Themes:
- Partnership working between cancer care and
urgent care teams - Collaborating across systems
- Improving quality and patient experience
Background
The Clatterbridge Cancer Centre NHS Foundation Trust (CCC) is one of the UK's leading specialist cancer centres. CCC provides non-surgical cancer treatments to a population of 2.4 million people across Cheshire and Merseyside and employs 1,700 specialist staff.
It is part of the Cheshire and Merseyside Health and Care Partnership, which is one of the largest integrated care systems (ICSs) in the country.
Treating cancer patients with urgent care needs
There are some persistent challenges in managing cancer patients at home. Care delivery is often focused on cancer centres, and there can be gaps where services span multiple ICSs. Cancer patients can therefore find it difficult to access appropriate and timely urgent care close to home.
In 2017, North Mersey cancer partnership group and Macmillan Cancer Support partnered to explore the challenges of managing cancer patients with urgent care needs in North Mersey.
The project found cancer patients were more likely to be conveyed to hospital by ambulance or admitted through A&E departments compared to those with other chronic diseases. As Dr Ernie Marshall, consultant medical oncologist, CCC, describes: "Clinicians were sometimes fearful of managing cancer patients, it was easier to send them to hospital."
Bringing together partners from urgent care and cancer care
In 2021, the Cheshire and Merseyside urgent cancer care board (UCCB) was established to address some of the challenges identified in the North Mersey report. Its primary function is to collectively reduce avoidable emergency department presentations for cancer patients while supporting the development of safe alternatives through coordinated service improvement and innovation.
The UCCB is jointly led and funded by CCC, the Cheshire and Merseyside cancer alliance, and the Cheshire and Merseyside urgent and emergency care network. It brings those three partners together with other local stakeholders, including patients' groups, primary care, national NHS bodies and third-party organisations.
The board has supported better partnership working and collaboration between cancer care and urgent and emergency care at both an operational and strategic level. The teams communicate regularly and attend meetings held by partner organisations, and a framework has been developed to support the work.
Opportunities borne out of the pandemic
Laura Jane Brown, acute oncology senior project manager, CCC, says: "Although Covid-19 was a horrendous challenge, it opened up multiple opportunities." The shift to remote working and the use of technology to aid remote communication made it possible for local cancer specialists to speak to other experts regionally and at a national level. This has been important for the team, because, as Dr Ragit Varia, acute medical lead for the urgent cancer care programme based at St Helens and Knowsley Teaching Hospitals NHS Trust, says: "The more you talk to people, the more opportunities come about."
Furthermore, the pandemic prompted a focus on keeping patients, and especially cancer patients, out of hospital where possible. This gave a range of system partners a common purpose and encouraged collaboration to provide appropriate alternatives to emergency care.
This is critical because national cancer strategies are mainly focused on planned care, meaning there is often, as Ernie describes: "Limited strategic bandwidth to consider the urgent care needs of cancer patients."
In addition, the team from combined intelligence for population health action, which is a population health management platform for the NHS, were brought in to support with data during the Covid-19 pandemic. As Laura explains: "We caught the ear of the team, and we are now working as a system to build an acute oncology regional dashboard." At present, data on cancer patients accessing urgent care is quite fragmented, and not always visible to the wider system. The dashboard will give greater oversight of planned and unplanned cancer care.
A better understanding of this group of patients can also drive quality improvement and reduce avoidable variation in care. Ernie says: "In some cases patients coming into urgent care with cancer are interfaced between acute and oncology teams, but in others the need is not recognised, and the referral is not made."
Alignment with existing national priorities
The UCCB is aligned with the national same day emergency care strategy, and Ernie says: "From the outset we wanted to consider both hospital and community pathways." The team have been engaging informally with urgent community response (UCR) teams to explore the opportunities. Ernie says: "At first they saw UCR as focused on frailty and were hesitant to take on cancer patients." However, there is growing agreement about the opportunity this presents, and there are now more formal discussions about how UCR can support cancer patients seeking urgent care. Ernie reflects: "We're not there yet, but we've shown the value of including cancer eligibility on those pathways."
Ragit says: "A lot of work is being undertaken around UCR and virtual wards, making it the right time to work with partners on admission avoidance."
Fulfilling the UCCB's potential
The team acknowledge they are at the beginning of their journey with UCCB. They are in the process of describing baseline data, identifying opportunities, and building the right relationships to take this collaboration forward.
The team see great potential here, and point to the fact that, at a national level, 20% of cancer patients are admitted to hospital for a short stay. With the right coordination and collaboration, there are significant opportunities around admission avoidance, improving patient experience, and enabling alternative pathways that reduce the number of days people with cancer spend in hospital.
Next steps
A key next step is the expansion and redevelopment of a regional cancer hotline. This will provide a single point of contact that uses the optimum pathways being built, including the streaming of calls into urgent community response teams.
NHS England is interested in this approach; the national same day emergency care project has created a cancer focus that draws on the learning from Cheshire and Merseyside.
However, the team recognise there are challenges ahead. Ernie reflects that: "Workforce resilience will limit what we can do, and that's why we need a system-wide approach." Also, keeping up the drive and momentum amidst other operational challenges will be difficult.
However, they are confident they can continue to build on the progress they have made over the last year. Despite the pressures they have faced, people have remained committed even in a year that has seen unprecedented operational pressure on NHS services. As Laura says: "Committed and passionate people are at the heart of this."