Dr Jill Murie explains how meeting the cancer indicators will mean better follow-up and support in the community for patients and their carers


   

Cancer care is undeniably a clinical priority. From a public health perspective, mortality rates from all causes fell across the UK between 1950 and 1999, while for cancer, age-standardised mortality rates have changed relatively little.1,2

Improving the quality of life of cancer patients is the goal of care, particularly at the end of life, when patients with cancer should be assured a pain-free, dignified and peaceful death.

The Cancer Services Collaborative (CSC) summarises the aim of cancer care as: “to improve the experience and outcomes for patients with suspected or diagnosed cancer by optimising care delivery systems across the whole pathway of care”.3

How this is achieved relies very much on secondary and tertiary care services, but GPs can contribute significantly to the delivery of care by ensuring a prompt diagnosis and referral, facilitating coordination arrangements and supporting patients through their journey. A clinical pathway for cancer care has six main features:

  • The pathway describes an organisational process
  • Care settings are multisectoral
  • Care delivery is multidisciplinary
  • Care incorporates guidelines and evidence-based practice
  • The pathway integrates education and practice
  • The process is outcomes focussed e.g. a ‘good death’.

The cancer indicators in the nGMS contract provide an important stepping stone to improving continuity of care for patients in the community.

 

Cancer indicator 1 states that the practice can produce a register of all cancer patients diagnosed after 1 April 2003 (Table 1, below). The rationale behind this indicator is that all cancer patients should be identified and followed up to maximise the benefits of care.

Table 1: Clinical indicators for cancer
Disease/ indicator no Clinical indicator Points Qualifier Preferred Read code Exception reporting and suggested Read code Payment stages
Records
Cancer 1
The practice can produce a
register of all cancer patients
diagnosed after 1 April 2003
6 This must be
kept updated. All
cancers should
be included except
non-melanotic
skin lesions
B...%
B0-B6%
Byu..%

Exception reporting, cancer quality indicators 9h8..
Excepted from cancer quality indicators:

- patient unsuitable 9h81
- informed dissent 9h81
Non-melanotic skin cancers: 9h81.

---
Ongoing Management
Cancer 2
The % of patients with cancer
diagnosed from 1 April 2003 with
a review by the practice recorded
within 6 months of confirmed
diagnosis. This should include
an assessment of support
needs, if any, and a review
of coordination arrangements
with secondary care
6 Should be recorded
within 6 months of
confirmed diagnosis
8BAV
(was 8CLO)
  25-90%

In our practice we identified patients with cancer by conscientious, opportunistic data recording during the consultation and meticulous attention to diagnoses, medications and interventions included in discharge and clinic attendance letters from secondary care.

In Forth, Lanarkshire, where our practice is based, patients with a diagnosis of cancer were generally known to staff and, where appropriate, discussed regularly with the district nurses.

This small and remote town once relied on coal mining and mineral extraction for its daily bread. Industrial decline has resulted in high levels of unemployment in the community. The practice is fortunate to have access to the Lockhart Hospital – a 26-bed community hospital run by local GPs.

Records from the local community hospital were also examined for admissions with a diagnosis of cancer. Recommended codes were entered excluding non-melanomatous skin lesions.4

 

In the Forth practice, the proportion of people with cancer is around 55 out of 2700. This is consistent with the overall prevalence figure for Lanarkshire of 11 000 out of 550 000 (2%).

In addition to all diagnoses of cancer since 1 April 2003, the number of patients added to the register in the 12-month period up to 1 April 2004 had to be distinguished from the total on the register and their proportion calculated as a percentage of the total. Lanarkshire data suggest that 3200 out of 11 000 people with cancer (29%) are diagnosed with the disease every year.

An accurate snapshot of cancer statistics is available in Cancer Atlas of the United Kingdom and Ireland 1991-2000.5 This atlas describes the geographical patterns of cancer incidence and mortality and relates them to risk factors and to socioeconomic factors.This data may help practices understand local variations in cancer prevalence. Practices in England can also search for a community profile.6

 

The nGMS contract requires practices to review patients with cancer within 6 months of their diagnosis. The purpose of the review is to provide support to the patient and to ensure that follow-up arrangements between the GP and secondary care service are clear to both the patient and the GP.

Fulfilling the nGMS contract clinical indicators mirrors existing work taking place in the UK. For example, GPs in England have been contributing to the CSC Improvement Partnership (CSC IP) since 2002.3

The contract reflects the CSC IP’s three priorities:

  • Early diagnostic pathways
  • Effective communication
  • Supportive care.

GPs should record that discussion of the diagnosis has taken place using the preferred Read code 8BAV. The date of diagnosis will usually be derived from hospital discharge letters but sometimes it will not be possible to verify the date.

The second aim of the CSC IP is effective communication between healthcare professionals and also between professionals in contact with patients and carers.

Patients may receive a variety of medications, including opiates, from several doctors which can cause confusion.

Failure to liaise with out of hours services; poor communication between GPs, district nurses and specialist nurses, such as the Macmillan nursing services; and lack of involvement of carers in decision-making can all result in home care being abandoned.

The CSC IP also promotes supportive care throughout the patient journey. This support should focus on patient information, cancer registers and coordination of the clinical pathway.

Cooperation with nursing staff and use of family teaching programmes are essential components of a palliative approach to symptom control.

The nGMS contract requires the practice to report the number of patients with cancer diagnosed since 1 April 2003 with a review recorded in the six months after diagnosis. QMAS automatically identifies this aggregate entry with the code 8BAV ‘cancer care review’.

