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Psychological support for people living with cancer

Commissioning guidance for cancer care in London

June 2015

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The London Mental Health Strategic Clinical Network (SCN) and Transforming Cancer Services Team
for London would like to thank all of our patient and carer representatives for sharing their experiences
as a person affected by cancer. Your input has been invaluable throughout the development of the
recommendations and this guidance.

A special thank you to Helen Davies, patient coordinator, whose support to the project and patient and carer
voice representatives has reinforced the benefits of working collaboratively.

Thank you to all steering group members, stakeholders and partners for their time and commitment in
providing their expertise and experiences that has informed this document.

We are grateful to the teams who submitted their case studies providing a wealth of information. The
case studies highlight useful evidence for shared learning across a variety of service models locally and
nationally.

Many thanks goes to the Integrated Cancer Systems (ICS), with particular thanks to Dr Mark Barrington,
chair of the psychosocial expert reference group for London Cancer and Dr Andrew Hodgkiss, co-chair of
the mental health and psychological support pathway for London Cancer Alliance and their ICS teams who
supported the evidence review and mapping exercise of services for patients who are in active treatment.

Thanks also goes to Liz Price, senior strategy lead, living with and beyond cancer, Sarita Yaganti, strategy
implementation lead and Dr Afsana Safa, associate GP for Transforming Cancer Services for London
and Dr Stefan Holzer, specialty registrar at Central and North West London NHS Foundation Trust, who
supported the evidence review, mapping and scoping exercise of psychological support for people living
with cancer across CCGs and the IAPT services in London.

Finally, thank you to Cerrie Baines, Mental Health SCN project manager and Helen O’Kelly, Mental Health,
Dementia and Neuroscience SCN assistant lead who pulled the report together and helped keep this
project on track to produce the guidance we present here.

ACKNOWLEDGEMENTS

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Aims
The enhanced prostate cancer follow-up is a joint project with Prostate Cancer UK. The aim is to develop and
test support needs through a follow-up service in primary care for people with prostate cancer who are stable
at two years after radical treatment or are undergoing “watchful waiting”. The service will support primary care
nurses and GPs to deliver an enhanced care package that is co-ordinated, brings care closer to home and
tailored to the emotional and physical well-being of people in their care. Croydon CCG GP practices are the pilot
site for testing the model.

Rationale
A review of patients being followed-up in the community showed that whilst patients were satisfied with their
follow-up care, the majority have not received relevant information on the potential side effects and consequence
of treatment or signposts to psycho-sexual, social and incontinence services.

The review also highlighted the need for improvements to be made to patient and primary care clinician experi-
ences and access to other services, follow-up processes to shift care from secondary to primary care for suit-
able patients. As part of the follow-up service better outcomes can be achieved by embedding a supportive and
holistic element to individual needs assessments; this will include signposting and referral to local emotional and
psychological support or wellbeing services.

Development
Locally arranged GP clinical network meetings provided an opportunity to discuss issues pertaining to the exist-
ing pathway, the quality of information provided from the hospital, the opportunities to sustain the enhanced
service and GP’s views of a holistic model adapted for primary care. The following points were taken from these
discussions:
» The need to increase GPs awareness of support groups and services and cancer specific charity resources

for signposting people affected by cancer
» The need for a primary care based process to help identify suitable patients for primary care follow-up.

Produce a template for use in follow-up appointments
» To ensure information given to patients about their follow-up care is accurate and relevant
» Ensure the current pathways and processes are appropriate.
» Training required for primary care professionals for managing and supporting people with prostate cancer,

including; prostate follow up system, explicit PSA referral thresholds, symptomatic and psychological red
flags, and safety netting protocols to ensure clinically governed management of referrals between primary and
secondary care.

A prostate cancer urology locally commissioned service (LCS) specification was revised in light of the issues
raised and launched in December 2014. Practices that sign up to the new LCS are required to:
» Complete a minimum one hour training session accredited by BMJ Learning to refresh training gaps.
» Use the patient identifier guide to identify suitable patients on practice lists that could be discharged from

secondary care follow-up to primary care follow-up. GPs to send the list to the secondary care consultant to
formally request discharge and the consultant is to outline follow-up requirements for the patients.

» Offer a 30 minute ‘welcome appointment’ to all newly discharged patients within four weeks of discharge from
secondary care with the primary care nurse or GP. This is an opportunity for the practice to start a holistic care
plan developed for the project which should be reviewed at subsequent follow-up consultations.

» Conduct PSA blood tests and relay results to patients via a PSA consultation appointment using the bespoke
PSA follow-up template specifically developed and designed for integration into EMIS and VISION clinical
systems. This includes the use of validated tools to objectively assess symptoms such as lower urinary
symptoms, erectile dysfunction, low mood and anxiety. Resources to promote self-management of other
symptoms such as fatigue are also embedded in to the template to facilitate signposting to appropriate
resources.

