Improving Cancer Care Delivery and Patient Experience

Macmillan 1-1 Oldham Community Personalised care and Support Susanne Holt & Jade Hughes

Background Macmillan 1-1 are a team of healthcare professionals including clinicians initially established to deliver the Macmillan recovery package. The service has adapted and developed over the years in line with cancer care pathways and the national drive to deliver Personalised Care and Support. Including Holistic Needs Assessment, Personalised Care and Support Planning Care Plans along with quarterly Health and Wellbeing events held within the Oldham locality. The service provides an array of provisions whilst supporting our specialist teams within the community sector such as the Physiotherapists/ Occupational Therapists/ Dieticians/ District Nurses and Specialist Palliative Care Team. This reduces waiting times, increased patient experience and satisfaction and reduces service burden. *First line nutritional support including nutritional supplement provisions and prescription *Equipment ordering and provisions *Pressure relieving assessment/ skin assessment and pressure relieving equipment provisions *Minor adaptations *Advanced Care Planning- ACP *Continuing Healthcare assessments- CHC *Stable palliative support *Low level psychological and emotional support *Short term bereavement support

The challenge What can we do to further support our colleagues in both the primary and secondary care sector? How can we build towards improving patient experience and ensuring delivery of defined cancer care elements which patients should expect to be delivered throughout their cancer journey? What elements can be delivered in the Primary Care community sector to free up Primary and Secondary Care appointments and care delivery demands, whilst giving patients the choice to choose where elements of their care and support planning is delivered?

The plan Further supporting the Primary and Secondary Care teams We can further support our colleagues by delivering all elements of Personalised care for people navigating life with cancer within the Community/ Primary Care setting where feasible. This would also mean the team are able to deliver three of the four key ambitions of the NHS Long Term Plan within a Primary Care/ Community setting freeing up the specialist teams to deliver care and support to those in need Personalised Care and Support Planning End of Treatment Summaries - completed in secondary/tertiary care Primary Care Cancer Care Review (CCR) Health and Wellbeing Information and Support

The plan Improving patient experience and ensuring delivery of defined cancer care elements We support from diagnosis, through treatment, into recovery and living well with cancer. Work is underway for the Macmillan 1-1 team to complete CCR and commence the Electronic Palliative Care Coordinating Systems (EPaCCS) record alongside HNA assessment and care plan development. By delivering Cancer Care reviews alongside HNA care planning patients across the borough will not only have a standardised CCR but also a copy for their HNA care plan completed as part of this review. CCR will happen within the first 3 months of diagnosis and continue annually- unless there are concerns identified requiring a review before the proposed annual assessment. EPaCCS will be commenced at time of initial CCR and added to/ amended by professionals as warranted to capture potential sensitive information and information sharing. Along with standardising CCR, providing HNA assessment and care plan the Macmillan 1-1 team will free up GP time and appointments for those in need, thus proving cost and resource effective. This in turn ought to improve patient experience and outcome measures including better access to resources.

The plan What elements can be delivered in the Primary Care community sector Five of the eight ambitions of Promoting Person Centred Care are currently being effectively delivered at a time and place to suit the needs of the patients by Macmillan 1-1 a dedicated community-based service. Macmillan 1-1 link in with a sixth element by forming part of Patient Stratified Follow Up alongside the Secondary Care Specialist Teams to reduce unnecessary hospital admission and demand on the Specialist Clinical Services. Therefore improving productivity for the secondary care CNS teams by freeing up outpatient appointments, clinic time and phone queries which can be met by the community team, thus allowing resources to be targeted at patients with complex needs.

Outcomes, lessons learnt & aims The commencement of CCR s being completed by Macmillan 1-1 alongside the established HNA care planning is still a work in progress- initially piloting with one of the GP clusters before rolling out across the borough. Formulating the DPIA for access to GP records as part of CCR delivery and documentation as an extension of the GP practice was timely and required multiple version before being agreed by the PCN and NCA Governance and Digital Transformation Teams. The aim is to roll out Macmillan 1-1 across the NCA footprint to become the gold standard for Personalised Care and Support Delivery supporting both Primary and Secondary care teams. By ensuring the key elements of Personalised Care and Support are delivered where able in the community to improve patient outcomes, improve patient experience, being resource and service effective and freeing up specialist/ GP clinical appointments/ time for those with complex needs. A major ambition would be to replicate this service model across GM. We can certainly all agree that cancer care delivery is not a one size fits all We can certainly all agree that cancer care delivery is not a one size fits all approach! approach!