outpatient team IT support Breast Open Access Follow-up (OAFU): Pathways to Outcomes model Activities & outputs Number of patients seen in OAFU clinic Number of patients awaiting an appointment Number of calls One hour clinic appointment with CNS to complete end of treatment summary (ETS) reviewing history, long term side-effects of treatment, possible signs of recurrence, ongoing care e.g. mammograms & Dexa scan. Hormone treatment. Holistic Needs Assessment (HNA) Advice on self management Referral to Living well day Patient support groups Information on reaccessing service ETS & HNA to GP Patient information 1 Nurse led clinic (1hr clinic review/patient) completing above. Follow-up practice for next 4 years no longer required releasing consultant colleagues to see more complex and rising activity of new patients Groups targeted For intervention Adjuvant/early diagnosis breast cancer patients. Breast surgeons Breast MDT Medical & Clinical Oncologists Administrative support Outpatients department For training All Breast CNS Patient Pathway facilitator For partnership Swindon and Wiltshire Clinical Commissioning groups GP For delivery As for intervention Outcomes Staff outcomes Ability to deliver high quality care & streamline follow-up practice for breast cancer patients Improves quality of patient/nurse experience. Satisfaction of delivering a quality service meeting individual patient needs Nurse-led clinic activity Medical teams release capacity to see more complex and increasing new patient activity. Patient outcomes Patient access to specialist advice supporting Living well and beyond cancer initiative Improved patient experience; less anxious about follow up appointment Psychologically patients able to move forward and live well Organisational outcomes Prevention of inappropriate followup Meet National Cancer survivorship initiative Evidence of economic impact of change In house skills economic evaluation Trust Presentations at external events Potential publications V1 21 June 2015 1 Input Direct costs- Skilled Uro-oncology Clinical Nurse Specialist to provide variety of follow-up Uro-oncology MDT discussion Service provided in outpatient setting Clinic room Telephone service for PSA clinic Telephone line Computer to record Holistic Needs Assessment (HNA)and clinic assessment and letter Patient information on service and Living well information IT to access PAS and cancer services system Secretarial support to send to GP PCUK funding for 1 WTE Band 6 Macmillan 1WTE Band 7 funding (historicalpicked up by Trust) 1WTE funded by Trust Uro-Oncology Clinical Nurse Specialist clinics: Pathways to Outcomes model Activities & outputs Number of patients seen in each clinic PSA clinic Post Radiotherapy clinic Prostate histology clinic Bladder histology clinic HNA clinic Andrology clinic Holistic Needs Assessment (HNA) Advice on self management Referral to Living well day Patient support groups Patient information Groups targeted For intervention Uro-oncology patients. Urologists Urology MDT Medical & Clinical Oncologists Administrative support Outpatients department For training All Uro-oncology CNS For partnership Swindon and Wiltshire Clinical Commissioning groups GP For delivery As for intervention Outcomes Staff outcomes Ability to deliver high quality care & streamline follow-up practice for urology cancer patients Improves quality of patient/nurse experience. Satisfaction of delivering a quality service meeting individual patient needs Nurse-led clinic activity Medical teams release capacity to see more complex and increasing new patient activity. Patient outcomes Efficiency in patient pathway. Time to treatment more efficient Improved patient experience Consultant OPA x2 released allowing review of more complex and increasing patient numbers. Organisational outcomes Efficiency in service with consultants time released to cope with increasing demand and more complex patients. Evidence of economic impact of change In house skills economic evaluation Trust Presentations at external events Potential publications Indirect Costs Hospital accommodation/ overheads for clinic room Outpatient team IT support January 2016 1 26