Outcomes
Patients, GPs and practice nurses are invited to complete a survey and send directly to the Transforming Cancer
Services Team (TCST) as part of a full evaluation process of the entire service. An evaluation is due in Decem-
ber 2015.

Contact
Sarita Yaganti, Transforming Cancer Services Team for London, [email protected]

Appendix D: Case study detail | Enhanced prostate care in primary care

mailto:s.yaganti%40nhs.net?subject=

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Appendix D: Case study detail | Islington cancer survivorship programme
Aims
The Islington cancer survivorship programme aims to develop an innovative exercise pathway for cancer survi-
vors to improve their physical and psychological wellbeing during and post treatment which can be implemented
in the cancer care pathway. The intervention seeks to promote the physical and psychological wellbeing of par-
ticipants by supporting a healthy lifestyle in the rehabilitation phase of cancer and promote secondary preven-
tion.

Due to the unique and variable physical problems of cancer survivors, it is deemed appropriate to offer an in-
dividualised programme to meet the needs of each client in addition to the possibility to exercise as a part of a
group. American College of Sports Medicine (ACSM) guidelines and established programmes in other parts of
the country, Bournemouth after cancer survivorship programme (BACSUP) confirm this.

Rationale
The improvement in cancer survivorship figures comes with increased economic costs to the NHS, the patient
and their family and productivity; only 30 per cent of survivors over 50 will return to work. Macmillan cancer sup-
port says although it is good news that more people with cancer are living longer; many are struggling with long
term health problems caused by their treatment. The charity says this poses a huge challenge for the NHS in
planning better services. The clearest evidence for the impact on survival of lifestyle interventions (physical activ-
ity) following cancer diagnosis is for survivors of breast cancer, colorectal cancer and prostate cancer. However,
current advice states that physical activity is safe for all people living with and after cancer.

Most individuals are highly motivated to improve their lifestyle following diagnosis and treatment to enable them
to regain their role in the family as parent or carer and in society as an employee, but in many cases need sup-
port and guidance to make changes. Individualised exercise interventions designed around the short and long
term goals of clients can play a significant role in helping cancer survivors recover from the both the physical
and psychological side effects of cancer and its treatment, regain their ability to perform activities of daily living
improve quality of life.

Development
Clients will be offered a 12 week personalised programme to increase activity levels within a specialist and gen-
eral setting during which they will be educated about the benefits of physical activity and how to safely become
more active. The approach is to be client-centred with a strong emphasis on informed choice and personal
control.

The service consists of 12 sessions of individual or group-based exercise normally over 12 weeks. The first ses-
sion will be preceded by a one-to-one appointment (30-45 minutes) and will be based on motivational interview-
ing techniques. This would involve:

» Exploring and build readiness and confidence, concerns, goals and options.
» Information exchange.
» Developing a collaborative plan including goal-setting, relapse prevention, on-going support and monitoring.
» Arrangement for ongoing support.

All clients will be given a Macmillan cancer support approved ‘move more’ materials and ‘get active feel good’
pedometer including an activity diary to consolidate the benefits of increasing activity levels and to supplement
exercise session input. A formal review can be integrated into the six-month patient follow-up to offer further sup-
port and problem solving.

Outcomes
The impact of the intervention will be evaluated by recording various health measures such as cardio/respiratory
fitness, blood pressure, resting heart rate, weight/BMI, muscle tone and strength. Patient recorded outcomes
will also be measured (ie levels of physical activity, lifestyle behaviour change, energy/fatigue, mental wellbeing,
self-esteem/anxiety/depression, body image, confidence, enjoyment/sustainability). The intervention will also be
monitored on an ongoing basis, by reviewing relevant statistics (ie referral numbers, ethnicity, cancer site, refer-
rer, point on cancer pathway) and providing support and training to staff.

Contact
Elliot Rogers, Active health manager, Aquaterra, [email protected], 020 3474 0066.

mailto:elliot.rogers%40aquaterra.org?subject=

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About the Strategic Clinical Networks

The London Strategic Clinical Networks bring stakeholders
-- providers, commissioners and patients -- together to create
alignment around programmes of transformational work that will
improve care.

The networks play a key role in the new commissioning system by
providing clinical advice and leadership to support local decision
making. Working across the boundaries of commissioning and
provision, they provide a vehicle for improvement where a single
organisation, team or solution could not.

Established in 2013, the networks serve in key areas of major
healthcare challenge where a whole system, integrated approach
is required: Cardiovascular (including cardiac, stroke, renal and
diabetes); Maternity and Children’s Services; and Mental Health,
Dementia and Neuroscience.

Strategic Clinical Networks | NHS England (London region)
www.londonscn.nhs.uk | [email protected] MH-CA-0615-rev02

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