Supporting documentation states that the verification involves visiting teams randomly selecting a number of case records of patients to confirm that the two components of the indicator have been undertaken and recorded.

 

Palliative care is an essential component of cancer management and I am delighted that indicators for palliative care have been included in the proposed changes to the QOF from April 2006.

Across the UK, the Gold Standards Framework (see www.goldstandardsframework.nhs.uk) is providing many practices with a ‘how to do it’ programme of information, practical skills and resources to improve standards of palliative care in the community. 7 The framework is underpinned by seven ‘gold standards’ (Table 2, below).

Table 2: Gold Standards Framework
The Gold Standards Framework (GSF) aims to improve the quality and organisation of care in the community for all patients in the last year of life. It relates to cancer and non-cancer patients, and is currently used by about one-third of practices in the UK. GSF is supported by the NHS End of Life Care Programme, RCGP, NICE, Macmillan, CSC and others.
Gold Standards Requirements
Communication

A palliative care register to record, plan and monitor home care.This is to be discussed monthly with the primary health care team (PHCT) in order to:

  • improve the flow of information
  • facilitate advanced planning/proactive care
  • provide data for audit at individual, practice and PCO levels
Coordination

A practice lead clinician to oversee:

  • summarised data on symptom scores, care plans, handover arrangements and problems encountered
  • the planning of PHCT meetings, case analysis, education and training
  • the use of standardised tools to ensure that all aspects of care are considered
Control of symptoms

A patient-centred approach is adopted and covers the assessment, recording, discussion and management of:

  • physical symptoms
  • psychological problems
  • social needs
  • spiritual needs
Continuity

Continuity of care is encouraged by:

  • transferring patient information between the PHCT and out of hours services, hospices and oncology services using agreed documentation, e.g. patient-held records and medication cards
  • minimising the number of health professionals involved in the patient's care
Continued learning

Continued professional development is an integral component of quality improvement and comprises knowledge of, skills in, and attitudes to, palliative care. Education activities may include:

  • significant event analysis
  • audit
  • video consultation for communication skills
  • practice-based meetings
  • clinical attachments
  • self directed learning (personal development plans/appraisal)
  • lectures/seminars
  • courses/conferences
Carer support

Carers are regarded as an integral part of the PHCT.This is acknowledged through:

  • recognition of their contribution
  • emotional and practical support, e.g. respite, aids and appliances
  • information and education
  • bereavement care
Care of the dying Terminal care in the last days of life should follow an appropriate pathway, e.g. the Liverpool Care Pathway

The seventh gold standard is ‘Care of the dying’. A multidisciplinary meeting to discuss the Liverpool Care Pathway for the Dying8,9 was held in the Lockhart Hospital using teleconferencing technology to link the community hospital to St Andrew’s Hospice, Airdrie.

This was a unique opportunity for GPs, hospital and community staff to discuss ways of implementing the pathway in primary care settings.

Other important sources of information for health professionals include a NICE report on the scientific evidence for palliative care10 and the WHO analgesic ladder.11 There are also several CPD modules based on palliative care on the bmjlearning website.12

 

There are many charities and support centres in the UK that aim to provide help and information for anyone whose life is affected by cancer.

In Forth a community-based centre, the ‘Little Haven’, has been established in a former council flat. There people with cancer and other life limiting illnesses can access information, counselling and support.

A mobile information service is also providing outreach to residents of South Lanarkshire. For people who do not have such a facility, online support is available.

 

In our small practice in Forth, big changes are taking place in terms of methods of monitoring the incidence and prevalence of cancer and managing patients using the Gold Standards Framework and Liverpool Care Pathway for the Dying.

The nGMS contract has provided an opportunity for all practices to improve standards, but however laudable the contract’s aims, the ultimate benefit to patients will depend largely on secondary and tertiary care centres meeting waiting time targets.

Nevertheless, the aim of the indicators is to accompany patients on their journey no matter how stoney the way.

 

  1. Quinn MJ, Babb PJ, Brock A et al. Cancer trends in England and Wales 1950-99. Studies on Medical and Population Subjects. No. 66. London: The Stationery Office, 2001.
  2. General Register Office for Scotland. Scotland’s Population 2001: The Registrar General’s Annual Review of Demographic Trends. Edinburgh: General Register Office for Scotland, 2001.
  3. www.cancerimprovement.nhs.uk
  4. NHS Confederation, BMA. Investing in General Practice: the new GMS contract (Supporting Documentation). Birmingham NHS Confederation 2003 p.53-4.
  5. www.statistics.gov.uk
  6. http://neighbourhood.statistics.gov.uk/dissemination
  7. Thomas K. Caring for the Dying at Home: Companions on the Journey. Oxford: Radcliffe Medical Press, 2003.
  8. Ellershaw JE,Wilkinson S. Care of the Dying. A pathway to excellence. Oxford: Oxford University Press, 2003.
  9. National Council for Hospice and Specialist Palliative Care Services. Changing gear – guidelines for managing the last days of life in adults. Northamptonshire: Land and Unwin Ltd, 1997.
  10. NICE Improving supportive and palliative care for adults with cancer: research evidence. www.nice.org.uk
  11. www.who.int/cancer/palliative/painladder/en
  12. www.bmjlearning.com

Guidelines in Practice, February 2006, Volume 9(2)
© 2006 MGP Ltd
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