In 2022 a 12-month Cancer Care Review pilot was launched across two Primary Care Networks (PCNs) in Calderdale, supported by the West Yorkshire & Harrogate Cancer Alliance.
Cancer Care Reviews are a requirement of the Quality Outcomes Framework that all GP Practices must adhere to, and the pilot aimed to improve the uptake and patient experience of reviews by identifying alternative members of the healthcare team who could offer support to patients in a more holistic way.
Within Upper Calder Valley Primary Care Network (PCN) and North Halifax Primary Care Network (PCN) Care Coordinators and Social Prescribing Link Workers were identified as a possible solution. The roles were then upskilled in the knowledge of cancer, an understanding of the cancer care pathway and how to support patients with a cancer diagnosis.
This training also included the development of an education plan, competency framework and shadowing clinical teams within secondary care to ensure Care Coordinators and Social Prescribing Link Workers were equipped with what they needed to appropriately support patients. The roles were then tasked to deliver cancer care reviews in primary care, with a clear escalation process in place should a clinical concern be identified and require the necessary clinical expertise.
Prior to the pilot, cancer care reviews were carried out by GPs and Healthcare Assistants which often meant they were very clinically focused with appointments offered for 10 minutes.
Appointment slots with Social Prescribing Link Workers and Care Coordinators have the potential to be longer, benefiting from an established vast knowledge of community services and supportive networks. The pilot aimed to utilise this knowledge to ensure individuals with a cancer diagnosis also have their non-clinical concerns addressed, thereby ensuring they can access the invaluable holistic support available from their local communities.
Upper Calder Valley PCN Pilot – November 2022 to November 2023
Social Prescribing Link Workers and Care Coordinators in the Upper Calder Valley are employed by Pennine GP Alliance to support the needs of patients registered with Hebden Bridge Group Practice, Todmorden Group Practice and Calder Community Practice.
For the pilot, the upskilling of a Social Prescribing Link Worker was led by the local Macmillan Community Personalised Care Lead and the package of support and resources provided included:
- Introductory sessions to explore what a cancer care review is, the skills and knowledge required, and educational and training resources available.
- Directory of online educational resources about cancer, cancer care reviews and the support available for people affected by cancer from Macmillan and other organisations.
- Shadowing of clinical teams within secondary care
- Competency framework, template and evidence portfolio for participants and their line managers to assess and document their competency and development during the course of the pilot.
- Monthly peer reflection sessions for participating staff to meet virtually and share reflections on their experiences as the pilot progressed.
- Collection of data for case studies and patient/staff feedback
- Extensive dedicated support from the Macmillan Community Personalised Care Lead to help with troubleshooting and addressing queries or concerns as the pilot progressed.
The social prescribing link worker then began directly supporting patients who were due a cancer care review and offering the appropriate support via a phone call, face-to-face or a home visit.
How Cancer Care Reviews are carried out in Upper Calder Valley PCN
Evaluation
From January 2022 to October 2022 (before the pilot was introduced) there was a total of 294 cancer care reviews undertaken by a GP or Healthcare Assistant to support patients in the Upper Calder Valley PCN.
From November 2022 to November 2023 (duration of the pilot) this increased to 472 cancer care reviews undertaken by a Social Prescribing Link Worker. Which equates to an overall 60% increase.
In addition, the duration of each cancer care review was extended, allowing for a more thorough and holistic approach. This enabled the Social Prescribing Link Worker to provide support for non-clinical issues, resulting in a more comprehensive review, with increased referrals into local cancer support groups. This increase in referrals signifies improved access to additional support services for individuals undergoing cancer treatment or living with a cancer diagnosis.
The pilot may have come to an end, but for the foreseeable, any patient diagnosed with cancer who is registered at a GP practice within the Upper Calder Valley PCN will be offered a 3 month and 12-month cancer care review with a Social Prescribing Link Worker.
In summary, the pilot was successful, marked by an overall increase in cancer care reviews and overwhelmingly positive feedback from patients and staff.
Feedback from patients:
“I felt the review was very beneficial, as recovery is slow and having contact with Nadia helps me to understand where I’m at. Nadia’s contact helps with mental wellbeing and alleviates isolation. I truly believe this contact is very beneficial.”
“Very reassuring to have a contact in the surgery in case I need some advice. In the referral letter with the appointment time, I would have liked to know I wasn’t going to speak to a clinician so I could ask a question about my tablets to the pharmacist or someone more appropriate.”
“It was a positive chat about moving forward and felt really supportive. There is help there if needed.”
“No improvement required. I was surprised and pleased to receive the initial letter from Hebden Bridge Group Practice. Good to know there’s help available in my area.”
“I am confident that I will benefit from further help as my treatment continues as my radiotherapy is due in early October 2023.”
“As it was my first time, I felt personally at ease talking and could not think how you could improve.”
“Guaranteed future funding for it! It was really good to know that whilst I am currently managing really well, I can contact them in the future if I need them.”
“The coordinator was well informed & with appropriate access to my medical records.”
“Couldn’t do enough for me plenty of support.”
Feedback from West Yorkshire and Harrogate Cancer Alliance:
“A huge well done to everyone involved in this fantastic piece of teamwork. It’s great to see how committed and enthusiastic colleagues have embraced the opportunity to get involved and make a real difference for patients.”
Dinah Coggon, Macmillan Community Personalised Care Lead, West Yorkshire and Harrogate Cancer Alliance said:
‘It has been a pleasure to observe the progress of our Social Prescribers and Care Coordinators in this project. Their increasing confidence and expertise, along with their deep understanding of local resources, are invaluable in addressing non-clinical support needs and connecting patients with essential services. Seeing the uptake of cancer care reviews increase and more importantly the patients’ experience improve, is rewarding. It’s reassuring to know that individuals affected by cancer are receiving personalised support within their local community.’